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Title: Study on Status of Free Health Services at Primary Health Care Centers and District Hospitals in selected districts of Nepal
Authors: Nepal Health Research Council (NHRC), Ramshah Path, Kathmandu, Nepal
Issue Date: 2009
Publisher: Nepal Health Research Council
Abstract: INTRODUCTION: Human Right has been accepted in principle by many countries including Nepal since 1948, the Interim Constitution of Nepal 2063 (2007) has enshrined and declared the state's commitment and responsibility to people's health for the first time in the history of Nepal. Cost sharing policies of past had silently pushed away the poor, helpless, disable, vulnerable and aged people from essential health care services which comprised of specific health programs such as safe motherhood and family planning, child health, control of communicable diseases and strengthened outpatient services etc. To increase the access and utilization of health care services the policy of free essential health services is in practice since one year. Ministry of Health & Population (MOHP) is in operation with frequent monitoring and supervision to free health service sites. However, there is lack of evaluation studies to guide policy makers in identifying the status of free essential health services and accessibility of poor people, and to assess the extent and intensity of the use of free essential health services in Nepal. General Objective To describe the status of targeted free essential health services for poor, helpless, disable, vulnerable and elderly people with special emphasis on preparing reference documents for policy makers. Specific Objectives (1) To describe the process of specified free service program implementation in PHCC and District hospitals of study districts (2) To find out the extent of use of free health services by target groups (3) To find out the status of use of free health services as per the criteria of the target group. (4) To find out the service utilization of District hospital and PHCC by gender and ethnic group in study districts (5) To assess the management of FHS program including financial, management of the free health services, recording system of such services, drug supplies, human resource, supervision/monitoring and coordination. (6) To describe the relevancy of policy as per status of availability of specified free essential health services and user fee policy of DH and PHCC to poor, helpless, disabled, vulnerable and elderly people, Methodology The study opts to know the status of the situation, thus; the descriptive study design is the choice of research study. The study was applied in both quantitative and qualitative methodologies at district hospital and PHCC including D/PHO of six districts- Sunsari, Taplejung, Dolakha, Chitwan, Bajhang and Dang. The study focused to review and describe the situation on FHS policy guideline review, implementation process, status of FHS management (logistic, information, human resourceand financial) , availability of identified health services in study districts and health service utilization in District hospitals and PHCC of study districts as per the criteria of the target groups. The study focused to analyze the main outcome on FHS policy guideline and its issues of implementation, management (logistic, information, human resource and financial) of FHS as per policy guideline, issues of identified health service availability as FHS policy in study districts and utilization of FHS on identified health care target groups as per policy guideline. Main findings 1. FHS policy guideline (operational) Policy clearly states the definition of the target groups and specific essential health services. The processes of policy implementation inclusion criteria, managerial guideline are mentioned in the guideline. The policy states the additional work to maintain all types or record and reporting, communication, coordination, ID card preparation etc. The policy guideline does not identify the responsible staff to coordinate all these activities and the policy guideline does not state clearly on BCC and IEC strategy to raise awareness among the service providers and service users. 2. Preparation to launch the policy at district level Program introduced within 3 months period timeframe after preparation of policy guideline. Therefore there was insufficient time for orientation of the district stakeholders and service providers in mass scale. The district stakeholders from local development, health sector did get opportunity to participate in central level preparation before launching the program in district. Most of the district stakeholders were not taking ownership on the policy. 3. Status of free service implemented in study districts The status of implementation of free service policy is not of consistent manner as per the policy guideline. In Dang and Dolakha most of the process and procedures are implemented in district hospital and PHCC as per the policy guideline. In Chitwan and Sunsari the process partially implemented as per free policy guideline and in Bajhang and Taplejung the more patients are getting free services but not following the policy guidline. The service utilization and management of policy is better in Dang and Dolakha compared to Chitwan and Sunsari. In Taplejung poor patients, elderly and disabled patients are getting free service as per support of Women Development Office and district hospital fund as per patient's verbal request and doctor's personal discretion. In Bajhang most of the patients are getting free services as per their demand and they mentioned that the target approach is not appropriate in this district because most of the patients are from poor family. The pattern of free service utilization in study districts varies as per awareness program, location, and infrastructure and service availabilityin the health facility. The service utilization and management of policy is better in Dang and Dolakha compared to other study districts. It could be due to frequent monitoring from MoHP, involvement of the key person from Ministry of health who actually participated in policy formulation and Orientation on policy launching process in the districts. 4. Implementation process at health facility level Most of the free service users are 100% poor according to the self declaration of the patient. Health workers mentioned that they cannot manage time to assess the economic status of the patient. Some health workers mentioned- we are not appropriate faculty in recognizing the patients who really are poor. This should be done by local authority and also expert faculty who are involved in social security program. 5. Relevance due to service availability (HR/drug/other supply) The policy is not relevant in all district hospitals of the country. The specified free services are mostly available in accessible districts (with transportation facilities In remote districts (Bajhang/ Taplejung), the policy seems to be not relevant due to distance there were no adequate orientation program, no regular supervision and monitoring. The target group approach policy is not relevant in remote districts because most of the patients claim that they from poor community. In most of the PHCC the policy is not relevant because the specified services such as indoor and emergency are not available. However, In some PHCC (Sunsari and Chitwan) the infrastructure and staff are available. But in remote district (Bajhang/ Taplejung), the OPD /indoor and emergency free policy for target groupsis not relevant unless the service is available and the sanctioned health workers manned (filled). 6. Fee policy in DH and PHCC and relevancy of FHS policy The user fees policy of the district hospitals and PHCC are not consistent. Most of the district hospital user fees policy is comparatively high and the poor patients can not afford most of the services. The user fees policy of PHCC also is not affordable for poor patients where the services are available. The MIS is complementing the FHS policy for target groups of low HDI districts. 7. Management of FHS policy/program Financial, Drug Management: Most of the districts are not maintaining financial records as per the operational guideline. In most of the districts, the PHCC and FHS fund is used to procure drug and reimburse CDP as per the prescription, however the policy is not clear with process of adaptation with CDP, Hill Drug Scheme, and Health Insurance Program. Community Awareness program: Most of the PHCC except Dang and Bajhang, did not take initiative to provide information (notice board/citizen charter) to the target group regarding availability of free policy. Supervision and Monitoring: The existing Hospital Management Board and PHCC Management Committee is functioning as monitoring committee of FHS program (Dolakha, Dang, Sunsari). ID card introduction: In most of the study districts ID card preparation process was not initiated. The concerned authorities think that the local development sector should take initiative to produce ID card of target group. Recording system and pattern of free service user's profile: It is too early to analyze the impact of the policy immediately after the policy implementation. Thus, the aim of the study is to assess the recording and reporting system. However, there is no consistency in recording system of the free service. The medical recorder is not clear about the reporting format. Recommendations FHS policy operational guideline The operational policy guideline should state: The responsible staff to carry out the activities: coordinate all activities, technical and managerial aspects of District hospital and PHCC; Mobilize the local development bodies to facilitate the policy implementation such as DDC, women development, media and community based health workers regarding targeted FHCP; Mobilize the NGO and Government social welfare (women development, welfare for disabled, Pro-poor program. Preparation to launch the policy at district level: Adequate time for planning and preparation to launch the policy at both central and district level should be allocated. The district level stakeholders including local development sectors should be involved in the process of policy drafting and development of plan of action. There should be strategic planning to cover all districts located in remote areas. The mass media could be mobilized to raise awareness on the policy, targeting both service providers and service users. Implementation process at health facility level: The FHS policy implementation should not be introduced in blanket approach. To make policy relevant, some criteria should be considered- the geography, HDI, and availability of specified essential services. Social service unit should be organized with coordination of focal point and the member of health facility management committee with representative of social welfare stakeholder of the district. Relevance due to service availability (HR/drug/other supply): The specified free services as per policy guideline should be available in all districts in order to make the policy relevant. The sanction post of district hospital and PHCC should be manned (filled) to provide regular services for relevancy of the free health care policy. Fee policy in DH and PHCC and relevancy of FHS policy: The free health care service for target group should be promoted at district and PHCC. The Maternal Incentive Scheme should be promoted for institutional delivery. Management of FHS policy/program Financial, Drug and Information Management: The orientation program should be organized to focus on financial management including recording, reporting of financial and, use of fund and service users profile in District hospital, DHO and PHCC. The guideline should be updated for clarity regarding use of CDP, Hill Drug Scheme and Health Insurance and FHS fund. Awareness and motivation to implement the program: The policy guideline should clearly mention the IEC and BCC strategy to communicate the FHS policy and the district concerned authority/staff should be motivated to implement the policy. Supervision and Monitoring: In each health facility the FHS monitoring committee should be established and strengthened as per policy guideline and the central level monitoring committee should conduct regular supervision in district. ID card introduction: The regular meeting of District Coordination Committee (DDC) should be used to decide on process of ID card preparation for specific target group in order to facilitate FHS policy implementation at district hospital and PHCC. Need further study: Further study should be conducted after strengthening the identified problems to review on impact of the policy.
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