Why do some district hospitals in Nepal achieve better provision of comprehensive emergency obstetric and neonatal care services than others?

Since 2004, the Government of Nepal has sought to increase availability of comprehensive emergency obstetric and neonatal care (CEONC) services at district hospitals. However, significant and persistent bottlenecks exist in the health system which prevent effective scale-up. A “quick fix” strategy to address bottlenecks and ensure that hospitals had resources to deliver CEONC 24/7 was the creation of a “CEONC Fund” to “top-up” routine hospital budgets. The intention was the CEONC fund should only be used for CEONC services, not for any other hospital purpose. In 2015, the government decided to include the fund as a long-term policy and expand its availability to all district hospitals. However, routine data on fund utilisation and service data is limited. What is available indicates that utilisation varies substantially by hospital and actual provision of CEONC services also varies widely. This study aimed to understand why some district hospitals achieve a better provision of CEONC services than others. It employed a multiple case study design, purposefully selecting four district hospitals using an extreme case selection framework. It triangulated data from the districts with semi-structured interviews from central level key informants. The study results show provision of the fund to hospitals has limited impact on CEONC availability. Several other factors in hospitals and the health system have greater influence on uptake of funding and service availability. The conclusion is, not only is a CEONC fund grant alone insufficient to ensure service availability, several other critical factors need to be taken into consideration to ensure that CEONC services are consistently and universally available. CEONC availability is heavily influenced by the quality of leadership and management of the hospitals and their capacity to maintain or develop the service as financial resources permit. Therefore, the fund’s utility as a sole mechanism to improve CEONC services is limited.