Author: Fielden, R.; BASICS
After a period of expanding the number of facilities at the periphery and recruiting female volunteers to work in their communities, the emphasis is now on ensuring that resources allocated to the health sector are used to address Nepal’s health priorities more effectively. The process of operationalizing the Second Long Term Health Plan is still in progress, and includes a concerted effort to prioritise interventions in the health sector within a framework that is agreed between the major stake-holders.
Purpose / Objective
It is anticipated that His Majesty's Government (HMG) of Nepal will apply to the Global Alliance for Vaccines and Immunization (GAVI). GAVI requests countries to provide background information on the status of their health systems. The Ministry of Health (MoH), WHO, UNICEF and USAID were involved in recruiting an Advance Team of two national and two international consultants to help prepare for an assessment of immunization services, and to carry out a broad assessment of the health system within which immunization is carried out. This assessment has at least three objectives:
- to provide the requested information on the development of Nepal's health system, in preparation for HMG's anticipated application to GAVI
- to contribute to the Advantage Team's development of a feasible approach to the overall assessment of immunization
- to pretest Part II and provide feedback to WHO/HQ
- Desk review (analysis of existing data)
- Collection of primary data (desk review, interview, observation, group discussion)
- Collection of secondary data with different line agencies, donors, NGOs/INGOs.
- Field visit (the latest assessment methodology from WHO [B23] was used)
- Data analysis and reporting (focussing on sustainability, effectiveness and efficiency)
Key Findings and Conclusions
Public sector spending on health in Nepal, including external sources, is less than US$3 per capita per year. Yet, during the past decade, there have been problems with underspending of allocated budget, reallocation of funds and off-budget expenditure. In the MoH, connections between allocation of budget and control of expenditure appear to have been weak, and donor partners have funded some of their activities outside the budget framework. In an effort to improve the health gain that might be achieved from allocated resources, a sector-wide framework has been developed for planning, choosing priorities, and committing funds in accordance with agreed priorities. In order to support this effort, any proposed support to the health sector should be programmed through the planning and financial framework. This process should include an assessment of the medium- to long-term financial and programmatic implications of the proposal.
Human resources management has been characterized by very frequent changes in staff, at all levels. The MoH has taken measures to address this. Its own excellent human resources database (HuRDIS) can be used to monitor the expected reduction in the frequency of transfers for key categories of staff. The proposed approach is outlined in Section 5.3.2.
Rearrangement of organizational structures, integration of functions, dismantling of vertical programs, and the cutbacks in development budgets and staff that accompanied these changes have placed the remaining staff under unenviable pressures. Not only must they co-ordinate with many separate units at central level, which takes more time; the accumulation of technical experience has also been hindered and dissipated by frequent transfers into and out of key posts. There is evidence that the technical and operational requirements of immunization are not always recognized within the more generalized, integrated systems, and that for immunization, the allocated staffing level is insufficient for the task at hand. There is also evidence from Nepal's success at achieving international standards for polio eradication indicators that adding staff, nurturing their skills, and supporting them with good management and appropriate resources have produced outcomes that exceed the minimum requirements. Lessons learned from positive experiences (such as Vitamin A distribution and surveillance for polio) should be examined for their approaches, to identify key elements and processes for improving service quality and sustaining it in Nepal.
The integrated health information system has been running for several years, but reporting is only one aspect of using information. Research shows that health workers in Nepal know how to report satisfactory results; discrepancies between immunization coverage from monthly reports and cross-sectional surveys indicate that information is not put into use at the point of service delivery. Immunization has powerful indicators of service quality; staff and community should be supported in discovering the messages in the data, interpreting them and applying them in practical ways. Section 5.8 includes a recommendation for building on existing developments in community participation in monitoring, to use information for improving services.
The health sector's planning framework provides an opportunity for addressing cross-cutting issues such as the safety of injections, and other parenteral procedures and infection control. This topic involves many of the essential functions of the health system discussed in Section 5. That section ends with a recommendation to carry out an independent assessment of injection safety. The methodology should serve as: (a) a needs assessment of skills, preceding any training activities, (b) an indication of equipment, spare parts and supplies needed, (c) a basis for supportive, technical supervision, and (d) an exploration of alternative strategies (including use of drums instead of racks). The approach should be participatory, problem solving, competency based and practical, and should pretest how to convey information to health staff effectively, and how best to support them in adhering to safe injection practices.
Proposals to include additional components of the prioritized main interventions should be considered within the framework for health sector planning and financing, giving highest priority to those additional components that are feasible and will lead to the most cost-effective improvement in the population's health status.
Any new financial support that may be obtained from GAVI should be programmed through the planning and financing framework.
An assessment of the medium- to long-term financial implications of adding a new vaccine to the immunization schedule is needed before accepting a short-term donation of a vaccine.
Additional staff must be allocated to cover specific technical aspects of immunization. Mapping of key posts should be extended to all 75 districts.
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USAID, Ministry of Health, WHO, World Bank