Evaluation Study of Decentralised Health Facilities In Nepal

Abstract

EXECUTIVE SUMMARY: In a more explicit way, after the enactment of Local Self Governance Act (LSGA) and its regulation 1999, Government of Nepal (GoN) decided to decentralise management responsibility to its lower authorities. Decentralisation of Sub Health Posts (SHPs) to Village Development Committees (VDCs) begun in 2002 with a decision to form a local health facility operation and management committee, therefore giving ultimate responsibility for health development to communities themselves. Over the years several documents dealing with decentralisation of health services were produced. Although the government and its stakeholders who are involved in health sector decentralisation have produced different studies, the comprehensive study covering the wider community coupled with literature review, self-observation and along side the international experience was yet to be carried out. However, it was realised that a review of all related documents on decentralisation of health facilities and handover status with the verification of SHPs with empirical data need to be carried out. This report is the one that has been carried out to realise those needs, which provides first hand information to the wider communities of those who are involved. The objectives of the study were to review the existing documents and studies related to decentralisation of health facilities in Nepal, analyse the current status of handover of health facilities to the community and recommend the appropriate strategy for the effective operation of the community managed health facilities. Retrospective review coupled with cross sectional descriptive study was conducted. Information was basically collected from primary sources while literature review served the secondary source of information. Purposive sampling technique was applied putting the geographic regions into strata. In this connection five districts, each representing each development region, were selected. They were Jhapa, Lalitpur, Kaski, Banke and Kanchanpur. In-depth interviews and focused group discussions were carried out covering 30 SHPs (20% of the total handed over SHPs). Besides, on-site observation of few SHPs perdistrict was also carried out. The data received were triangulated with other respondents. For in-depth interviews, key informants of central, district andvillage level were contacted. This research also reached out to the health management committee, SHP In-charges and exit clients level. Literature review revealed that 1251 SHPs, 237 HPs and 90 PHCs of 27 districts were already handed over to the local communities. In the fiscal year 2059/60, the government handed over 146 SHPs in the selected sample districts only. It was found that majority of HMC Chairperson; SHP In-charges and district level authorities had sufficient background information about the handover who mentioned, this being a good one. The communities, on the other hand were found to have very limited knowledge and even uninformed in many cases. The stakeholders who are part of the handover process took capacity building as major concern. None of the respondents found satisfied with the one or two time of orientation, hence needing 'a package' training in a modular basis. It was suggested that the package should have good mix of technical and managerial contents. Majority of the respondents claimed that there havebeen remarkable changes in the condition of SHPs after handover. Community awareness is increasing than before, and communities started to take ownership of towards SHPs. The utilisation aspect of the health service was also found to be increased. However, some of the respondents perceived that after handover tocommunities there was no change observed as of before, and very few responded only a minor change. Generally speaking respondents were satisfied with the inclusiveness of the HMCs. This committee was trying to be take initiatives however, is just limited within the paper. Because, firstly there were no elected local bodies and secondly the VDC secretaries were unable to be on the site to chair and run the SHPs. Second this associated with this was the authority delegated to the committee and the status conflict between VDC secretaries and SHP In-charges. In general the behavior and punctuality of SHP staff was found to be improved. Mixed results came out in terms of SHPs preparing plans and implementing them. Generally speaking dominant number of SHPs had annual or long-term plans however failed to implement due to financial constraints. Communities were unable to mobilise local resources. Apart from regular drug supply from the government, very few SHPs have community drug programme. SHPs were also found to be charging certain extra fees, which has served them as a source of income, however communities were not found satisfied with those rates. It is important that resource mobilization is important for the sustainability of the services provided by SHPs and they must be able to generate income for the running of the SHP activities, but at the same time effective policy protecting the access of the poor to the services must be implemented. To maintain the willingness of the population to pay for the services and the quality of the services must be improved simultaneously with the implementation of user fees. The drug supply system was criticised being delay one and not providing quality medicines or medicines that are about to be expired. The budget transfer system was also found to be lengthy and time consuming hence requiring DDC to transfer budget directly to VDCs from where SHPs can get funds. Majority of SHPs also lack required infrastructure.This ranges from not having toilets to the pregnancy check up in the storeroom. Many respondents have urged to have at least one separate room for the maternity related check up. Conflict has also adversely affected the proper decentralisation process. In comparison to other sectors, the effect in health sector was found to be minimal, however demands from rebels in terms of donation, looting of medicines and in some cases the destroying of SHP, has affected the proper implementation of the process. Besides, the conflict has its major impact denying VDC Secretaries to reside in their own VDC sites, and for the timely elections at local and district level. Needless to emphasize, regardless of many bottlenecks there has been remarkable changes occurred at the local level. These changes were communities taking initiatives towards SHPs' activities, increased service utilization, changes in staff behavior and punctuality, building of SHP infrastructures etc. Saying these it does not mean that all changes happened in a positive way. Whatever mentioned, there is still a room to question about staff attitude towards their support in the decentralization process wholeheartedly. Because the recent strike of over 26,000 paramedical staff demanding to end the SHP handover does not support their field level opinion. This is one of the serious areas that tarnish the overall credibility. At the 'policy making communities' level, there is also a concern that whether government really takes forward the decentralisation movement or not. If we say they do, current forms of authority and responsibility handed over to local levels does not support their positive intention. If we say no, there are some forms of deconcentration rather a complete devolution where very limited authorities have been given up. Current forms of deconcentration has put the both SHP staff and VDC Secretaries in a dilemma that what should they do or not. It is not yet clear what are their working lines and accountability mechanisms. Because the LSGA, which has been taken as a major basis of health services decentralisation, does not explicitly draws a clear picture for health services decentralisation and responsibility and accountability mechanisms. Further, some laws still contradict with LSGA. Therefore, a need for a new act to for health services decentralisation has been realised. Needless to emphasize, policies does not work out itself rather it needs to be worked by the people who are in positions and power. As other things remain constant, we still need a higher degree of resources, not in terms of millions of rupees, but in terms of greater commitment to institutionalise a functional system of health service decentralization at local level.