This case study describes the health response provided by the Ministry of Health of Nepal with support from UN agencies and several other organisations, to the 1.4 million women and adolescent girls affected by the major earthquake that struck Nepal in April 2015. After a post-disaster needs assessment, the response was provided to cater for the identified sexual and reproductive health (RH) needs, following the guidance of the Minimum Initial Service Package for RH developed by the global Inter-Agency Working Group. We describe the initiatives implemented to resume RH services: the distribution of medical camp kits, the deployment of nurses with birth attendance skills, the organisation of outreach RH camps, the provision of emergency RH kits and midwifery kits to health facilities and the psychosocial counselling support provided to maternity health workers. We also describe how shelter and transition homes were established for pregnant and post-partum mothers and their newborns, the distribution of dignity kits, of motivational kits for affected women and girls and female community health volunteers. We report on the establishment of female-friendly spaces near health facilities to offer a multisectoral response to gender-based violence, the setting up of adolescent-friendly service corners in outreach RH camps, the development of a menstrual health and hygiene management programme and the linkages established between adolescent-friendly information corners of schools and adolescent-friendly service centres in health facilities. Finally, we outline the gaps, challenges and lessons learned and suggest recommendations for preparedness and response interventions for future disasters.

Background: We describe an on-site clinical mentoring program aimed at improving emergency obstetrical and newborn care (EmONC) in Nepal and assess its effectiveness on nurses' knowledge and skills. In Nepal, both the maternal mortality ratio (MMR, 239/100,000 live births) and the neonatal mortality rate (NMR, 21/1000 live births) were among the highest in the world in 2016, despite impressive progress over recent decades considering the challenging environment. Methods: From September 2016 to April 2018, three experienced nurses conducted repeated mentoring visits in 61 comprehensive or basic EmONC centers and birthing centers located in 4 provinces of Nepal. Using updated national training manuals and teaching aids, these clinical mentors assessed and taught 12 core EmONC clinical skills to their nurse-mentees. Clinical mentors worked with management mentors whose goal was to improve the nurses' working environment. We assessed whether the cohort of nurse-mentees performed better as a group and individually performed better at the end of the program than at baseline using relevant tests (chi-square test, Wilcoxon matched-pairs signed-rank test, and Kruskal-Wallis equality-of-population rank test). Results: In total, 308 nurses were assessed, including 96 (31.2%), 77 (25.0%) and 135 (43.8%) who participated in all three, two or only one mentoring session, respectively. In total, 225 (73.0%) worked as auxiliary nurse-midwives (ANMs), while 69 (22.4%) worked as nurses. One hundred and ninety five (63.3%) were trained as skilled birth attendants, of which 45 (23.1%) were nurses, 141 (72.3%) were auxiliaries and 9 (4.6%) had other positions. The proportion of ANMs and nurse-mentees who obtained a knowledge assessment score ≥ 85% increased from 57.8 to 86.1% (p < 0.001). Clinical assessment scores increased significantly for each participant, and therefore for the group. SBA-trained mentees had better knowledge of maternal and newborn care and were better able to perform the 12 core clinical skills throughout the program. Conclusions: Our study suggests that on-site clinical mentoring of nurses coupled with health facility management mentoring can improve nurses' clinical competences in and performance of maternity and newborn care. Assessing evidence of impact on patient safety would be the next stage in evaluating this promising intervention.

Health Care systems are facing several challenges. The lack of resources, such as health workers, costing and financing are open and urgent questions in Health Care Systems. Tools from HRManagement (e.g. the Workload Indicator of Staffing Need (WISN) – method, WHO - HR-Management Tool) and Cost-Accounting can help to improve current financing and further develop healthcare reimbursement systems, such as DRG-Systems. Based on empirical data and interviews with healthcare professionals from multiple healthcare institutions in Kyrgyzstan the WISN method was applied to calculate human resource needs in a new perinatal health centre in Bishkek, Kyrgyzstan. The results of the analysis show that it is possible to calculate the required personal resources using the WISN method. Additionally, WISN can be used to calculate personnel costs. The results also show that in combination with material costs, e.g. from a DRG – Cost – Matrix, such as the G-DRG-Report Browser, it is possible to calculate the total costs of healthcare services and to use this as the basis for the reimbursement system. WISN in combination with additional Cost-Accounting systems is a good way to calculate the total costs for an intervention in a healthcare institution, e.g. a hospital. These tools can help to make financing in healthcare more transparent and efficient.

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