Utilization, Availability, Accessibility and Quality of Basic Health Care Services in Nepal: A Cross-Sectional Demographic and Health Facility Survey

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This study aims to evaluate the availability, accessibility, quality and utilization of BHCS in the public health facilities of Nepal, using data from two nationally representative surveys. Methods We analyzed data from the Nepal Demographic and Health Survey (NDHS) 2022 and the Nepal Health Facility Survey (NHFS) 2021, focusing on the services included in Nepal’s BHCS package. A descriptive analysis of BHCS availability, accessibility, service quality, and utilization using data from 1,448 public health facilities, 457 observations, and 320 client interviews from the NHFS 2021, along with data from 14,845 women (15–49 years) from the NDHS 2022. It assessed 41 NHFS 2021 services across eight of ten BHCS categories for availability, two NDHS 2022 indicators for accessibility, five NHFS 2021 indicators for facility readiness, 13 for adherence to care standards, seven for experience of care, and nine NDHS 2022 indicators for service utilization. The quality of care index was calculated with equal weight assigned to three domains: experience of care, Adherence to standards, and service readiness. Results Out of the 41 services in the BHCS package, 16 were available at more than 90% of the public health facilities included in the study, although less than 1% of facilities offered all 41 services. Over half (54%) of women reported that the nearest health facility to their residence was a public facility. Utilization of child health services was relatively low, with only 6% of children under five receiving growth monitoring and care-seeking for common illnesses also being low—19.6% for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections. In contrast, maternal services such as antenatal care (80.5%) and deworming (84.1%) were more widely utilized by pregnant women. The overall quality of care for normal, low-risk deliveries at the national level was rated 69.3 out of 100. Conclusions Despite a constitutional mandate to provide BHCS, this study found low availability of BHCS in public health facilities in Nepal. Although accessibility was not a significant problem, we found low utilization of services (especially regarding child health) and moderate quality of care. Early BHCS implementation demonstrates the need for realism and service review. Accessibility Availability Basic Health Care Services Constitution Nepal Quality of care Utilization Figures Figure 1 Figure 2 Figure 3 Introduction A well-defined, essential package of health services (EPHS) is key to universal health coverage (UHC) reforms worldwide [ 1 , 2 ]. Publicly financed basic health care services (BHCS) are the approach adopted by the Government of Nepal to fulfill the constitutional mandate of providing an essential health services to Nepalese citizens and making sure the country is moving towards achieving UHC [ 3 ]. Countries like Afghanistan, Ethiopia, Somalia, Sudan, and Zanzibar-Tanzania have implemented EPHS as a policy tool to expand UHC [ 4 ]. South Asian countries Bangladesh, Pakistan and Sri Lanka developed EPHS tailored to their specific health needs especially maternal and child health service, screening of common non communicable diseases, screening and management of infectious diseases and health promotion related services [ 5 ]. Ethiopia's approach emphasizes a broad EPHS scope [ 6 ], while Pakistan’s implementation is more limited, with only the Punjab province fully defining an EPHS [ 7 ]. Each country adapts their EPHS to local needs, such as addressing high-burden diseases, like maternal and child health issues and chronic illnesses [ 8 ]. Similarly, in countries like Zambia and Yemen, EPHS are often included in broader health policy frameworks rather than distinct packages [ 9 ]. Countries typically use disease burden and cost-effectiveness criteria, with added factors like acceptability, feasibility, equity, and budget impact to develop EPHS [ 10 ]. An EPHS must drive the country’s health system [ 11 ]. A successful EPHS relies on health system readiness and quality of care [ 12 ]. If the government enhances the quality and availability of services at public health facilities, more people are likely to choose public health facilities for their healthcare needs [ 13 ]. Improving services for non-communicable diseases, mental health, and emergency obstetric care is key to enhancing the availability of essential health services [ 14 ]. Similarly, focusing on both quality and utilization, EPHS can achieve its goal of UHC and better public health outcomes [ 15 ]. We did not find any large-scale study, assessing the availability of BHCS in Nepal. Published studies in Nepal have focused either on the readiness, availability, and utilization of selected services or on assessing the health system in a federalized context [ 16 – 20 ]. This paper aims to examine the availability of BHCS, accessibility, quality and utilization of maternal and child health services (components of BHCS) in Nepal. This study will provide evidence on BHCS provision in the federalized context, guiding improvements to align with the constitution and revision of BHCS package. Materials and Methods Basic Health Care Services (BHCS) With the promulgation of its constitution 2015, Nepal moved from a unitary to a federal system with three government tiers: a federal government, seven provincial governments, and 753 local governments [ 3 ]. The BHCS is a minimum set of health services that the Government of Nepal (GoN) commits to providing free of cost to all Nepali citizens [ 21 ], irrespective of their demographic, geographic, and socio-economic status [ 22 ]. Nepal’s Public Health Service Act 2018 defines BHCS as free and accessible promotional, preventive, diagnostic, curative, and rehabilitative health services and categorizes it into ten components [ 23 ] (Table 1 ). Table 1 Basic Health Care Services (BHCS) as defined by the Public Health Service Act 2018 of Nepal SN Categories of Services 1 Immunization services 2 Integrated management of newborn and childhood illnesses; nutrition services; pregnancy, labor, and delivery services; maternal, newborn, and child health services, such as family planning, abortion, and reproductive health 3 Services related to infectious diseases 4 Services related to non-communicable diseases and physical disability 5 Services related to mental health conditions 6 Services related to elderly citizen’s health 7 General emergency services 8 Health promotion services 9 Ayurveda and other accredited alternative health services 10 Other services prescribed by the government by a notification in the Nepal Gazette Analytical Framework Considering the broader legal and policy framework governing BHCS, this study planned an extensive framework (Fig. 1 ) to assess BHCS across six components: service availability, service accessibility, service readiness, adherence to standards, experience of care, and service utilization [ 24 ]. Given that all six components are interdependent and essential for delivering BHCS, this framework treats them separately to ensure that each one is thoroughly addressed. Three of these components-readiness, adherence to standards and experience of care—were assessed within the quality-of-care domain. For the quality-of-care analysis, this study exclusively focused on normal low-risk delivery services, which is one of the service categories of the BHCS package [ 25 ]. The study analyzed data from the Nepal Demographic and Health Survey (NDHS) 2022 and the Nepal Health Facility Survey (NHFS) 2021, focusing on the services included in the BHCS package. Data on health service use and accessibility were taken from the NDHS 2022, while data on service availability and quality of care, encompassing readiness of a facility to provide services, adherence to standards, and experience of care were taken from the NHFS 2021. Based on the availability of data in the respective surveys, the study used 41 discrete services, covering eight of the ten broad categories of services within the BHCS package from the NHFS 2021 for assessing accessibility, two variables from the NDHS 2022 for assessing service accessibility, five variables related to the normal low-risk delivery service from the NHFS 2021 for assessing health facility’s readiness to provide the services, 13 variables from the labor and delivery observation module of the NHFS 2021 for assessing adherence to standards of care, seven variables from the labor and delivery post-partum exit interview module of the NHFS 2021 for assessing experience of care, and nine variables were used from the NDHS 2022 for assessing service utilization. This is summarized in Table 2 and all the variables of different components are listed in supplementary table S1 . Table 2 Components, categories, number of variables, and sources used in the study Components Categories of services Variable Sample size Unit of study Sources Service availability 1–8 (All categories except Ayurveda services) 41 1448 Public health facilities NHFS, 2021 Service accessibility 2 (Maternal health services) 2 8,049 15–49 years women NDHS, 2022 Quality of services Service readiness 2 (Normal low-risk delivery services) 5 804 Public health facilities NHFS, 2021 Adherence to standards 2 (Normal low-risk delivery services) 13 457 15–49 years women NHFS, 2021 Experience of care 2 (Normal low-risk delivery services) 7 320 15–49 years women NHFS, 2021 Service utilization 1 and 2 (Child health and maternal health services) 9 8,049 15–49 years women NDHS, 2022 Characteristics of Participants The NHFS 2021 included 1,576 health facilities, of which 1,448 were public and 128 were private facilities. Since BHCS is provided only through public health facilities, the unit of analysis for assessing availability of BHCS in this study was solely the 1,448 public health facilities included in the NHFS 2021. These facilities include all public health facilities (hospitals) managed by federal and provincial governments (excluding standalone specialized hospitals), hospitals, and primary health care centers managed by local governments. Other public facilities managed by local governments, such as health posts (HPs), community health units (CHUs), and urban health units (UHCs), were sampled in the survey. All the 1,448 public health facilities were considered when assessing BHCS availability. Similarly, nine indicators from the NDHS 2022 were chosen for analyzing the utilization of nutrition, treatment of sick children, child vaccination, women’s vaccination, antenatal care, and delivery services from the BHCS package. For the assessment of the accessibility of public health facilities, 14,845 women aged 15–49 years from 13,786 sampled households represented the unit of analysis. Of these women, 8,049 reported that the nearest health facility to their residence, based on walking distance and mode of transportation, was a public facility. Women, whose labor and delivery were observed and who were then interviewed as they were discharged from the health facility, represented the unit of analysis for assessing quality of care using data from NHFS 2021. The study considered all 804 public facilities providing normal low-risk delivery services for assessing the readiness of health facilities to provide normal low-risk delivery services. A total of 457 normal low-risk delivery cases were observed to assess adherence to standards of care (practice of care) using 13 indicators from the labor and delivery observation module of the NHFS 2021. Likewise, out of the 457 women observed for normal low-risk delivery services, exit interviews were conducted with 320 women form 94 health facilities to assess the experience of care using seven indicators from the labor and delivery post-partum exit interview module of the NHFS 2021. The remaining 137 women could not be interviewed for various reasons, e.g., they suffered complications, were referred to another health facility, refused to be interviewed, or remained in the same health facility for a prolonged period. Processes The study analyzed NDHS 2022 and NHFS 2021 data available in the public domain [ 26 ]. Both surveys are nationally representative, were conducted under the global Demographic and Health Surveys (DHS) program and received approval from the Nepal Health Research Council. For the NHFS, written consent was obtained from service providers, while verbal consent was secured from all subjects who were observed or interviewed. The NDHS 2022 obtained written consent from all interview respondents. Data analysis The study used binary variables to assess all six components: service availability, accessibility, service readiness, adherence to standards (process of care), experience of care, and utilization of services. Frequencies and percentages of distributions, as well as average scores, were calculated. The quality of care index was stated on a scale from 0 to 100, indicating the level of healthcare service quality. It was computed and presented as a domain and their respective index or sub-index values giving equal weight to the three domains of normal low-risk delivery services, viz. experience of care, Adherence to standards, and service readiness of health facilities. Further information regarding the different components among sub-domains is included in Supplementary Information Tables S2, S3 and S4. The analysis of BHCS service utilization was conducted using five child health and four maternal health service-related variables from the NHDS 2022. Stata 18 and SPSS (IBM SPSS Statistics 25) software were used for the analysis. Relevant results were disaggregated by the level of health facilities. Results Availability of Basic Health Care Services (BHCS) by Authority of Health Facilities The weighted analysis of public health facilities included in the NHFS 2021 showed that an overwhelming majority (98.2%) were local-level health facilities. Only 1.4% were provincial-level facilities, and 0.4% were federal-level facilities. It revealed that 0.5% of public health facilities in Nepal had all types of BHCS available at the time of assessment. Among health facilities, only 0.2% of local-level facilities provided all services, compared to 17.2% of provincial-level facilities and 14.5% of federal-level facilities (Table 3 ). Table 3 Weighted distribution of health facilities by the three tiers of government Authority Level Health facilities Weighted percentage Weighted number Availability (%) Federal General hospitals 0.4 6 14.5 Province General hospitals 1.4 21 17.2 Local/Municipality Hospitals Primary health care centers Health posts Urban health center Community health unit 98.2 1,421 0.2 Total 100 1,448 0.5 Health Facilities (HFs) by Distribution of Basic Health Care Services (BHCS) Among all types of BHCS captured in the NHFS 2021, sixteen out of 41 services were available in more than 90% of public health facilities, ranging from the management of childhood illnesses to basic cardiovascular disease services. Nine types of BHCSs were available in 80–90% of the facilities. Some services, such as mental health services (22%), treatment of obstetric fistula (17%), abortion care (16%), treatment of Kala-azar (8%), and cervical cancer screening (8%), were available in less than one-fourth of the facilities (Fig. 2 ). Accessibility of Basic Health Care Services Overall, more than half (54%) of the women surveyed in the NDHS 2022 (8,049 out of 14,845 women) reported that the health facility nearest to their residence was a public facility. Of these women, approximately two-thirds (65.1%) confirmed that they could reach the nearest public health facility within a 30-minute travel time from their residence. For the large majority (82.3%) of pregnant women, walking was the primary mode of transportation to reach the nearest public health facility. When disaggregated at the provincial level, women residing in the Karnali (56.1%) and Sudurpashchim (54.1%) provinces faced the greatest difficulty in reaching the nearest public health facility within a 30-minute walking distance. Only about 3% of women in Karnali Province had access to a motorable road to the nearest public health facility, with an overwhelming majority (96.9%) relying on walking (Table 4 ). Table 4 Accessibility of BHCS, 2022 NDHS (N = 8049) BHCS Accessibility component National Koshi Madhesh Bagmati Gandaki Lumbini Karnali Sudur Paschim Public HF as a nearest HF 54.0 Nearest health facility by walking distance < 30 minutes 65.1 60.5 81.8 61.5 62.9 65.4 56.1 54.1 30–59 minutes 20.2 21.9 16.1 19.4 22.3 19.7 19.7 26.1 60–119 minutes 10.6 10.8 2.1 12.3 12.3 12.4 16.8 16.5 ≥ 2 hours 4.1 6.9 0.1 6.8 2.4 2.5 7.3 3.3 Nearest health facility by mode of transportation Motorized 11.9 20.0 11.6 11.6 12.0 11.1 2.8 11.9 Non-motorized 5.6 9.9 3.4 5.4 2.2 5.3 0.2 10.6 Walking 82.3 70.0 84.8 82.7 85.5 83.4 96.9 84.2 Other 0.2 0.1 0.2 0.3 0.3 0.1 0.2 0.1 Quality of Care for Normal Low-risk Delivery Services Table 5 provides information about different aspects of healthcare quality. The overall quality for normal and low risk delivery service (components of BHCS) stood at 69.3 out of 100, with the experience of care scoring 86.4, the Adherence to standards scoring 77.8 (including general examination at 61.8, abdominal examination at 76.3, and vaginal examination at 95.3), and service readiness scoring 43.6 at national level. Table 5 Quality of care for normal low-risk delivery services SN Domains Index/sub-index value 1 Experience of care 86.4 2 Adherence to standards 77.8 2a General examination 61.8 2b Abdominal examination 76.3 2c Vaginal examination 95.3 3 Service readiness 43.6 Quality of care index 69.3 Utilization of Basic Health Care Services (BHCS) The utilization of child health services was relatively low compared to maternal health services. Six percent of under five children received growth monitoring. Care-seeking was also low for common illnesses, with 19.6% for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections (ARI). Four antenatal care (ANC) visits were utilized by 80.5% of pregnant women. Deworming medication was the most used service, with 84.1% of pregnant women receiving it. (Fig. 3 ). Discussion Basic Health Care Services (BHCS) Package: Realistic vs. Idealistic Out of the 41 services assessed in 1448, public health facilities included in this study, less than 1% offered all services. Some services, such as cervical cancer screening and breast cancer screening, were recently introduced, with only 8% of the health facilities ready to provide these services. In the current study, 89.8% of public health facilities provided screening for cardiovascular diseases, 80.9% offered tuberculosis services, 51.3% provided delivery and neonatal care services, and 21.7% offered mental health services. These findings are similar to the previous review study in which a significant proportion of facilities provide essential services, with 61.7% offering Non-Communicable Disease (NCD) services, 53.0% providing mental health services, and 59.7% delivering Basic Emergency Obstetric Care, demonstrating progress in improving service availability [ 14 ]. Achieving UHC requires the availability of all services included in BHCS to the population without causing financial hardship [ 7 ]. Although it was the government’s commitment to its people to include human papilloma virus (HPV) vaccines and cancer screening in the BHCS, it was an ambitious goal rather than a realistic step. Most importantly, the government needs to ensure continued financing for the BHCS to provide the included services free of charge while ensuring compliance with the national standards of care [ 27 ]. This suggests that the BHCS package needs to be dynamic, starting with the basic services a country should include in its BHCS, and it should be informed by evidence on cost-effectiveness, priority to the worse-off, and financial risk protection [ 28 , 29 ]. In our study, more than half (54%) of women in the NDHS 2022 reported that a public health facility was the closest to their home, with 65.1% reaching it within 30 minutes, mostly by walking (82.3%). This suggests that while public health facilities are geographically accessible for most women, reliance on walking as the primary mode of transport may indicate potential barriers related to transportation availability, distance, or emergency access. The vision of the BHCS is the provision of a package of health care services that can be delivered through the smallest unit of a public health facility, even in the most remote area of the country [ 22 ]. The overall quality for normal low risk delivery was 69.3 out of 100, with high scores for experience of care (86.4%) and adherence to standards (77.8%), but lower scores for specific examinations like general examination and abdominal examination of pregnant women. Service readiness was notably low at 43.6% for normal low risk delivery. This suggests that while patients generally have positive experience with care and adherence to standards is relatively good, significant improvements are needed in service readiness, which could be due to inadequate resources, training, or facility preparedness. One of the study, conducted on married women aged 18–45 years with at least one child living in Tiruchirappalli District, Tamil Nadu, India found that almost all respondents (98%) were satisfied with health services, and 92% benefited from the government’s childbirth-related scheme [ 30 ]. The utilization of child health services was much lower than maternal health services, with only 6% of children under five receiving growth monitoring service. Care-seeking for common illnesses was also low, with only 19.6% of under five children seeking care for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections (ARI). In contrast, 80.5% of pregnant women received four antenatal care visits, and deworming medication was the most widely used service, with 84.1% of pregnant women receiving it. Several international studies have highlighted disparities in the utilization of maternal and child health services, particularly in low- and middle-income countries (LMICs). While maternal health services, such as antenatal care and institutional deliveries, have seen notable improvements, child health services, including growth monitoring and treatment for childhood illnesses, often experience lower utilization rates [ 31 ]. To improve child health service utilization, it's essential to improve access and integrate child health services with existing maternal care programs. All health services listed in the BHCS package are meant to be provided free of charge to citizens at the point of care [ 21 ]. However, Nepal’s BHCS package was ambitiously developed and included services that were not available within the existing service delivery mechanism. Through the BHCS, the government made commendable efforts to translate the constitutional mandate into action; however, these promises have not effectively translated into reality. Policy and Research Implications The BHCS package needs to be realistic—not idealistic. Based on the lessons learned from the initial years of implementation, the service components of the BHCS need to be revisited. The service components that are in the very early stage of development, where the procedures and protocols for service provision are not defined, need to be reviewed in light of the limited resources available [ 32 ], the capacity to provide and manage quality health services as per the standards, and the provision of the legal framework of fines and compensation. As the citizens’ awareness and literacy of BHCS increases, people will demand quality BHCS, and not receiving the services, or services not meeting the standards, means a breach of the legal provision that might result in citizens taking legal action [ 23 ]. A successful BHCS requires commitment, sustainable financing, system readiness, and institutionalization [ 12 ]. Local governments play a significant role in the delivery of the BHCS [ 3 ]. Improved collaboration with federal and provincial authorities to deliver free BHCS at federal- and provincial-level health facilities is important in urban areas [ 22 ]. A strong BHCS monitoring mechanism, mass awareness campaigns, and community mobilization will be key for the effective implementation of the BHCS. In Ethiopia, a recent revision of the EHCP integrated monitoring and evaluation frameworks to more effectively align services with health priorities. This process has encouraged the adoption of the Disease Control Priorities (DCP-3) initiative, which provides structured guidance for selecting and ranking interventions based on cost-effectiveness. Such frameworks are vital for the systematic expansion of the scope of essential services, particularly in resource-constrained settings where healthcare access and quality can vary significantly by region [ 4 ]. In Zambia and Yemen, essential health services are integrated into broader health policies rather than offered as separate packages. In general, services like immunizations, maternal care, and family planning are prioritized, but specialized interventions, like respiratory treatments for preterm infants, are less consistently covered due to resource limitations​ [ 9 ]. Pakistan’s experience also emphasizes the role of EPHS in resource allocation and planning, demonstrating how systematic evaluations can reveal gaps in service coverage and help refine policies to meet UHC goals. Evaluations of these packages suggest a need for improved data collection and policy coordination across government and donor organizations to enhance the reach and sustainability of health services [ 33 ]. The Government of Nepal has formulated policies and made institutional arrangements for the provision of BHCS delivery [ 34 ]. However, implementing BHCS is challenging due to the lack of a comprehensive framework for the monitoring of the availability, accessibility, financing, and quality of services [ 35 ]. The BHCS should be revised based on prioritization criteria, evidence, and inclusive participation of stakeholders [ 36 ]. Strengths and Limitations of the Study This study used data from the nationally representative NDHS 2022 and NHFS 2021, which included both population-level and health facility-level data. Validated, standardized, and pre-tested tools were used in accordance with the quality standards [ 37 , 38 ]. NDHS data were collected by trained enumerators. NHFS data were collected by trained nurses, medical officers, and public health professionals; a computer-based data collection system employing various data checks ensured high-quality data. Limitations include the low number of cases observed at lower-level health facilities which limited informative analyses for different types of health facilities. The study variables were carefully selected from the large datasets of public health facilities only. Various composite measures were developed to reduce the large number of variables, allowing for more meaningful analyses and avoiding power limitations. This study used a conceptual framework-led approach informed by the primary health care and UHC concepts. Both surveys were, however, not specifically designed for the research question addressed in this study. As a result, several variables of interest, like services which were included in the availability components were missing in utilization, adherence to standards of all services, service readiness and experience of care were missing from the datasets. The sample sizes used to analyze the four components of the BHCS varied largely, potentially leading to some of the comparisons being skewed. Conclusions This study revealed that the availability of a full set of BHCS was substantially low across all levels, especially at the local-government level. Accessibility, in terms of travel time and distance to a health facility, was satisfactory. Most women had a public health facility nearby, with most being able to reach it within 30 minutes, primarily by walking. The utilization of child health services was relatively low compared to maternal health services. Inadequate readiness, and a consequential low quality of care, was one of the major concerns, even for the services that were available. Lessons learned from the early BHCS implementation highlighted the need for realism and a review of service components. The Government of Nepal first needs to redefine the services to be included in the BHCS for the country as a whole and contextualize them for various geographical regions so that the availability of all or most of the services can be ensured, and each level of government should work on ensuring optimal readiness and quality of care. This would support a gradual and progressive realization of UHC in Nepal across all three levels of governments. Declarations Consent for publication Not applicable. Competing interests The authors declare no competing interests. Conflicts of interest The authors declare that the research was conducted without any commercial or financial relationships that could be construed as potential conflicts of interest. Availability of data and materials Data are provided within the manuscript or supplementary information files. Ethical approval and consent to participate Not applicable. We used publicly accessible, de-identified datasets from the Demographic and Health Survey program (https://dhsprogram.com/data/available-datasets.cfm). The survey received ethical approval from the ICF Institutional Review Board in the USA and the Nepal Health Research Council in Nepal. Given that this research involved only a secondary analysis of completely anonymized data, there was no need for additional ethical clearance. The author (PP) received approval to access and utilize the de-identified data. Acknowledgements The authors would like to thank the DHS program for granting permission to use the data for analysis. We sincerely thank Jana Wilbricht for her valuable support in reviewing the English language. Funding No funding was received for the development of this manuscript. Contributions RKM: Literature review, conceptualization, data analysis, interpretation of the findings, preparation of the first draft of the manuscript. RKM, ST, PP, TRT and KKA: Literature review, validation, and interpretation of the findings. RKM, ARP, PK, SS, KPP, BPS, KAJ, KKA and SRA: interpretation of findings, provision of critical comments, and revision of the manuscript. All authors agreed and approved the final version of the manuscript. 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Ministry of Health and Population, Department of Health Service, Curative Service Division. Basic Health Service Package, 2018 Nepal. 2018. The DHS Program - Quality information to plan, monitor and improve population, health, and nutrition programs. https://dhsprogram.com/. Accessed 24 Aug 2024. Poudel P, Khatri R, Bhatt L, Thapa P, Mishra RK, Tuladhar S, et al. Baseline Status of Basic Health Service Delivery, 2022 Nepal DHS and 2021 Nepal HFS. Norheim OF. Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services. BMC Med. 2016;14:75. Norheim OF, Baltussen R, Johri M, Chisholm D, Nord E, Brock D, et al. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Eff Resour Alloc. 2014;12:18. Jeganathan G, Srinivasan SK, Ramasamy S, Govindharaj P. Accessibility and availability of maternal and reproductive health care services: ensuring health equity among rural women in Southern India. BMC Prim Care. 2024;25:145. Sidze EM, Wekesah FM, Kisia L, Abajobir A. Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings. Matern Child Health J. 2022;26:250–79. Ministry of Health and Population, Nepal. National Health Financing Strategy 2023-2033. Yang D, Nikoloski Z, Khalid G, Mossialos E. Pakistan’s path to universal health coverage: national and regional insights. Int J Equity Health. 2024;23:162. Subha Sri Balakrishnan and Margaret Caffrey, Nepal Country Profile.pdf https://www.unicef.org/rosa/media/18176/file/Nepal%20Country%20Profile.pdf. Thapa R, Bam K, Tiwari P, Sinha TK, Dahal S. Implementing Federalism in the Health System of Nepal: Opportunities and Challenges. Int J Health Policy Manag. 2018;8:195–8. Baltussen R, Mwalim O, Blanchet K, Carballo M, Eregata GT, Hailu A, et al. Decision-making processes for essential packages of health services: experience from six countries. BMJ Glob Health. 2023;8 Suppl 1:e010704. Ministry of Health and Population [Nepal], New ERA, and ICF. Nepal demographic and health survey 2022. Kathmandu, Nepal: Ministry of Health and Population, Nepal DHS 2022 - Report.pdf. Ministry of Health and Population, Nepal; New ERA, Nepal; and ICF. Nepal Health Facility Survey 2021 Final Report. Kathmandu, Nepal: Ministry of Health and Population, Kathmandu; New ERA, Nepal; and ICF, Rockville, Maryland, USA; 2022. Additional Declarations No competing interests reported. Supplementary Files SupplimentaryinformationBHCS.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviews received at journal 04 May, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviews received at journal 20 May, 2025 Reviewers agreed at journal 10 May, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers invited by journal 20 Apr, 2025 Editor invited by journal 27 Mar, 2025 Editor assigned by journal 26 Mar, 2025 Submission checks completed at journal 26 Mar, 2025 First submitted to journal 23 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Mishra","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYJCCAwwMEgwGDAyMDxgMDpCmhdmAaC1gANTCJgHWTgiYt58xPMCYY2FvLn34WTVPwR0Gc/YG/FpkzuQYHGDcJpG4sy/N7DaPwTMGyx4CNkkwpCWAtCQYnGEAaTnMYHAjgYAW/mdgLfYGZ9i/FROnRSL5AEgL44YzPGbMRGp5fOBAItAvQC3FknMMnvEYnCHkF/7E5g8ft9WBHLbxw5s/d+QMjjfg1wIGyC7hIUL9KBgFo2AUjAJCAABOckKqZQt9ugAAAABJRU5ErkJggg==","orcid":"","institution":"Bergen Centre for Ethics and Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","correspondingAuthor":true,"prefix":"","firstName":"Ravi","middleName":"Kanta","lastName":"Mishra","suffix":""},{"id":435755569,"identity":"002b1135-1072-456a-b7be-fd13aa97927f","order_by":1,"name":"Sabita Tuladhar","email":"","orcid":"","institution":"Center for International Health, Ludwig Maximilian University of Munich","correspondingAuthor":false,"prefix":"","firstName":"Sabita","middleName":"","lastName":"Tuladhar","suffix":""},{"id":435755570,"identity":"e94a732c-9a9a-4e58-b880-01fde2624dec","order_by":2,"name":"Pradeep Poudel","email":"","orcid":"","institution":"Learning for Development","correspondingAuthor":false,"prefix":"","firstName":"Pradeep","middleName":"","lastName":"Poudel","suffix":""},{"id":435755571,"identity":"c0015775-8800-4a58-a232-e8b78f72611f","order_by":3,"name":"Pratik Khanal","email":"","orcid":"","institution":"Bergen Centre for Ethics and Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Pratik","middleName":"","lastName":"Khanal","suffix":""},{"id":435755573,"identity":"e4ff6a98-46f9-497e-9c3d-6a747bf52b32","order_by":4,"name":"Achyut Raj Pandey","email":"","orcid":"","institution":"Bergen Centre for Ethics and Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Achyut","middleName":"Raj","lastName":"Pandey","suffix":""},{"id":435755574,"identity":"593d12d8-baf0-47fd-81e8-329e3e5a7e42","order_by":5,"name":"Suman Sapkota","email":"","orcid":"","institution":"Nepal Health Economics Association","correspondingAuthor":false,"prefix":"","firstName":"Suman","middleName":"","lastName":"Sapkota","suffix":""},{"id":435755575,"identity":"d28d0604-efc8-48d4-8b39-1d5c407ea364","order_by":6,"name":"Tulsi Ram Thapa","email":"","orcid":"","institution":"Ministry of Health and Population","correspondingAuthor":false,"prefix":"","firstName":"Tulsi","middleName":"Ram","lastName":"Thapa","suffix":""},{"id":435755576,"identity":"3d15f767-d61f-46a0-ba3f-180148b47837","order_by":7,"name":"Krishna Prasad Paudel","email":"","orcid":"","institution":"Ministry of Health and 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Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Krishna","middleName":"Kumar","lastName":"Aryal","suffix":""},{"id":435755582,"identity":"6bacabc9-d734-4e2d-ae90-ea38ff802c61","order_by":11,"name":"Shiva Raj Adhikari","email":"","orcid":"","institution":"Bergen Centre for Ethics and Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Shiva","middleName":"Raj","lastName":"Adhikari","suffix":""}],"badges":[],"createdAt":"2025-03-23 16:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6289279/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6289279/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79678109,"identity":"046adc60-924f-43b7-b58d-9ca70e1b7931","added_by":"auto","created_at":"2025-04-01 12:25:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36858,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe legal and policy framework governing BHCS and the critical components impacting BHCS delivery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6289279/v1/fdc65e5b79a20bc88a675e70.png"},{"id":79676760,"identity":"f5c357c6-bf0d-4c4e-b0af-eec40b6d4d8c","added_by":"auto","created_at":"2025-04-01 12:17:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":546138,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of the health facilities with the basic health care services component availability, NHFS 2021 (N=1448)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6289279/v1/3fb4c1c7e1eaaf4acc06a0bf.png"},{"id":79678108,"identity":"cd6c6ca2-0928-446f-b1af-61c69297d75c","added_by":"auto","created_at":"2025-04-01 12:25:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of utilization for maternal and child health services\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6289279/v1/50c3f9ace3e5f19a27df1316.png"},{"id":79680278,"identity":"7a923efa-a399-48c3-9807-7e84c83a88e7","added_by":"auto","created_at":"2025-04-01 12:41:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1760954,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6289279/v1/79bea6fe-37f0-4084-9835-3e01e625f055.pdf"},{"id":79676757,"identity":"08dcf52d-f672-4384-9db0-9793f6f6c710","added_by":"auto","created_at":"2025-04-01 12:17:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31795,"visible":true,"origin":"","legend":"","description":"","filename":"SupplimentaryinformationBHCS.docx","url":"https://assets-eu.researchsquare.com/files/rs-6289279/v1/fa198da0c157e2538a5f99a6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilization, Availability, Accessibility and Quality of Basic Health Care Services in Nepal: A Cross-Sectional Demographic and Health Facility Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA well-defined, essential package of health services (EPHS) is key to universal health coverage (UHC) reforms worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Publicly financed basic health care services (BHCS) are the approach adopted by the Government of Nepal to fulfill the constitutional mandate of providing an essential health services to Nepalese citizens and making sure the country is moving towards achieving UHC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCountries like Afghanistan, Ethiopia, Somalia, Sudan, and Zanzibar-Tanzania have implemented EPHS as a policy tool to expand UHC [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. South Asian countries Bangladesh, Pakistan and Sri Lanka developed EPHS tailored to their specific health needs especially maternal and child health service, screening of common non communicable diseases, screening and management of infectious diseases and health promotion related services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Ethiopia's approach emphasizes a broad EPHS scope [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], while Pakistan\u0026rsquo;s implementation is more limited, with only the Punjab province fully defining an EPHS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Each country adapts their EPHS to local needs, such as addressing high-burden diseases, like maternal and child health issues and chronic illnesses [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, in countries like Zambia and Yemen, EPHS are often included in broader health policy frameworks rather than distinct packages [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Countries typically use disease burden and cost-effectiveness criteria, with added factors like acceptability, feasibility, equity, and budget impact to develop EPHS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn EPHS must drive the country\u0026rsquo;s health system [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A successful EPHS relies on health system readiness and quality of care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. If the government enhances the quality and availability of services at public health facilities, more people are likely to choose public health facilities for their healthcare needs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Improving services for non-communicable diseases, mental health, and emergency obstetric care is key to enhancing the availability of essential health services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, focusing on both quality and utilization, EPHS can achieve its goal of UHC and better public health outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe did not find any large-scale study, assessing the availability of BHCS in Nepal. Published studies in Nepal have focused either on the readiness, availability, and utilization of selected services or on assessing the health system in a federalized context [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This paper aims to examine the availability of BHCS, accessibility, quality and utilization of maternal and child health services (components of BHCS) in Nepal. This study will provide evidence on BHCS provision in the federalized context, guiding improvements to align with the constitution and revision of BHCS package.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBasic Health Care Services (BHCS)\u003c/h2\u003e \u003cp\u003eWith the promulgation of its constitution 2015, Nepal moved from a unitary to a federal system with three government tiers: a federal government, seven provincial governments, and 753 local governments [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The BHCS is a minimum set of health services that the Government of Nepal (GoN) commits to providing free of cost to all Nepali citizens [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], irrespective of their demographic, geographic, and socio-economic status [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Nepal\u0026rsquo;s Public Health Service Act 2018 defines BHCS as free and accessible promotional, preventive, diagnostic, curative, and rehabilitative health services and categorizes it into ten components [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic Health Care Services (BHCS) as defined by the Public Health Service Act 2018 of Nepal\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories of Services\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmunization services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegrated management of newborn and childhood illnesses; nutrition services; pregnancy, labor, and delivery services; maternal, newborn, and child health services, such as family planning, abortion, and reproductive health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eServices related to infectious diseases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eServices related to non-communicable diseases and physical disability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eServices related to mental health conditions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eServices related to elderly citizen\u0026rsquo;s health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral emergency services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth promotion services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAyurveda and other accredited alternative health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther services prescribed by the government by a notification in the Nepal Gazette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalytical Framework\u003c/h3\u003e\n\u003cp\u003eConsidering the broader legal and policy framework governing BHCS, this study planned an extensive framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to assess BHCS across six components: service availability, service accessibility, service readiness, adherence to standards, experience of care, and service utilization [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Given that all six components are interdependent and essential for delivering BHCS, this framework treats them separately to ensure that each one is thoroughly addressed. Three of these components-readiness, adherence to standards and experience of care\u0026mdash;were assessed within the quality-of-care domain. For the quality-of-care analysis, this study exclusively focused on normal low-risk delivery services, which is one of the service categories of the BHCS package [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe study analyzed data from the Nepal Demographic and Health Survey (NDHS) 2022 and the Nepal Health Facility Survey (NHFS) 2021, focusing on the services included in the BHCS package. Data on health service use and accessibility were taken from the NDHS 2022, while data on service availability and quality of care, encompassing readiness of a facility to provide services, adherence to standards, and experience of care were taken from the NHFS 2021.\u003c/p\u003e \u003cp\u003e Based on the availability of data in the respective surveys, the study used 41 discrete services, covering eight of the ten broad categories of services within the BHCS package from the NHFS 2021 for assessing accessibility, two variables from the NDHS 2022 for assessing service accessibility, five variables related to the normal low-risk delivery service from the NHFS 2021 for assessing health facility\u0026rsquo;s readiness to provide the services, 13 variables from the labor and delivery observation module of the NHFS 2021 for assessing adherence to standards of care, seven variables from the labor and delivery post-partum exit interview module of the NHFS 2021 for assessing experience of care, and nine variables were used from the NDHS 2022 for assessing service utilization. This is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and all the variables of different components are listed in supplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComponents, categories, number of variables, and sources used in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComponents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategories of services\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnit of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSources\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eService availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;8\u003c/p\u003e \u003cp\u003e(All categories except Ayurveda services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePublic health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNHFS, 2021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eService accessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(Maternal health services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u0026ndash;49 years women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNDHS, 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQuality of services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService readiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(Normal low-risk delivery services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePublic health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNHFS, 2021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdherence to standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(Normal low-risk delivery services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u0026ndash;49 years women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNHFS, 2021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperience of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(Normal low-risk delivery services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u0026ndash;49 years women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNHFS, 2021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eService utilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 and 2\u003c/p\u003e \u003cp\u003e(Child health and maternal health services)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u0026ndash;49 years women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNDHS, 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eCharacteristics of Participants\u003c/h3\u003e\n\u003cp\u003eThe NHFS 2021 included 1,576 health facilities, of which 1,448 were public and 128 were private facilities. Since BHCS is provided only through public health facilities, the unit of analysis for assessing availability of BHCS in this study was solely the 1,448 public health facilities included in the NHFS 2021. These facilities include all public health facilities (hospitals) managed by federal and provincial governments (excluding standalone specialized hospitals), hospitals, and primary health care centers managed by local governments. Other public facilities managed by local governments, such as health posts (HPs), community health units (CHUs), and urban health units (UHCs), were sampled in the survey. All the 1,448 public health facilities were considered when assessing BHCS availability.\u003c/p\u003e \u003cp\u003eSimilarly, nine indicators from the NDHS 2022 were chosen for analyzing the utilization of nutrition, treatment of sick children, child vaccination, women\u0026rsquo;s vaccination, antenatal care, and delivery services from the BHCS package. For the assessment of the accessibility of public health facilities, 14,845 women aged 15\u0026ndash;49 years from 13,786 sampled households represented the unit of analysis. Of these women, 8,049 reported that the nearest health facility to their residence, based on walking distance and mode of transportation, was a public facility.\u003c/p\u003e \u003cp\u003eWomen, whose labor and delivery were observed and who were then interviewed as they were discharged from the health facility, represented the unit of analysis for assessing quality of care using data from NHFS 2021. The study considered all 804 public facilities providing normal low-risk delivery services for assessing the readiness of health facilities to provide normal low-risk delivery services. A total of 457 normal low-risk delivery cases were observed to assess adherence to standards of care (practice of care) using 13 indicators from the labor and delivery observation module of the NHFS 2021. Likewise, out of the 457 women observed for normal low-risk delivery services, exit interviews were conducted with 320 women form 94 health facilities to assess the experience of care using seven indicators from the labor and delivery post-partum exit interview module of the NHFS 2021. The remaining 137 women could not be interviewed for various reasons, e.g., they suffered complications, were referred to another health facility, refused to be interviewed, or remained in the same health facility for a prolonged period.\u003c/p\u003e\n\u003ch3\u003eProcesses\u003c/h3\u003e\n\u003cp\u003eThe study analyzed NDHS 2022 and NHFS 2021 data available in the public domain [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Both surveys are nationally representative, were conducted under the global Demographic and Health Surveys (DHS) program and received approval from the Nepal Health Research Council. For the NHFS, written consent was obtained from service providers, while verbal consent was secured from all subjects who were observed or interviewed. The NDHS 2022 obtained written consent from all interview respondents.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe study used binary variables to assess all six components: service availability, accessibility, service readiness, adherence to standards (process of care), experience of care, and utilization of services. Frequencies and percentages of distributions, as well as average scores, were calculated. The quality of care index was stated on a scale from 0 to 100, indicating the level of healthcare service quality. It was computed and presented as a domain and their respective index or sub-index values giving equal weight to the three domains of normal low-risk delivery services, viz. experience of care, Adherence to standards, and service readiness of health facilities. Further information regarding the different components among sub-domains is included in Supplementary Information Tables S2, S3 and S4. The analysis of BHCS service utilization was conducted using five child health and four maternal health service-related variables from the NHDS 2022. Stata 18 and SPSS (IBM SPSS Statistics 25) software were used for the analysis. Relevant results were disaggregated by the level of health facilities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAvailability of Basic Health Care Services (BHCS) by Authority of Health Facilities\u003c/h2\u003e \u003cp\u003eThe weighted analysis of public health facilities included in the NHFS 2021 showed that an overwhelming majority (98.2%) were local-level health facilities. Only 1.4% were provincial-level facilities, and 0.4% were federal-level facilities. It revealed that 0.5% of public health facilities in Nepal had all types of BHCS available at the time of assessment. Among health facilities, only 0.2% of local-level facilities provided all services, compared to 17.2% of provincial-level facilities and 14.5% of federal-level facilities (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWeighted distribution of health facilities by the three tiers of government\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthority Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facilities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeighted percentage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeighted number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAvailability (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvince\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal/Municipality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospitals\u003c/p\u003e \u003cp\u003ePrimary health care centers\u003c/p\u003e \u003cp\u003eHealth posts\u003c/p\u003e \u003cp\u003eUrban health center\u003c/p\u003e \u003cp\u003eCommunity health unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHealth Facilities (HFs) by Distribution of Basic Health Care Services (BHCS)\u003c/h3\u003e\n\u003cp\u003eAmong all types of BHCS captured in the NHFS 2021, sixteen out of 41 services were available in more than 90% of public health facilities, ranging from the management of childhood illnesses to basic cardiovascular disease services. Nine types of BHCSs were available in 80\u0026ndash;90% of the facilities. Some services, such as mental health services (22%), treatment of obstetric fistula (17%), abortion care (16%), treatment of Kala-azar (8%), and cervical cancer screening (8%), were available in less than one-fourth of the facilities (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAccessibility of Basic Health Care Services\u003c/h2\u003e \u003cp\u003eOverall, more than half (54%) of the women surveyed in the NDHS 2022 (8,049 out of 14,845 women) reported that the health facility nearest to their residence was a public facility. Of these women, approximately two-thirds (65.1%) confirmed that they could reach the nearest public health facility within a 30-minute travel time from their residence. For the large majority (82.3%) of pregnant women, walking was the primary mode of transportation to reach the nearest public health facility.\u003c/p\u003e \u003cp\u003eWhen disaggregated at the provincial level, women residing in the Karnali (56.1%) and Sudurpashchim (54.1%) provinces faced the greatest difficulty in reaching the nearest public health facility within a 30-minute walking distance. Only about 3% of women in Karnali Province had access to a motorable road to the nearest public health facility, with an overwhelming majority (96.9%) relying on walking (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccessibility of BHCS, 2022 NDHS (N\u0026thinsp;=\u0026thinsp;8049)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBHCS Accessibility component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKoshi\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMadhesh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBagmati\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGandaki\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLumbini\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKarnali\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSudur Paschim\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic HF as a nearest HF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e \u003cp\u003e54.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNearest health facility by walking distance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e62.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;59 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;119 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNearest health facility by mode of transportation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotorized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-motorized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e83.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e84.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eQuality of Care for Normal Low-risk Delivery Services\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e provides information about different aspects of healthcare quality. The overall quality for normal and low risk delivery service (components of BHCS) stood at 69.3 out of 100, with the experience of care scoring 86.4, the Adherence to standards scoring 77.8 (including general examination at 61.8, abdominal examination at 76.3, and vaginal examination at 95.3), and service readiness scoring 43.6 at national level.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality of care for normal low-risk delivery services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDomains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndex/sub-index value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExperience of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAdherence to standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbdominal examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVaginal examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eService readiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eQuality of care index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eUtilization of Basic Health Care Services (BHCS)\u003c/h2\u003e \u003cp\u003eThe utilization of child health services was relatively low compared to maternal health services. Six percent of under five children received growth monitoring. Care-seeking was also low for common illnesses, with 19.6% for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections (ARI). Four antenatal care (ANC) visits were utilized by 80.5% of pregnant women. Deworming medication was the most used service, with 84.1% of pregnant women receiving it. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBasic Health Care Services (BHCS) Package: Realistic vs. Idealistic\u003c/h2\u003e \u003cp\u003eOut of the 41 services assessed in 1448, public health facilities included in this study, less than 1% offered all services. Some services, such as cervical cancer screening and breast cancer screening, were recently introduced, with only 8% of the health facilities ready to provide these services. In the current study, 89.8% of public health facilities provided screening for cardiovascular diseases, 80.9% offered tuberculosis services, 51.3% provided delivery and neonatal care services, and 21.7% offered mental health services. These findings are similar to the previous review study in which a significant proportion of facilities provide essential services, with 61.7% offering Non-Communicable Disease (NCD) services, 53.0% providing mental health services, and 59.7% delivering Basic Emergency Obstetric Care, demonstrating progress in improving service availability [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Achieving UHC requires the availability of all services included in BHCS to the population without causing financial hardship [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although it was the government\u0026rsquo;s commitment to its people to include human papilloma virus (HPV) vaccines and cancer screening in the BHCS, it was an ambitious goal rather than a realistic step. Most importantly, the government needs to ensure continued financing for the BHCS to provide the included services free of charge while ensuring compliance with the national standards of care [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This suggests that the BHCS package needs to be dynamic, starting with the basic services a country should include in its BHCS, and it should be informed by evidence on cost-effectiveness, priority to the worse-off, and financial risk protection [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, more than half (54%) of women in the NDHS 2022 reported that a public health facility was the closest to their home, with 65.1% reaching it within 30 minutes, mostly by walking (82.3%). This suggests that while public health facilities are geographically accessible for most women, reliance on walking as the primary mode of transport may indicate potential barriers related to transportation availability, distance, or emergency access. The vision of the BHCS is the provision of a package of health care services that can be delivered through the smallest unit of a public health facility, even in the most remote area of the country [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe overall quality for normal low risk delivery was 69.3 out of 100, with high scores for experience of care (86.4%) and adherence to standards (77.8%), but lower scores for specific examinations like general examination and abdominal examination of pregnant women. Service readiness was notably low at 43.6% for normal low risk delivery. This suggests that while patients generally have positive experience with care and adherence to standards is relatively good, significant improvements are needed in service readiness, which could be due to inadequate resources, training, or facility preparedness. One of the study, conducted on married women aged 18\u0026ndash;45 years with at least one child living in Tiruchirappalli District, Tamil Nadu, India found that almost all respondents (98%) were satisfied with health services, and 92% benefited from the government\u0026rsquo;s childbirth-related scheme [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe utilization of child health services was much lower than maternal health services, with only 6% of children under five receiving growth monitoring service. Care-seeking for common illnesses was also low, with only 19.6% of under five children seeking care for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections (ARI). In contrast, 80.5% of pregnant women received four antenatal care visits, and deworming medication was the most widely used service, with 84.1% of pregnant women receiving it. Several international studies have highlighted disparities in the utilization of maternal and child health services, particularly in low- and middle-income countries (LMICs). While maternal health services, such as antenatal care and institutional deliveries, have seen notable improvements, child health services, including growth monitoring and treatment for childhood illnesses, often experience lower utilization rates [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. To improve child health service utilization, it's essential to improve access and integrate child health services with existing maternal care programs.\u003c/p\u003e \u003cp\u003eAll health services listed in the BHCS package are meant to be provided free of charge to citizens at the point of care [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, Nepal\u0026rsquo;s BHCS package was ambitiously developed and included services that were not available within the existing service delivery mechanism. Through the BHCS, the government made commendable efforts to translate the constitutional mandate into action; however, these promises have not effectively translated into reality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and Research Implications\u003c/h2\u003e \u003cp\u003eThe BHCS package needs to be realistic\u0026mdash;not idealistic. Based on the lessons learned from the initial years of implementation, the service components of the BHCS need to be revisited. The service components that are in the very early stage of development, where the procedures and protocols for service provision are not defined, need to be reviewed in light of the limited resources available [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], the capacity to provide and manage quality health services as per the standards, and the provision of the legal framework of fines and compensation. As the citizens\u0026rsquo; awareness and literacy of BHCS increases, people will demand quality BHCS, and not receiving the services, or services not meeting the standards, means a breach of the legal provision that might result in citizens taking legal action [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A successful BHCS requires commitment, sustainable financing, system readiness, and institutionalization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLocal governments play a significant role in the delivery of the BHCS [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Improved collaboration with federal and provincial authorities to deliver free BHCS at federal- and provincial-level health facilities is important in urban areas [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A strong BHCS monitoring mechanism, mass awareness campaigns, and community mobilization will be key for the effective implementation of the BHCS. In Ethiopia, a recent revision of the EHCP integrated monitoring and evaluation frameworks to more effectively align services with health priorities. This process has encouraged the adoption of the Disease Control Priorities (DCP-3) initiative, which provides structured guidance for selecting and ranking interventions based on cost-effectiveness. Such frameworks are vital for the systematic expansion of the scope of essential services, particularly in resource-constrained settings where healthcare access and quality can vary significantly by region [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Zambia and Yemen, essential health services are integrated into broader health policies rather than offered as separate packages. In general, services like immunizations, maternal care, and family planning are prioritized, but specialized interventions, like respiratory treatments for preterm infants, are less consistently covered due to resource limitations​ [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePakistan\u0026rsquo;s experience also emphasizes the role of EPHS in resource allocation and planning, demonstrating how systematic evaluations can reveal gaps in service coverage and help refine policies to meet UHC goals. Evaluations of these packages suggest a need for improved data collection and policy coordination across government and donor organizations to enhance the reach and sustainability of health services [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The Government of Nepal has formulated policies and made institutional arrangements for the provision of BHCS delivery [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, implementing BHCS is challenging due to the lack of a comprehensive framework for the monitoring of the availability, accessibility, financing, and quality of services [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The BHCS should be revised based on prioritization criteria, evidence, and inclusive participation of stakeholders [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eThis study used data from the nationally representative NDHS 2022 and NHFS 2021, which included both population-level and health facility-level data. Validated, standardized, and pre-tested tools were used in accordance with the quality standards [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. NDHS data were collected by trained enumerators. NHFS data were collected by trained nurses, medical officers, and public health professionals; a computer-based data collection system employing various data checks ensured high-quality data. Limitations include the low number of cases observed at lower-level health facilities which limited informative analyses for different types of health facilities. The study variables were carefully selected from the large datasets of public health facilities only. Various composite measures were developed to reduce the large number of variables, allowing for more meaningful analyses and avoiding power limitations.\u003c/p\u003e \u003cp\u003eThis study used a conceptual framework-led approach informed by the primary health care and UHC concepts. Both surveys were, however, not specifically designed for the research question addressed in this study. As a result, several variables of interest, like services which were included in the availability components were missing in utilization, adherence to standards of all services, service readiness and experience of care were missing from the datasets. The sample sizes used to analyze the four components of the BHCS varied largely, potentially leading to some of the comparisons being skewed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study revealed that the availability of a full set of BHCS was substantially low across all levels, especially at the local-government level. Accessibility, in terms of travel time and distance to a health facility, was satisfactory. Most women had a public health facility nearby, with most being able to reach it within 30 minutes, primarily by walking. The utilization of child health services was relatively low compared to maternal health services. Inadequate readiness, and a consequential low quality of care, was one of the major concerns, even for the services that were available. Lessons learned from the early BHCS implementation highlighted the need for realism and a review of service components. The Government of Nepal first needs to redefine the services to be included in the BHCS for the country as a whole and contextualize them for various geographical regions so that the availability of all or most of the services can be ensured, and each level of government should work on ensuring optimal readiness and quality of care. This would support a gradual and progressive realization of UHC in Nepal across all three levels of governments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted without any commercial or financial relationships that could be construed as potential conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are provided within the manuscript or supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. We used publicly accessible, de-identified datasets from the Demographic and Health Survey program (https://dhsprogram.com/data/available-datasets.cfm). The survey received ethical approval from the ICF Institutional Review Board in the USA and the Nepal Health Research Council in Nepal. Given that this research involved only a secondary analysis of completely anonymized data, there was no need for additional ethical clearance. The author (PP) received approval to access and utilize the de-identified data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the DHS program for granting permission to use the data for analysis. We sincerely thank Jana Wilbricht for her valuable support in reviewing the English language.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for the development of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRKM: Literature review, conceptualization, data analysis, interpretation of the findings, preparation of the first draft of the manuscript. RKM, ST, PP, TRT and KKA: Literature review, validation, and interpretation of the findings. RKM, ARP, PK, SS, KPP, BPS, KAJ, KKA and SRA: interpretation of findings, provision of critical comments, and revision of the manuscript. All authors agreed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePublic Spending on Health: A Closer Look at Global Trends. 1st ed. Geneva: World Health Organization; 2021.\u003c/li\u003e\n\u003cli\u003eCotlear D, Nagpal S, Smith O, Tandon A, Cortez R. Going Universal: How 24 Developing Countries are Implementing Universal Health Coverage from the Bottom Up. World Bank Publications; 2015.\u003c/li\u003e\n\u003cli\u003eGovernment of Nepal, Constitution of Nepal. 2nd ed.; 2015 [cited 2024 Dec 30]. Available from:https://lawcommission.gov.np/en/wp-content/uploads/2021/01/Constitution-of-Nepal.pdf.\u003c/li\u003e\n\u003cli\u003eAlwan A, Yamey G, Soucat A. Essential packages of health services in low-income and lower-middle-income countries: what have we learnt? BMJ Glob Health. 2023;8 Suppl 1:e010724.\u003c/li\u003e\n\u003cli\u003ePrinja S, Purohit N, Kaur N, Rajapaksa L, Sarker M, Zaidi R, et al. The state of primary health care in south Asia. Lancet Glob Health. 2024;12:e1693\u0026ndash;705.\u003c/li\u003e\n\u003cli\u003eEregata GT, Hailu A, Geletu ZA, Memirie ST, Johansson KA, Stenberg K, et al. Revision of the Ethiopian Essential Health Service Package: An Explication of the Process and Methods Used. Health Syst Reform. 2020;6:e1829313.\u003c/li\u003e\n\u003cli\u003eAlwan A, Jamison DT, Siddiqi S, Vassall A. Pakistan\u0026rsquo;s Progress on Universal Health Coverage: Lessons Learned in Priority Setting and Challenges Ahead in Reinforcing Primary Healthcare. Int J Health Policy Manag. 2024;13:8450.\u003c/li\u003e\n\u003cli\u003eDanforth K, Ahmad AM, Blanchet K, Khalid M, Means AR, Memirie ST, et al. Monitoring and evaluating the implementation of essential packages of health services. BMJ Glob Health. 2023;8 Suppl 1:e010726.\u003c/li\u003e\n\u003cli\u003eWright, J., Health Finance \u0026amp; Governance Project. February 2016 https://content.sph.harvard.edu/wwwhsph/sites/2413/2017/05/1-Essential-Packages-of-Health-Services-May-23-2016.pdf.\u003c/li\u003e\n\u003cli\u003eGlassman A, Giedion U, Sakuma Y, Smith PC. Defining a Health Benefits Package: What Are the Necessary Processes? Health Syst Reform. 2016;2:39\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eSoucat A, Tandon A, Pier EG. From Universal Health Coverage services packages to budget appropriation: the long journey to implementation. BMJ Glob Health. 2023;8 Suppl 1.\u003c/li\u003e\n\u003cli\u003eAlwan A, Majdzadeh R, Yamey G, Blanchet K, Hailu A, Jama M, et al. Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries. BMJ Glob Health. 2023;8 Suppl 1.\u003c/li\u003e\n\u003cli\u003eMustafa A, Shekhar C. Is quality and availability of facilities at Primary Health Centers (PHCs) associated with healthcare-seeking from PHCs in rural India: An exploratory cross-sectional analysis. Clin Epidemiol Glob Health. 2021;9:293\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eNjuguna C, Tola HH, Maina BN, Magambo KN, Phoebe N, Tibananuka E, et al. Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda. BMC Health Serv Res. 2023;23:1387.\u003c/li\u003e\n\u003cli\u003eKruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6:e1196\u0026ndash;252.\u003c/li\u003e\n\u003cli\u003eSapkota, S., Panday, S., Wasti, S.P. et al. 2022. Health system strengthening: the role of public health in Federal Nepal. Journal of the Nepal Public Health Association, 7 (1). pp. 36-42. ISSN 2392-408X. https://www.researchgate.net/publication/364656438_Health_System_Strengthening\u003cbr\u003e_The_Role_of_Public_Health_in_Federal_Nepal. Accessed 9 Feb 2025.\u003c/li\u003e\n\u003cli\u003eWasti SP, van Teijlingen E, Rushton S, Subedi M, Simkhada P, Balen J. Overcoming the challenges facing Nepal\u0026rsquo;s health system during federalisation: an analysis of health system building blocks. Health Res Policy Syst. 2023;21:117.\u003c/li\u003e\n\u003cli\u003eTuladhar S, Paudel D, Rehfuess E, Siebeck M, Oberhauser C, Delius M. Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021. BMC Pregnancy Childbirth. 2024;24:79.\u003c/li\u003e\n\u003cli\u003eGovernment of Nepal, Ministry of Health and Population. 2019. SITUATION ANALYSIS OF HEALTH FINANCING IN NEPAL. MOHP, World Bank, WHO, GIZ, Kathmandu, Nepal.\u003c/li\u003e\n\u003cli\u003eAdhikari B, Mishra SR, Schwarz R. Transforming Nepal\u0026rsquo;s primary health care delivery system in global health era: addressing historical and current implementation challenges. Glob Health. 2022;18:8.\u003c/li\u003e\n\u003cli\u003eGovernment of Nepal. Public Health Service Regulations 2077. http://rajpatra.dop.gov.np/welcome/book/?ref=24233. Accessed 4 Feb 2024.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Population, Nepal. National Health Sector Strategic Plan 2023-2030. 2023.\u003c/li\u003e\n\u003cli\u003eGovernment of Nepal, The Public Health Service Act, 2075 (2018) [Internet] [cited 2024 Dec 30]. Available from: https://fwd.gov.np/cms/the-public-health-service-act-2075-2018/.\u003c/li\u003e\n\u003cli\u003ePrimary Health Care Performance Initiative. Conceptual Framework | PHCPI. https://www.improvingphc.org/phcpi-conceptual-framework. Accessed 9 Feb 2025.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Population, Department of Health Service, Curative Service Division. Basic Health Service Package, 2018 Nepal. 2018.\u003c/li\u003e\n\u003cli\u003eThe DHS Program - Quality information to plan, monitor and improve population, health, and nutrition programs. https://dhsprogram.com/. Accessed 24 Aug 2024.\u003c/li\u003e\n\u003cli\u003ePoudel P, Khatri R, Bhatt L, Thapa P, Mishra RK, Tuladhar S, et al. Baseline Status of Basic Health Service Delivery, 2022 Nepal DHS and 2021 Nepal HFS.\u003c/li\u003e\n\u003cli\u003eNorheim OF. Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services. BMC Med. 2016;14:75.\u003c/li\u003e\n\u003cli\u003eNorheim OF, Baltussen R, Johri M, Chisholm D, Nord E, Brock D, et al. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Eff Resour Alloc. 2014;12:18.\u003c/li\u003e\n\u003cli\u003eJeganathan G, Srinivasan SK, Ramasamy S, Govindharaj P. Accessibility and availability of maternal and reproductive health care services: ensuring health equity among rural women in Southern India. BMC Prim Care. 2024;25:145.\u003c/li\u003e\n\u003cli\u003eSidze EM, Wekesah FM, Kisia L, Abajobir A. Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings. Matern Child Health J. 2022;26:250\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Population, Nepal. National Health Financing Strategy 2023-2033.\u003c/li\u003e\n\u003cli\u003eYang D, Nikoloski Z, Khalid G, Mossialos E. Pakistan\u0026rsquo;s path to universal health coverage: national and regional insights. Int J Equity Health. 2024;23:162.\u003c/li\u003e\n\u003cli\u003eSubha Sri Balakrishnan and Margaret Caffrey, Nepal Country Profile.pdf https://www.unicef.org/rosa/media/18176/file/Nepal%20Country%20Profile.pdf.\u003c/li\u003e\n\u003cli\u003eThapa R, Bam K, Tiwari P, Sinha TK, Dahal S. Implementing Federalism in the Health System of Nepal: Opportunities and Challenges. Int J Health Policy Manag. 2018;8:195\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eBaltussen R, Mwalim O, Blanchet K, Carballo M, Eregata GT, Hailu A, et al. Decision-making processes for essential packages of health services: experience from six countries. BMJ Glob Health. 2023;8 Suppl 1:e010704.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Population [Nepal], New ERA, and ICF. Nepal demographic and health survey 2022. Kathmandu, Nepal: Ministry of Health and Population, Nepal DHS 2022 - Report.pdf.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Population, Nepal; New ERA, Nepal; and ICF. Nepal Health Facility Survey 2021 Final Report. Kathmandu, Nepal: Ministry of Health and Population, Kathmandu; New ERA, Nepal; and ICF, Rockville, Maryland, USA; 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Accessibility, Availability, Basic Health Care Services, Constitution, Nepal, Quality of care, Utilization","lastPublishedDoi":"10.21203/rs.3.rs-6289279/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6289279/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Government of Nepal is committed to the progressive realization of universal health coverage through the provision of basic health care services (BHCS). This study aims to evaluate the availability, accessibility, quality and utilization of BHCS in the public health facilities of Nepal, using data from two nationally representative surveys.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analyzed data from the Nepal Demographic and Health Survey (NDHS) 2022 and the Nepal Health Facility Survey (NHFS) 2021, focusing on the services included in Nepal\u0026rsquo;s BHCS package. A descriptive analysis of BHCS availability, accessibility, service quality, and utilization using data from 1,448 public health facilities, 457 observations, and 320 client interviews from the NHFS 2021, along with data from 14,845 women (15\u0026ndash;49 years) from the NDHS 2022. It assessed 41 NHFS 2021 services across eight of ten BHCS categories for availability, two NDHS 2022 indicators for accessibility, five NHFS 2021 indicators for facility readiness, 13 for adherence to care standards, seven for experience of care, and nine NDHS 2022 indicators for service utilization. The quality of care index was calculated with equal weight assigned to three domains: experience of care, Adherence to standards, and service readiness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of the 41 services in the BHCS package, 16 were available at more than 90% of the public health facilities included in the study, although less than 1% of facilities offered all 41 services. Over half (54%) of women reported that the nearest health facility to their residence was a public facility. Utilization of child health services was relatively low, with only 6% of children under five receiving growth monitoring and care-seeking for common illnesses also being low\u0026mdash;19.6% for fever, 25.4% for diarrhea, and 25.5% for acute respiratory infections. In contrast, maternal services such as antenatal care (80.5%) and deworming (84.1%) were more widely utilized by pregnant women. The overall quality of care for normal, low-risk deliveries at the national level was rated 69.3 out of 100.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite a constitutional mandate to provide BHCS, this study found low availability of BHCS in public health facilities in Nepal. Although accessibility was not a significant problem, we found low utilization of services (especially regarding child health) and moderate quality of care. Early BHCS implementation demonstrates the need for realism and service review.\u003c/p\u003e","manuscriptTitle":"Utilization, Availability, Accessibility and Quality of Basic Health Care Services in Nepal: A Cross-Sectional Demographic and Health Facility Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 12:17:01","doi":"10.21203/rs.3.rs-6289279/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T17:53:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T03:21:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106265235887946052351751510075321011096","date":"2026-04-27T15:11:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124540182691279390394082009170977031063","date":"2026-04-26T12:34:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161823159954343540783856626187454048570","date":"2026-04-26T11:47:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15448232947839406327171402888861825879","date":"2026-04-24T12:04:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-20T20:18:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312540656003567639892050784717939776484","date":"2025-05-10T11:30:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133774507955100009553995315759068867089","date":"2025-04-20T04:41:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-20T04:37:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-27T15:58:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T07:54:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T07:52:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-03-23T15:56:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f7030696-2a18-4329-a6f3-9b905e0f7304","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T17:53:29+00:00","index":87,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T03:21:11+00:00","index":86,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-20T04:53:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 12:17:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6289279","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6289279","identity":"rs-6289279","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}