District Health Systems Assessment within Inter­Sectoral Context

Abstract

The WHO defines health systems as “all the organizations, institutions, and resources that are devoted to producing health actions”. Health sector projects engage with all levels and elements of the health system and frequently encounter constraints that limit their effectiveness. There are four key functions of the health system: (1) stewardship (often referred to as governance), (2) financing, (3) human and physical resources, and (4) organization and management of service delivery. On the other hand, Inter‐sectoral coordination among the different actors in the district that directly or indirectly has a role in strengthening and supporting the health system forms an important component of improved health system. The Alma Ata declaration has already reiterated inter‐sectoral coordination as one of its main component in achieving Health For All. In the NHSP IP II (2010‐2015),the MoHP has clearly put forward its stand in the importance of Inter‐sectoral coordination and collaboration and to have a lead role in areas of its comparative advance. This study was aimed to describe the major four key functions of the health systems and find out the situation of inter‐sectoral coordination that may have an equally important role in improving the function of health system. Furthermore, we also tried to identify on which areas of health systems requirements the inter‐sectoral coordination & collaboration plays a role. In the above context to achieve the above said objectives we chose two districts each from three ecological belts on the basis of performance indicators as reported by MoHP for the year 2066/67. Hence the districts selected for the study were Sarlahi and Rupandehi from Terai, Bhaktapur and Kaski from Hill and Sidhupalchowk and Rasuwa from Mountain. Within the selected district an in depth interview with the chief of DHO or DPHO as well as group interview with relevant personnel of D(P)HO was carried out using semi structured questionnaire. FGDs were also conducted with the organizations of health and non health sectors in the district along with D(P)HO chief and personnel of D(P)HO. Furthermore, a semi structured group interview was carried out with the In Charge and selected personnel as well as HFOMC members of one selected PHC in every district. The data received in such way was transcribed and then edited. The quantitative information was tabulated which was then summarized fro key findings. The findings from the FGDs which was mainly focused on finding out the situation of Inter‐sectoral coordination were summarized in four key thematic areas namely Existing Situation of Coordination, Problems and Constraints, Potential Areas for Coordination and Who should lead. The key findings in relation to the major key functions of district health systems showed that the overall management of the district health system happens under the leadership of chief of D(P)HO with the cooperation of all the personnel in different sections. The PHCs on the other hand have HFOMC in all of them as a management structure where members from marginalized, women and dalit are included and participate in the meetings in all the PHCs. The financial management issues of the district offices mainly happen in a predetermined pattern that is decided and directed from the central level. None of the districts received budget on time and none of the finance head and chief of D(P)HO are satisfied with that. Most of the public HFs of districts are found to be charging fees for some of their services. None of the chief's are satisfied with the allotted posts for the HFs. The number of posts of HR in the D(P)HO are filled in almost all the districts except one. The HFs in the district have many areas of lacking in terms of HR fulfillment. The situation is worse with the lower level facilities the worst being the SHPs. Most of the PHCs included in the study suffered with the deficient number of staffs. Community involvement and participation is visible in the form of youth and mother's groups in all the districts except one involved in some or the other health and health related issues. All of the PHCs are found providing services related to priority health activities. However, in terms of disease prevention and control as well as treatment of certain diseases such as NCDs the PHCs are not found to be capable enough and do not have the resources. Inter‐sectoral coordination and collaboration of the health system within the health sectors exist only to a very limited extent which usually happens with non public HFs in health camps, preventive and promotive health service, immunization and urban health. In some of the districts traditional healers and practitioners of traditional medicine are involved in some meetings. Most of the districts also have coordination with NGOs and the major areas are Disaster, HIV/AIDS, RH, WASH, ASRH. Inter‐sectoral coordination with the sectors beyond health is limited mainly to DEO, DDC and DAO as well as some activities with agriculture and livestock services. The major activities include immunization, school health, water supply, sanitation, malnutrition, zoonotic diseases. Also theseoffices have representation in the various committees in the district. The major constraints for inter‐sectoral coordination to be effective is lack of its planning and enforcement. The key areas where inter‐sectoral coordination could be important are preventive and promotive health care, waste management, water supply and sanitation, health service utilization, pesticides and human health, agriculture and nutrition, air pollution. In terms of specific diseases, diarrheal diseases, VBDs, nutritional disorders, NCDs, ARI and TB are some of the important areas where inter‐sectoral coordination could be important. The main components in the district health system that needs an immediate attention are number of new posts to be created to fulfill the deficit, provision of area specific incentives and benefit packages. Bottom up approach should be enhanced for effective for effective planning and management. Inter‐sectoral effort should be initiated from the central level and implemented in all the levels. Key areas need to be identified which will have significant impact on public health system by promoting inter‐sectoral coordination.