Citation: NHSSP Lessons Learned and Sustainability Review (2010-15), Aryal and Saville, October
2015
This report has been funded by UKaid from the UK Government’s Department for International
Development (DFID); however the views expressed do not necessarily reflect the UK
Government’s official policies.
This report is submitted in compliance with NHSSP’s Payment Deliverable M9 ‘Sustainability
Review and Exit Strategy’.
ii
ACKNOWLEDGEMENTS
We would like to thank those who gave time from their busy schedules to participate in this
assessment including from the Ministry of Health and Planning, Department of Health Services,
development partners, including DFID advisors and the NHSSP advisors. Without the willingness
of these officials to express their opinions openly and objectively, this report would not have
been possible. We offer our sincere appreciation.
Amit Aryal and Esther Saville
Kathmandu
October, 2015
iii
EXECUTIVE SUMMARY
NHSSP LESSON LEARNED AND SUSTAINABILITY REVIEW
Introduction
The second National Health Sector Programme (NHSP-2, 2010 - 2015) aimed to improve the use
of essential health care and other health services, especially by women and poor and excluded
people. Technical assistance (TA) to NHSP-2 is being provided from pooled external development
partner (Department for International Development (DFID), World Bank, Australian Aid [DFAT],
KfW and GAVI) support through the Nepal Health Sector Support Programme (NHSSP). NHSSP is a
five and a half year programme in two phases (Phase 1: Sept 2010 to 2013 and Phase 2: 2013 2015) funded by DFID and managed and implemented by Options Consultancy Services Ltd and
partners, Oxford Policy Management (OPM) and Crown Agents. NHSSP is providing technical
assistance and capacity building support to help the Ministry of Health and Population (MoHP)
deliver against the NHSP-2 Results Framework. NHSSP has provided support across the following
thematic areas:
- health policy and planning;
- procurement and infrastructure;
- health financing (HF);
- essential health care services (EHCS);
- public financial management (PFM);
- gender equality&social inclusion (GESI);
- monitoring and evaluation (M&E);
- preparations for HSS 2015-20201
- human resources for health (HRH);
- support to five regional directorates.
Purpose of review
This review aimed to assess overall progress of NHSSP against programme logframes, to identify
areas requiring additional support and to describe underlying processes and lessons learned in
order to inform the future deployment of TA in MoHP/Dept. of Health Services (DoHS). The
assessment includes a quantitative review of progress against targets in the results frameworks, a
review of programme documentation as well interviews with a wide range of sector stakeholders
(Government of Nepal [GoN] officials, NHSSP Advisers, key pool partners and other development
partners [DPs]).
Background
DFID Nepal has been central to health sector development and achievements. DFID is the largest
bilateral donor to provide financial assistance to the government’s health budget and UK funds
account for approximately 8% of the total health budget. The DFID Terms of Reference (ToR) for
the TA to NHSP-2 stated that it should “demonstrate credible evidence of knowledge transfer and
develop capacity of MoHP on a longer term basis and with broader scope to deliver NHSP 2
results framework and beyond”. DFID’s TA provides an embedded team of mainly Nepali
advisers to the MoHP and DoHS to drive best practice and reform in the sector. In Phase 2, the TA
also included a flexible fund - the Technical Assistance Response Fund (TARF) - that agencies
under the Ministry of Health and Population (MoHP) can use to fund work that is not funded in
their annual work plans and budgets (AWPBs).
Based on the results from capacity assessments undertaken by NHSSP, a capacity enhancement2
strategy was developed with MoHP and development partners to guide and monitor the TA
support provided to the sector. NHSSP agreed with MoHP an organisational development
approach that placed emphasis on the ‘systems, structures and roles’ of Potter and Brough’s
conceptual framework (2004). Ownership by the GoN was identified as a critical factor in
sustainable capacity enhancement whereby TA respects and works through existing MoHP
governance arrangements and is aligned with existing MoHP policies, strategies and operations.
1
Previously referred to as NHSP-3
Originally referred to as capacity development but changed in response to Nepali staff and counterparts who felt that
capacity enhancement was a more appropriate term acknowledging that capacity already exists.
2
iv
Contribution of NHSSP TA to NHSP-2
There has been considerable progress across key areas of NHSP-2 as a result of the contribution
made by DFID, and, more specifically, as a result of the TA programme. As the DFID annual review
stated in 2014 ‘It is rare to find substantive progress on so many health systems and processes
within such a politically and capacity-challenged environment, yet maintaining strong leadership
and commitment across partners’. The combined investment in NHSP-2 of sector budget support
and an associated embedded technical assistance programme is seen to have resulted in a
strengthened health system and to represent good value for money, particularly in terms of
longer-term systems building and sustainable service delivery3.
GoN counterparts and DPs reported that the strength of DFID TA is seen to be in core systems
strengthening, such as PFM and infrastructure, at a central level embedded within GoN. The DFID
TA programme has been a critical force in supporting the MoHP to develop new systems and
implementation models, in particular in the areas of technical guidelines, strengthened processes
and information management systems which in turn drive efficiencies, transparency and
accountability, and enhance the ability of MoHP and its partners to take a more strategic and
needs-based approach to planning, budgeting and service delivery.
Areas of significant progress as a result of the contribution of NHSSP include:
 Improved health governance, financial management and transparency through the
implementation of the Transaction Accounting and Budget Control System (TABUCS),
eAWPB and strengthened audit clearance and internal control systems. These new
systems, processes and tools have been embraced and are largely institutionalised across
the sector. These enhanced approaches to financial management and expenditure
tracking have improved absorptive capacity and thus, in theory, ability to lobby for a
greater proportion of GoN budget to be allocated to health.
 Streamlined health sector infrastructure planning. NHSSP has contributed to the
strengthening of infrastructure planning based on catchment populations and geography,
reducing ad-hoc planning and resulting in a more rational approach to new construction
and facility upgrading. The introduction of a new building works (infrastructure) ebidding system, with support from NHSSP, is estimated to have reduced the average
price of new contracts by 12%, resulting in around £3.4 million savings in the first year
following its introduction alone. Sustainability of these developments, in the absence of
appropriate counterparts to take this work forward and ensure tools and systems are
updated and maintained, is a critical issue.
 Strengthening of tools and systems for improved transparency of procurement
processes. NHSSP TA has made a critical contribution to developing tools (specifications
bank, contract management system, web-based e-bidding) and systems (consolidated
annual procurement plan, International Competitive Bidding/National Competitive
Bidding [ICB/NCB]) to improve procurement but there has been limited partial use of
systems/tools and the procurement process is still slow. The support provided by NHSSP
on procurement is recognised by the GoN counterparts and other development partners,
and, at least in the short term, capacity substitution is required to support Logistics
Management Division (LMD) to develop procurement documents until it has appropriate
cadres in place with procurement expertise.
 Strengthening the use of evidence in planning and strategy development for Essential
Health Care Services (EHCS) and broader planning processes. Embedded TA is seen by
stakeholders to have played a critical role in building capacity (especially in Family Health
Division/Child Health Division) to use evidence for policy and planning and for developing
context-specific strategies e.g. integrating the Aama programme and 4ANC (ante-natal
3
DFID Annual Review 2015
v
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care, demand-side financing [DSF] and incentive programmes); improving access to
speciality care (i.e. caesarean sections) through improved functionality of Comprehensive
Emergency Obstetric and Neonatal Care (CEONC) services; addressing overcrowding in
referral hospitals; the expansion of new approaches to family planning to reach
underserved populations and the use of data for AWPB.
Improved implementation of Aama. NHSSP has contributed to improved
implementation and governance of the Aama DSF scheme, increasing institutional
deliveries across all ethnicities and castes. NHSSP worked closely with FHD to conduct
rapid assessments to strengthen governance of Aama and other DSF schemes and
developed tools to monitor implementation of Aama funds which are regularly updated
and analysed for planning and budgeting at FHD.
Gender Equality and Social Inclusion. NHSSP TA has provided a significant contribution
to establishing an institutional structure to communicate and support the introduction of
GESI into the health system; provision of tools and, capacity enhancement to build skills
on concepts, principles and application of GESI guidelines. GESI interventions including
Social Service Units (SSUs), One Stop Crisis Management Centres (OCMCs) and social
audit have been piloted and scaled-up with support from NHSSP. A multi-sectoral
response to Gender Based Violence (GBV) at district level has also been supported by
NHSSP.
Health policy and planning DFID TA was designed to focus largely at the central level in
terms of supporting the GoN with drafting the NHSS (now approved by cabinet),
successfully supporting the GoN to lead the Joint Annual Review (JAR) process, preparing
a draft of the Public Private Partnership Policy and developing the National Health Policy.
NHSSP is also seen by DPs to have strengthened GoN’s leadership of Joint Consultative
Meetings (JCMs)/JARs.
Areas of moderate progress as a result of the contribution of NHSSP include:
 Human Resources for Health (HRH). Whilst some of the building blocks for strengthening
HRH were established with support from NHSSP (HRH Strategic Plan, costed M&E
framework, workforce plans and projections, HRH profile, institutional assessment of
National Health Training Centre [NHTC]), a lack of political will within Government limited
broader HRH reform and substantive improvements to HRH systems and planning. In
addition, the failure to pass an Amended Health Services Act until the end of 2013,
resulting in a recruitment freeze to sanctioned posts in the health sector, also
contributed to limited progress in this area. In response, DFID did not include HRH in the
ToR for the second phase of NHSSP except if drawn down through TARF by GoN.
Added contribution of NHSSP TA beyond the logframe
NHSSP’s advisers are recognised by both GoN and DPs across the sector as engaging in activities
that go far beyond work plan requirements on a daily basis including responding at short notice
to requests, providing high level strategic guidance and taking on additional areas of work. There
were also broader operational or organisational shifts in terms of ways of working that are seen
to be attributable, at least in part, to NHSSP highlighted by those interviewed for this review.
Some examples are:

Embedded TA is well positioned to respond to rapidly emerging needs. The postearthquake response by NHSSP phase 24 demonstrates how embedded TA is able to
rapidly respond to support the GoN with emerging situations. NHSSP also took on
support to the GoN to implement family planning pilots to expand access to remote
4
This refers to the initial support provided as part of NHSSP Phase 2 and not as part of the separate Transition and
Recovery Programme.
vi
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
areas after an earlier DFID contract to a service provider was cancelled and responded to
the drive to rationalise the frequency/number of national surveys conducted.
NHSSP has strengthened organisational culture and capacity within the MoHP/DoHS
for reform. In addition to strengthening the structures, systems, tools and skills that
facilitate an improved health system, NHSSP is seen by development partners to have
supported a stronger bureaucratic cadre with a desire to drive reform and a broader way
of thinking beyond vertical programming.
NHSSP has strengthened TA as a ‘process’ within the health sector. Development
partners reported that NHSSP has contributed to strengthening the model of delivery of
TA across the sector from a discrete activity or output with limited dialogue to an
iterative ‘process’ between the GoN and the TA provider(s).
NHSSP facilitates effective contributions from other TA actors. NHSSP was seen to
provide a welcoming ‘hub’ of knowledge/’a reference point’; skills and experience of the
health system and GoN ways of working, and play a critical role in helping to coordinate
and encourage partnership and coordinated and collaborative TA.
Embedded TA supports GoN to build partnerships with other DPs/NGOs at district level
to support scale-up/implementation of GoN strategies. Embedded TA is seen to play a
critical role in leveraging support from development partners to implement GoN
approaches at district level. The value of having embedded TA within FHD to provide the
technical support to guide implementation and to link with the GoN system was
recognised by development partners and advisers.
NHSSP has supported establishing effective mechanisms and processes for multisectoral working. NHSSP has been instrumental in promoting effective multi-sector
working on a range of areas of work, most notably in relation to the development of
integrated gender based violence (GBV) guidelines.
DFID TA has contributed to effective partnership working and a mature SWAp through
building and fostering relationships with GoN and development partners.
The embedded TA programme has provided DFID with additional influence and is seen
to represent value for money. NHSSP provides both a mechanism to support the GoN in
a relatively flexible and supportive manner and a pathway through which DFID has been
able to exercise significantly more influence than it might otherwise have done through
direct pooled funding to the SWAp alone.
Lessons learned from NHSSP for delivering sustainable TA
Ensure focus of TA deliverables is relevant, appropriate, aligned to GoN priorities and has
senior level buy-in:
 New systems were best embraced or owned by the GoN when developed alongside GoN,
aligned to their priorities, and when there was an incentive for those using the system.
 TA has been most effective at driving technical innovations in terms of systems and tools
that enhance working practices and show results.
 GoN ownership at a senior level helps to drive forward change.
Ensure the delivery model for TA is appropriate
 Embedded TA is seen as accountable to GoN, which fosters trust and increases the
influence of advisers to advocate for sustainable change.
 Direct sector budget support, flexibility and responsiveness of DFID TA is highly valued by
GoN and DPs.
 The flexibility that the TARF provides is valued by GoN.
 Appropriate team composition is critical with size, mix of expertise, experience and age
across the advisers all impacting the effectiveness of TA delivery.
 Building and supporting a coherent team of advisers strengthens the TA approach and
enables advisors to better navigate formal and informal political structures and
institutions.
vii

Using evidence to drive policy decisions and strategy development leads to sustainable
change.
Work within GoN systems and structures
 Ensure TA is positioned at an appropriate level within the GoN structure and is aligned to
new federal structures as they emerge.
 Strengthening and working through Technical Working Groups supports consensus,
coordination, harmonisation of TA and partnerships resulting in sustainable change.
Work with GoN to ensure systemic barriers are addressed from the outset
 Agree with the GoN from the outset a detailed capacity enhancement (CE) plan, including
GoN commitment to stable posts, and an exit strategy for TA to ensure the system is able
to absorb capacity enhancement sufficiently.
 Working with GoN to identify the correct institutional home is key to effective CE and
sustainability. Where an appropriate division is identified to lead, the potential for
longer-term sustainability is seen to be greater.
 Support GoN to issue multi-year contracts, e.g. for NGOs and human resources, to enable
scale-up of interventions and service delivery.
Work closely with development partners to create an enabling environment for TA
 Aid effectiveness and harmonisation across the TA sector needs strengthening to ensure
continued GoN receptiveness to TA.
Recommendations for future TA in transition to NHSS
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Stakeholders see the strength of DFID TA to be at the core systems reform and policy
level. Stakeholders recommended that DFID prioritise TA in the areas of: procurement
and infrastructure, public financial management and EHCS. These will remain major
priorities for the sector with no foreseeable significant technical assistance being
provided by other TA agencies in these areas. Other areas of support where DFID TA is
seen as important in the next phase include HRH, health policy and planning, M&E and
further support to sustain GESI interventions/GBV response.
DFID should continue to actively coordinate with other agencies or NGO partners and
build upon their respective comparative advantages to ensure that TA inputs are
coordinated across partners to support the NHSS (incl. USAID, GIZ, Save the Children).
A dual focus on strengthening central systems and supporting districts to ‘build back
better’ should be sustained. In view of the transition and recovery from the earthquake
as well as the planned move to federalism, it is critical that DFID TA sustains a dual focus
on maintaining central level systems support in key areas (infrastructure, procurement,
PFM, EHCS) whilst focusing on district level strengthening of health systems and services
and decentralised planning and budgeting.
Ensure equitable access to and functionality of quality essential health services. The
aspiration to ‘build back better’, supported by DFID’s TA to the Health Sector Transition
and Recovery programme, will support strategic transition to recovery and restoration of
systems and contribute to the expanded availability and functionality of essential health
services. This will require, for example, TA to work with Government to ensure that
infrastructure assessments inform designs and plans that meet short-term emergency
needs as well as longer term strategic rebuilding efforts. TA should continue to provide
valuable support for the careful sequencing of infrastructure repairs, with procurement,
EHCS and financing activities, to ensure that buildings, supplies and services are in place
in a coordinated and timely manner.
The impact of the federal structure on health service delivery should be taken into
account in the design of future TA. Planned transition to a federal state and devolved
responsibility for health services could result in deterioration in the quality and scope of
viii
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service delivery, in particular to the poor and excluded. Continuing to support
FHD/Management Division (MD) to improve quality through the scale-up and
consolidation of Quality Improvement systems like the Hospital Quality Improvement
Process (HQIP) will be critical as will continued support to translate evidence from pilots
into strategies and approaches to improve the scope of services and increase access
amongst the poor and underserved.
Strengthening district planning and implementation systems. TA has a critical role at
central and district levels to support the transition to longer-term health systems
planning in line with NHSS and federalism and to ensure that all the components of
rebuilding and strengthening the health system are delivered with an evidence-based
and coordinated approach across partners. Support to district planning and
implementation to build back better systems and services and through the strategic
prioritisation of health services will provide valuable lessons to inform planning for
decentralisation in the move to a federal structure.
Federalism provides an opportunity for critical reform in core areas. NHSS and
federalism present opportunity for reform of existing systems within the new structure.
TA should engage with the ministry on functions and structures and support the process
of devolved planning and decision-making. Further TA support to MoHP budget
management and delivery is critical to ensure better absorption of current allocations
and negotiation for greater investments. Federalism also presents an opportunity for TA
to support GoN to lay the foundations for much needed procurement and HR reform to
support transparent, rational and effective systems.
TA has a critical role to play in harmonising social health protection. TA is required to
draw lessons from Aama and to contribute learning to develop the capacity of MoHP to
consolidate demand side financing schemes under a social health protection framework.
For detailed findings on the contribution of TA, sustainability of progress and further TA needs
across NHSSP thematic areas see Table 3 and Annex 4.
ix
TABLE OF CONTENTS
Acknowledgements ...................................................................................................................... i
EXECUTIVE SUMMARY NHSSP LESSON LEARNED AND SUSTAINABILITY REVIEW ........................... iv
Added contribution of NHSSP TA beyond the logframe ...................................................................vi
Lessons learned from NHSSP for delivering sustainable TA.............................................................vii
Recommendations for future TA in transition to NHSS .................................................................. viii
TABLE OF CONTENTS.................................................................................................................... x
LIST OF ACRONYMS .................................................................................................................... xi
1
Introduction ........................................................................................................................ 1
1.1
Background to the review..................................................................................................... 1
1.2
Rationale and approach ........................................................................................................ 1
1.3
Report structure ................................................................................................................... 2
2
Background and Context ...................................................................................................... 3
2.1
Health sector development .................................................................................................. 3
2.2
Health sector wide approach (SWAp)................................................................................... 3
2.3
DFID contribution to the health sector in Nepal .................................................................. 4
2.4
Shifting governance structures – the move to federalism ................................................... 5
2.5
Social and economic factors influencing technical assistance to the health sector............. 5
3
Mode of TA delivery for NHSSP ............................................................................................ 6
4
Contribution of NHSSP TA to NHSP-2 .................................................................................... 9
4.1
Overview of progress of NHSP-2 and the contribution of TA ............................................. 10
4.2
Significant progress............................................................................................................. 11
4.3
Moderate progress ............................................................................................................. 14
4.4
Added contribution of TA beyond the logframe ................................................................ 15
4.5
Conclusions on sustainability and recommendations for further TA across thematic
areas 17
5
Lessons learned for delivering sustainable TA ..................................................................... 20
5.1
Ensure focus of TA deliverables is relevant, appropriate, aligned to GoN priorities ......... 20
5.2
Ensure the delivery model for TA is appropriate ................................................................ 20
5.3
Work within GoN systems and structures .......................................................................... 22
5.4
Work with GoN to ensure systemic barriers are addressed from the outset .................... 22
5.5
Work closely with development partners to create an enabling environment for TA ...... 23
6
Recommendations for future TA in transition to NHSS ........................................................ 24
List of references ....................................................................................................................... 30
x
LIST OF ACRONYMS
AWBP
CE
DFID
DHO
DLIs
DoHS
DP
eAWBP
EDP
GESI
GoN
HF
HHS
HPP
HRH
HSPDF
JAR
JCM
JFA
JTAA
LSGA
LTTA
MoHP
NDHS
NGO
NHSS
NHSP-2
NHSSP
NLSS
NMICS
OOP
PFM
PHRCD
PPICD
RF
RHD
SC
STS
STTA
SWAp
TA
TARF
ToR
T&R
TWG
WHO
Annual Work Plan and Budget
Capacity Enhancement
Department for International Development (UK Aid)
district health office
Disbursement Linked Indicators
Department of Health Services
Development Partner
Electronic Annual Work Plan and Budget
External Development Partner
Gender Equality and Social Inclusion
Government of Nepal
Health Financing
Household Survey
Health Policy and Planning
Human Resources for Health
Health Sector Partnership Development Forum
Joint Annual Review
Joint Consultative Meetings
Joint Financing Agreement
Joint Technical Assistance Arrangements
Local Self-Governance Act
Long-term Technical Assistance
Ministry of Health and Population
National Demographic and Health Survey
Non-governmental organisation
National health Sector Strategy (2015-2020)
Second Nepal Health Sector Programme (2010–2015)
Nepal Health Sector Support Programme
National Living Standards Survey
Nepal Multi-Indicator Cluster Survey
Out of Pocket
Public Financial Management
Primary Health Care Revitalisation Division
Policy, Planning, and International Cooperation Division
Results Framework
Regional Health Division
Steering Committee
Service Tracking Survey
Short-term Technical Assistance
Sector Wide Approach
Technical Assistance
Technical Assistance Resource Fund
Terms of Reference
Transition and Recovery
Technical Working Group
World Health Organisation
xi
1 INTRODUCTION
1.1
Background to the review
The second National Health Sector Programme (NHSP-2) began in mid-July 2010 and aimed to
improve the use of essential health care and other health services, especially by women and poor
and excluded people. Technical assistance to NHSP-2 is being provided from pooled external
development partner support (DFID, World Bank, Australian Aid [DFAT], KfW and GAVI) through
the Nepal Health Sector Support Programme (NHSSP). NHSSP is a five and a half year programme
in two phases (Phase 1: mid-July 2010 to mid-July 2013 and Phase 2: mid-July 2013 - end Dec
2015) funded by the Department for International Development (DFID) and managed and
implemented by Options Consultancy Services Ltd and partners, Oxford Policy Management and
Crown Agents. NHSSP is providing technical assistance and capacity building support to help
MoHP deliver against the NHSP-2 Results Framework. The following are the key thematic areas of
current NHSSP support:
- health policy and planning;
- procurement and infrastructure;
- health financing;
- essential health care services;
- public financial management;
- gender equality and social inclusion;
- monitoring and evaluation;
- preparations for HSS 2015-2020
(previously referred to as NHSP-3).
Additional thematic areas supported in NHSSP Phase 1 included human resources for health and
support to MoHP’s five regional directorates.
In July 2015, following Nepal’s major earthquakes in April and May 2015, DFID contracted
Options to provide further TA to the sector under a Health Sector Transition and Recovery
Programme. This programme runs until July 2016 and is the subject of a separate review process.
1.2
Rationale and approach
The review of lessons learned and the preparation of a TA exit strategy for NHSSP aims to assess
the impact and sustainability of various inputs and work streams and to inform decisions on the
mode of deployment of TA under HSS 2015-2020. The purpose of this assignment is to assess
overall progress made in Phase 1 (mid-July 2010 – mid-July 2013) and Phase 2 (August 2013 –
December 2015) of NHSSP against programme logframes, to identify areas requiring additional
support and to describe underlying processes and lessons learned in order to inform the future
deployment of TA in MoHP/DoHS. See ToR at Annex 1. The specific objectives are to:
I.
II.
III.
IV.
V.
Carry out a quantitative review of progress made against programme targets;
Identify work streams requiring support during the transition to NHSS 2015-2020
to be captured in an exit strategy for the programme;
Describe the underlying processes and factors seen to have influenced the
success or failure of various TA inputs to include any shifts seen in MoHP
operational culture and perceptions on the optimal role of TA;
Identify the main lessons learned in deploying embedded TA and other related
resources within MoHP under NHSP-2 with recommendations on how these can
be carried forward under NHSS 2015-2020;
Comment on the added value provided by NHSSP TA to the sector including
levels of responsiveness to additional requests from MoHP, DFID and other EDPs
particularly in the aftermath of Nepal’s recent earthquakes.
The assessment includes a quantitative review of progress against targets in the results
frameworks, a review of programme documentation as well interviews with a wide range of
1
sector stakeholders in order to elicit perceptions on the activities, impact, effectiveness and value
of TA deployed under NHSSP. Stakeholders interviewed included GoN officials, the NHSSP
advisers and key pool partners and signatories to the Joint Financing Agreement (JFA) including
the World Bank, USAID, GIZ and AusAID. Interviews with UNICEF and WHO were also carried out.
See Annex 2 for a full list of respondents.
The analysis attributes findings to the different categories of respondents where there is
divergence of viewpoints (e.g. GoN counterparts, EDPs, advisers). Where the term stakeholders is
used this indicates that this was the predominant view across all categories of respondent.
This assessment has drawn upon the concepts set-out in a range of sustainability frameworks567
in terms of defining the parameters of enquiry and informing the assessment of sustainability
across the sector. Where appropriate subcomponents from these tools were adopted within the
context of the broader sector strategy – NHSP-2 and programme logframes and used as a
framework for analysis in this assessment8. Other concepts relevant to understanding the
analysis and findings include:



1.3
Definition of capacity enhancement: Strengthening of health systems for delivery of
equitable, inclusive services with an emphasis on enhanced institutional capacity, and on
quality, accountability and effective implementation of GoN programmes related to
women, new-borns, children and the underserved, in order to improve health (NHSSP
Phase 1 inception report);
Definition of sustainability: Areas of progress (as a result of TA contribution) that will
continue as planned without further TA input9;
Potter and Brough’s conceptual framework of capacity development and capacity
pyramid (see page 7 for more information).
Report structure
The report is organised around 6 sections. Section 2 provides the background and context to the
health sector in Nepal; Section 3 describes the mode of technical assistance delivery used by
NHSSP; Section 4 provides an assessment of the contribution made by NHSSP TA to deliver NHSP2 including recommendations for further TA across the NHSSP thematic areas; Section 5 provides
a summary of lessons learned from NHSSP for delivering sustainable technical assistance and
Section 6 provides recommendations for future technical assistance as Nepal delivers the
National Health Sector Strategy for 2015 – 2020.
5
http://www.ncbi.nlm.nih.gov/pubmed/19946943
www.ghm.org/CBPHC/Sustainability_Manual_FINAL_Lowres.pdf
7 http://pdf.usaid.gov/pdf_docs/Pnadd770.pdf
8 It was not feasible to use the approaches and tools set-out in the sustainability frameworks above in their entirety
given the scale of resources available for this assessment. As a result, where possible, the frameworks have been used
to inform the analysis conceptually, in the design of discussion guides and approach to the analysis. It was felt that
structuring the review within the Nepal-specific frameworks of the health sector strategy and results frameworks
whilst incorporating elements of the sustainability frameworks into discussions and analysis was seen to be a rational
and context appropriate approach.
9 Broader definitions of sustainability such as that included in the USAID framework referenced above which measures
sustainability in terms of sustained health outcomes were seen to be too high level for the purpose of this assessment.
Assessing sustainability of TA inputs within the context of achievements across the broader sector was seen to be more
appropriate in terms of understanding the contribution of TA and generating recommendations for future TA to the
sector.
6
2
2 BACKGROUND AND CONTEXT
2.1 Health sector development
In recent years the health status of Nepali citizens considerably improved. Nepal is on a
remarkable track to achieve most of the MDGs despite challenging political instability and a
decade long civil war (NMICS, 2014, WHO et. al., 2014). People are living longer; the current life
expectancy at birth is 68 years, an increase of 12 years in the same time period (NLSS, 2011). The
MDG targets of reducing the percentage of underweight children, the percentage of population
below the minimum dietary energy consumption and the reduction of under-five mortality were
met in 2010 (NDHS, 2011). An average Nepalese woman has only 2.3 children compared to 5 in
the early 1990s.
However, maternal and neonatal mortality rates remain high and significant disparities in health
outcomes and access to care persist between Nepal’s 126 distinct ethnic/caste groups, and
between people living in different regions. People in rural – particularly in mountainous areas,
poor people and people from lower castes are more vulnerable to diseases and have additional –
financial, geographic and cultural – barriers when accessing health services (NDHS, 2011). The
health system has a special responsibility to serve these vulnerable population groups and
guarantee that they can benefit equally from free essential health services.
The GoN of Nepal has shown its commitment to universal health coverage for all citizens. The
landmark National Health Policy (1991) brought GoN services closer to communities through a
decentralized district health system. The policy sought to expand community participation and
increase private sector engagement in health. The Interim Constitution of Nepal expanded
guarantees to health care as a fundamental right of every citizen – for the first time in Nepal’s
history.
2004 marked the beginning of a new and improved partnership between the GoN and EDPs with
the initiation of a Sector Wide Approach (SWAp). The partnership streamlined financial and
technical cooperation in the sector, yielded improved health governance and scale-up of
evidence-based service delivery initiatives. It led to joint formulation of three consecutive health
sector programmes starting in 2005 with a unified monitoring and evaluation framework: Nepal
Health Sector Programme – I (2004-2009); Nepal Health Sector Programme – II (2010-2015); and
Nepal Health Sector Strategy (2015-2020).
The recently drafted National Health Policy 2071 (2014) provides the main policy framework for
the health sector. Its vision 'All Nepali citizens have the physical, mental, social and spiritual
health to lead productive and quality lives' has shaped the development of the Nepal Health
Sector Strategy (2015-2020). NHSS seeks to implement this vision by upholding equity and quality
as its overarching principles and expanding health systems reform as a multi-sectoral
development agenda. NHSS provides an opportunity to build on the lessons learned from the last
health sector programme, NHSP-2, and to take forward recommendations from this review.
2.2 Health sector wide approach (SWAp)
The SWAp has given rise to various mechanisms to strengthen partnerships between the GoN
and its partners, to improve donor harmonization and alignment, while also fostering greater
partnership with NGOs and civil society. The Joint Financial Arrangement (JFA), signed between
MoHP and EDPs, harmonizes procedures for financial management, and coordinating planning,
monitoring and performance reviews and better aligns donor contributions through MoHP’s
3
annual work plan and budget (AWPB). Mechanisms such as the Joint Annual Review (JAR) and
Joint Consultative Meetings (JCMs) aim to provide a platform to the GoN, EDPs, NGOs, and civil
society groups to jointly discuss progress and set priorities for the sector. The SWAp has also led
to multiple technical working groups, comprising individuals from the GoN, technical agencies,
NGOs that support the ministry at various levels to harmonize technical and financial resources in
diverse areas. While there was interest in the GoN and EDPs to formalize the technical assistance
in the health sector through a Joint Technical Assistance Arrangements (JTAA), it remains to be
realized.
An important agenda for the EDPs and the GoN, as the new Nepal Health Sector Strategy (20152020) has been recently endorsed by the cabinet, is the future of this important partnership in
the health sector. Some of the donors are no longer contributing funding to the pool fund and
will fund interventions directly. The World Bank is in discussion with the GoN and EDPs about
funding through Disbursement Linked Indicators (DLIs).
Feedback from GoN and EDPs suggests that ensuring that instruments like JCMs and JARs provide
opportunities for two-way dialogue between EDPs and the Ministry and that the utility of this
process outweighs the administrative burden to the Ministry and TA (i.e. producing JAR reports
and arranging the event) is critical. The Health Sector Partnership Development Forum (HSPDF)
called for in the NHSS provides an opportunity to establish a joint platform that meets both GoN
concerns and donor needs, while strengthening the SWAp. New financial and technical
arrangements, yet to be signed, should define the modalities of HSPDF.
2.3 DFID contribution to the health sector in Nepal
DFID Nepal has been central to health sector development and achievements, providing financial
and technical assistance to the SWAp since its initiation in 2004. DFID, alongside the World Bank,
Germany, Australia and GAVI, provide funding directly to MoHP accounting for approximately
15% of the GoN’s health budget. DFID is the largest bilateral donor to provide financial assistance
to the budget and UK funds account for approximately 8% of the total health budget. The
programme is therefore owned, led and predominantly funded by the GoN of Nepal.
In 2010, the UK’s Department for International Development (DFID), allocated £55,000,000 to the
health sector in support of the GoN’s 5-year National Health Sector Programme (NHSP-2). Based
on strong performance and to assist in accelerating the delivery of health services, DFID
approved an additional £17,500,000 for NHSP-2 December 2013. The total support provided by
DFID between 2010 and 2015 was £72,500,000 of which £52,000,000 was for financial aid and
£20,500,000 for technical assistance.
Technical assistance to NHSP-2 has been provided from pooled external development partner
support (DFID, World Bank, Australian Aid [DFAT], KfW and GAVI) through the DFID-funded Nepal
Health Sector Support Programme (NHSSP) contracted by DFID on behalf of the pooled partners.
NHSSP provides technical assistance and capacity building support to help MoHP deliver against
the NHSP-2 Results Framework.
DFID’s TA has been competitively contracted out to a service provider to manage on behalf of
DFID. The service provider (a consortium led by Options Consulting Ltd) manages an embedded
team of mainly Nepali advisers to MoHP and DoHS to drive best practice and reform in the sector
on key issues including infrastructure, procurement, PFM and financial management.
4
2.4 Shifting governance structures – the move to federalism
Currently, the Local Self-Governance Act (LSGA) of 1999 and Regulations (2000) provides the
legal framework for local governance and includes health as one of the functions and
responsibilities of local bodies at different levels (village, municipality and district). The MoHP has
handed over a significant number of health facilities for operation and management to local
bodies in the past in the spirit of LSGA. Despite these efforts, the health sector remains highly
centralized. The local units remain little more than implementing units of centrally derived plans
and budgets, particularly challenged by the absence of elected leadership in local bodies.
On 20 September 2015, a new constitution was promulgated, paving the way for a federal
democratic republican system of governance in the country (Constitution of Nepal, 2015). Under
the constitution, Nepal’s new federal structure will see the country divided into seven provinces,
with clear lists of legislative powers for the central, provincial, and local bodies. While
overwhelmingly passed by the Constituent Assembly (CA), a wide range of ethnic and indigenous
groups, particularly Madhesi and Tharu based political parties from the Terai region, are
protesting the newly formed constitution. They continue to demand that the constituencies of
the Legislative-Parliament be divided on the basis of population alone and further demarcation of
provinces based on ethnicity.
The newly endorsed Constitution of Nepal (2015) is a remarkable departure from previous
constitutions, which guarantees distribution of power to subnational units (provinces) and
divides state powers and functions between the federal, provincial and local levels (Constitution
of Nepal, 2015). As Nepal implements its constitution, there are opportunities for the sector to
devolve functions and responsibilities to lower levels of GoN, commensurate with the spirit of
the constitution while ensuring the sector is responsive to people’s needs and is able to deliver
equitable and quality health services.
2.5 Social and economic factors influencing technical assistance to the health sector
Nepal experienced promising economic growth of 5.2% in 2014 and the population living under
the national poverty line is estimated to have declined from 42 percent in 1995 to 23.8 percent in
2013 (NLSS, 2011). Limited infrastructure development, however, is reflected in the low
proportion of population with access to electricity, low access to sanitation and low rate of adult
literacy (NLSS, 2011). There are widening variations in socio-economic development between
rural and urban areas, among development regions, ethnic groups and castes.
Despite making legal progress in addressing women’s fundamental rights (Constitution of Nepal,
2015), Nepal remains, fundamentally, a patriarchal society. While women have more access to
opportunities in education, health care services and careers outside the home than previously,
gender disparities in these key areas continue.
The earthquakes in early 2015 destroyed infrastructure, transport and communication networks
and struck the vulnerable and weak health system of Nepal. In the most severely affected 14
districts, 5 hospitals were completely damaged and 6 hospitals partially damaged. In addition 5
Primary Health Care Centres (PHCCs) and 348 health posts were completely destroyed in the 14
districts.
The catastrophic earthquakes, followed by strikes in the terai by ethnic Madhesis and Tharus and
the unofficial economic blockade by India following the promulgation of the new constitution in
September, 2015, has further undermined Nepal’s socio-economic outlook.
5
3 MODE OF TA DELIVERY FOR NHSSP
The DFID TOR for the TA to NHSP-2 stated that it should “demonstrate credible evidence of
knowledge transfer and develop capacity of MoHP on a longer term basis and with broader scope
to deliver NHSP 2 results framework and beyond”.
In response to this, the TA in Phase 1 was designed to strengthen the health system through
embedded long term technical advisers (LTTA) at the central MoHP; DoHS; Regional Health
Directorate (RHD) levels, supplemented by short term technical assistance (STTA) and mentoring
as required. Embedded specialists worked alongside an appropriate counterpart and worked to
this counterpart on a day to day basis. Where no obvious counterpart was available (e.g. health
financing, GESI), efforts were made to generate increased interest in the thematic area and work
closely with those staff most closely associated with related processes and outputs.
Capacity assessments to explore organisational capacity, skills and the environmental factors that
enhance change, e.g. the working environment in which individuals are expected to perform,
organisational culture, bottle-necks to delivering EHCS and links to wider reforms in the public
sector were undertaken. A capacity enhancement10 strategy was developed with MoHP and
development partners to guide and monitor the TA support provided to the sector (partly in
response to concerns raised that embedded staff might substitute rather than develop local
capacity). The NHSSP approach to TA was developed based on the best judgment of the key
actors involved: GoN, NHSSP advisers and mentors, and other development partners and was
underpinned by an adaptation of the framework developed by Potter et al (2004) (below).
Attachment 1 Potter and Brough’s Conceptual Framework of Capacity Development
See also Annex 3: capacity pyramid for parameters of enquiry for capacity assessments
For NHSSP purposes, in order to align with the NHSP-2 results framework, a working definition of
capacity enhancement was developed: Strengthening of health systems for delivery of equitable,
inclusive services with an emphasis on enhanced institutional capacity, and on quality,
accountability and effective implementation of GoN programmes related to women, new-borns,
children and the underserved, in order to improve health (inception report)
10
Originally referred to as capacity development but changed in response to Nepali staff and counterparts who felt
that capacity enhancement was a more appropriate term acknowledging that capacity already exists.
6
NHSSP agreed with MoHP an organisational development approach that included: ‘Enhancing
congruence between organizational structure, processes, strategy, people and culture’ and
‘developing new and creative organizational solutions’ (Beer 1980). The approach placed
emphasis on the ‘systems, structures and roles’ of Potter and Brough’s conceptual framework as
key areas to address so that individuals’ attempts to perform their jobs properly are not
undermined; rather, a ‘capacity releasing’ approach is employed.
A focus on what were believed to be the ‘key impediments’ to more effective policy
implementation identified in the assessments was adopted and included: human resources
numbers, skills and incentives; accountability; leadership; inclusion, participation and equity;
external relations; production of and access to quality information by GoN and society; financial
resources; and political uncertainty (similar to the UNDP 2008 key impediments).
Capacity assessments for each key area included a mixture of quick wins, relatively easily
achieved successes which may not be sustainable without continuing inputs, and an identification
of long-term, higher-risk interventions which need to be monitored carefully and revised
appropriately. Distinction between transactional CE (for example in the area of procurement) and
transformational CE (for example in the area of GESI) was also identified. The capacity
enhancement strategy warned of the need to manage expectations for transformation given the
timeframe for the programme.
Ownership by the GoN was identified as a critical factor in sustainable capacity enhancement. It
was recognised that greater ownership is achieved by respecting and working through existing
MoHP governance arrangements and by aligning with existing MoHP policies, strategies and
operations to avoid duplication and reduce transactional costs. Government counterparts
confirmed that NHSSP TA is aligned to GoN strategies, priorities and results frameworks.
Table 1: summary of the NHSSP TA approach and the key principles of the approach
Approach
Principles of approach
Training – to strengthen the effectiveness of individuals
and organizations which are important for achieving
programme objectives.
Technical support – to provide technical advisory
services to improve the quality of policies and delivery
processes, and to strengthen the management of
processes which are important to programme success.
Knowledge creation and management – NHSSP will
agree a workplan of studies which are coordinated with
other GON and EDP-supported studies, manage their
implementation and ensure quality.
Information dissemination – to make credible and
relevant information available for relevant actors, to
give them more influence on policy, resources and
services.
Facilitation – to facilitate coordination and cooperation
amongst relevant parties in the interest of more
effective pursuit of programme objectives within and
between sections of MOHP/DPHS, and amongst MOHP,
other Ministries, EDPs and civil society, facilitated by
NHSSP advisers and their counterparts.
Financial and material support – to provide financial
and material support in areas where shortfalls are
critical to programme success.
Flexible and responsive to emerging technical issues and the
views and guidance of MoHP officials and pool partners.
Inputs aligned and reflected in annual TA plans prepared by
MoHP. Focus on capacity enhancement requirements while
providing support and guidance to counterparts for the
implementation of NHSP-2 activities.
Building on previous systems and evidence rather than
reinventing; and coordinating/integrating processes to
reduce duplication and inconsistent incentives.
LTTA provided by the same senior consultant to ensure
consistency and coherence of TA, skills transfer and reduce
transaction costs for the MOHP and Development Partners.
Embedded not short-term TA where mainly national
advisors rather than short term technical assistance was
provided to ensure a consistent approach to advice from a
small group of advisors working closely with GoN staff. Short
term technical assistance was used for specific tasks but
always coordinated by embedded advisors.
Capacity building rather than capacity replacement except
where activities essential to functioning of NHSP-2, e.g.
timely financial reporting/procurement, needed to be
carried out by consultants but with the aim of developing
capabilities of GoN staff to ensure these activities can be
7
Enabling processes – to enable and empower actors
with an interest in quality EHCS services and in good
health governance and systems functioning, to have a
stronger voice and more influence on matters
important to those achievements.
sustained without TA in long-term.
A focus on support to enhance departmental function
focusing on institutional and organisational development of
functions and departments in the MOHP and DOHS rather
than single individuals and to ensure that support adapts to
changing circumstances.
Feedback from GoN counterparts and development partners on the delivery of TA by NHSSP
confirmed that the TA was delivered in line with the principles and approach set-out during the
inception phases for NHSSP1 & 2. TA was described as being aligned to GoN strategies and
policies; providing expert technical inputs and advice; influencing and advocating to GoN and
other partners; piloting and building an evidence base to test approaches and sharing the results
with GoN and development partners; transferring skills to counterparts; providing broader
capacity building i.e. through training; facilitating, coordinating and leveraging
inputs/collaboration with other key stakeholders including other Ministries, development
partners, NGOs etc; supporting scale-up/roll-out of interventions; and providing executive
TA/substituting where required in the absence of critical MoHP staff.
The first phase of NHSSP was a reflective TA programme with processes built-in to ensure
opportunity to take stock of progress, delivery and approach and to make improvements to the
programme based on the lessons learned. These learnings, along with the findings of the 2012
mid-term review (MTR) of progress against the Second Nepal Health Sector Programme (NHSP2), the 2013 Joint Annual Review (JAR), including important feedback from GoN counterparts,
were reflected in DFID’s ToR for the second phase. Phase 2 (2013-15) provided an opportunity to
integrate lessons learned from phase 1 in the second phase including the GoN’s request for more
flexibility to respond to emerging TA needs.
In Phase 2 a new streamlined management and team structure was put in place in Nepal to focus
technical inputs and transfer more management and administrative functions to the in-country
team. This enabled the NHSSP team to respond swiftly and flexibly to emerging needs and
requests from the MoHP. The overall scope of work for the second phase of the programme was
also reduced by DFID in agreement with the MoHP (e.g. HR and support to the Regional Health
Divisions were removed from the programme). The TA in Phase 2 was delivered through 3
mechanisms:
 A streamlined team of embedded long-term advisers working directly with GoN counterparts,
with a 50% reduction in team compared to Phase 1. Eleven Advisers from Phase 1 continued
work on Phase 2, providing valuable continuity.
 A small resource pool of consultants from which counterparts and Advisers could draw-down
technical inputs on an as needs basis.
 A flexible fund, the Technical Assistance Response Fund (TARF), that agencies under the
Ministry of Health and Population (MoHP) can use to fund work that is not funded in their
annual work plans and budgets (AWPBs). The rationale for this flexible fund was that not all
technical assistance needs can be predicted well in advance although all TARF work must be
aligned to the NHSP-2 or preparation of NHSS. Accordingly, it complements the more longterm planned assistance from NHSSP and other external development partners.
8
4 CONTRIBUTION OF NHSSP TA TO NHSP-2
This section provides an overview of the contribution of DFID’s TA programme to the
achievements of NHSP-2 as well as its perceived added value by GoN and development partners
beyond the key work streams. A brief overview of progress of NHSP-211 is provided followed by
an analysis of where NHSSP has made significant or moderate in its contribution to NHSP-2 and
the challenges experienced.
For a detailed quantitative assessment of NHSSP against logframe targets see Annex 4 which
reports on progress against logframe indicators for NHSSP 1 and 2, details of activities
delivered/progress, challenges experienced and lessons learned. Tables summarising the TA
contribution, the sustainability of activities and recommendations for future TA across each of
the work streams are also provided.
Table 2 below shows an overview of progress of NHSP-2 across the outputs to which NHSSP has
contributed and progress of the contribution of NHSSP to this area ranked as significant or
moderate progress.
Table 2: Contribution of NHSSP TA to NHSP-2 Outputs
Progress
Significant
NHSP-2
outputs
Progress of NHSP-2
Reduced
cultural and
economic
barriers to
assessing
health care
services
Improved
sector
management
Growing commitment to GESI policy and intention,
expansion of GESI targeted interventions but work
needed to institutionalise into service delivery as
Nepal works towards universal coverage.
Diversifying skilled HR for health still needs to be
addressed.
Strengthened
human
resources for
health
Moderate
NHSSP TA contribution to NHSP-2 outputs
Some improvements including regular JCMs, JARs,
TA coordination, improved eAWPB process, use of
evidence in planning, NHSS endorsed. Further
strengthening of organisational structure,
leadership, planning, regulation, management and
harmonisation required. Planning not driven by
local needs.
State Non-State Partnership policy not endorsed.
Little progress made on establishing an effective
HRH system. HRH policy and strategy need to be
implemented. Freeze on recruitment until end of
2013.
Improved
service
delivery
Good progress made at increasing access and
service provision. Disaggregated data shows
improvements but considerable inequities still
exist. Focus on quality and addressing inequities
are priorities.
Improved
M&E and
health
Progress made to HMIS strengthening as well as
studies and surveys. Better integration of systems
needed with improved data quality and data use.
11
(Significant, moderate)
Structures, tools, policies and capacity developed
to take forward GESI. Support provided to scaleup GESI interventions.
Contributed to strengthening the delivery of
Aama.
Critical support provided to drafting of the new
Health Policy and new Health Strategy (NHSS), to
and to strengthening MoHP leadership of
JAR/JCM.
Support to drafting of HRH strategic plan, HRH
profile, workforce plans and projections
developed, HRH activities across DoHS and
MoHP mapped to identify bottle necks, gaps and
overlaps between departments and functions.
No HR support provided in NHSSP2.
Critical contributions to use of evidence
micro/context specific planning and to develop
strategies to improve access, equity and quality,
CEONC provision at district level, HQIP piloting
and proposed scale-up, FP pilots, scale-up of
OCMCs supported.
Critical contribution to HMIS strengthening in
terms of systems (e.g. DHIS, DQA), tools (e.g. for
routine data collection, user manuals), and skills
Undertaking a systematic review of progress of NHSP-2 was not part of the ToR for this assessment
9
information
systems
More disaggregated data available.
Improved
physical
assets and
logistics
management
Some progress in terms of establishing systems and
controls for procurement and strengthened
systems for new construction and facility
upgrading. Lack of timely procurement planning
and execution. Limited progress on distribution and
stock management, QA processes and healthcare
waste management.
Improved
health
governance
and financial
management
Absorptive capacity of ministry increased. eAWPB
introduced and more timely FMRs, TABUCS
implemented, FMIP finalised and implemented,
social audits scaled-up
Improved
sustainable
health
financing
Lack of clearly articulated health financing strategy.
Proportion of total budget allocated to health
reduced. OOP remains high. Draft National health
Insurance policy developed. Demand-side
measures including Aama implemented and have
increased access. Share of budget to EHCS
increased.
4.1
(e.g. to support district level online data entry);
to harmonising and strengthening surveys; to
utilise data for planning.
Critical contribution to developing tools
(specifications bank, contract management
system, web-based e-bidding) and systems
(consolidated annual procurement plan,
ICB/NCB) to improve procurement but limited
partial use of systems/tools and procurement
slow; considerable progress with site selection
guidelines, building standards, HISS with GIS
mapping to strengthen construction and facility
upgrading.
Considerable progress made to this area in
NHSSP2 with support to the pilot and roll-out of
TABUCS; strengthening of internal control
systems, audit clearance guidelines and roll-out
of EAWBP software has improved transparency
and efficiency in financial management
Valuable contributions include rapid assessments
and support to roll-out and monitor Aama and
other demand-side financing schemes.
Supported Aama unit cost study, annual review
and development of action plan in view of costs
of additional new-born services added to free
care. TA has been limited to improving delivery
of the Aama incentive to health facilities and
individuals but was not designed to facilitate the
broader dialogue on health financing called for in
NHSS.
Overview of progress of NHSP-2 and the contribution of TA
There has been considerable progress across key areas of NHSP-2 due to the contribution made
by DFID. As the DFID annual review stated in 2014 ‘It is rare to find substantive progress on so
many health systems and processes within such a politically and capacity-challenged
environment, yet maintaining strong leadership and commitment across partners’. The combined
investment in NHSP-2 of sector budget support and an associated embedded technical assistance
programme is seen to have resulted in a strengthened health system and to represent good value
for money, particularly in terms of longer-term systems building and sustainable service
delivery12.
The mid-term review of NHSP-2 indicated that good progress was made across most areas
(healthcare access, health sector management, service delivery, health knowledge and
awareness, M&E and information systems, physical assets and logistics management). It found
more limited progress against three key areas – human resources, health governance and
financial management, and sustainable health financing.
While progress in some key areas was slow in the early years of NHSP-2 the last few years have
seen accelerated progress, with the support of the DFID TA programme, and enhanced GoN
leadership, particularly around the development and use of health information and accounting
information systems (e.g. TABUCS), and clear construction guidelines. This demonstrates the
importance of long-term engagement and support in order to drive reforms in the sector and the
influence that embedded TA can have in driving capacity-building in health policy, delivery and
monitoring.
12
DFID Annual Review 2015
10
GoN counterparts and development partners confirmed that the strength of DFID TA is seen to
be in core systems strengthening, such as PFM, infrastructure and HMIS, at a central level
embedded within GoN. The DFID TA programme has been a critical force in supporting the MoHP
and associated ministries to develop new systems and implementation models, building capacity
along the way. Much of the progress made has been across the wider health system and in
particular in the area of technical guidelines, strengthened processes and information
management systems which should in turn drive efficiencies and accountability, and enhance
the ability of MoHP and their partners to take a more strategic and needs-based approach to
planning, budgeting and service delivery.
4.2
4.2.1
Significant progress
Improved health governance and financial management through the implementation
of TABUCS, eAWPB and strengthened audit clearance and internal control systems
TA contribution NHSSP’s support to the pilot and roll-out of TABUCS nationwide, including realtime tracking of budget expenditures by cost-centres; strengthening of internal control systems
new audit clearance guidelines and roll-out of EAWBP software has improved transparency and
efficiency in financial management. These new systems, processes and tools have been
embraced and are largely institutionalised across the sector. For example, TABUCS now accounts
for around 76% for all expenditures from 287 cost centres and has improved governance and
transparency of expenditures across the system. Whilst there are some software related issues to
resolve and the system isn’t being used to its full potential (i.e. to track revenue, linked to
eAWPB) it is widely accepted across the sector. These enhanced approaches to financial
management and expenditure tracking has improved absorptive capacity and thus, in theory,
their ability to lobby for a greater proportion of GoN budget to be allocated to health.
Constraints Despite these developments, the % of the total GoN budget assigned to health sector
has fallen marginally from 7.1% in 2011 to 6.5% in 2013, to 5.4%13 in 2014/15 against a target of
10% by 2015 (although has increased in real terms i.e. actual spend). One suggested reason for
this is seen to be the failure of the MoHP to spend is the budget allocation each year, with budget
execution hovering around 70%, and therefore acting as a disincentive for the Ministry of Finance
to allocate more to the health sector. The ability of a line ministry to spend its budget has been
affected by the wider political situation – for example, in the first 6 months of the 2013/14
financial year an ordinance budget was in place for the payment of salaries only. Irregular
procurement practices and partial compliance with standard procurement procedures is also
seen as a contributing factor leading to delays to procurement (See page 46 for further
information) and subsequent budget reallocations and contract awards and payments are often
significantly late.
Also, health sector planning and budgeting continues to be centralised with little flexibility for
districts to implement needs-based plans. Continuing to improve the sector’s planning processes
where the centre provides the priorities and targets and districts plans and implements through
provision of flexible block grants to districts is critical. Evidently further support to MoHP budget
management and delivery so that it can better absorb its current allocations and negotiate for
greater investments is critical.
13
Recent improvements in Nepal’s revenue base mean that the health budget has increased in real terms on 2013/14
levels.
11
4.2.2
Streamlined health sector infrastructure planning
TA contribution NHSSP has contributed to a shift in organisational culture with infrastructure
planning now based on catchment populations and geography, reducing ad-hoc planning,
resulting in a more rational approach to new construction and facility upgrading. The quality of
buildings built through the introduction of standards has improved and reduced times for
completion of construction achieved. Standards for health facilities, guidelines for site selection
for health facilities while facilitating enhanced cooperation with Department of Urban
Development and Building Construction (DUDBC) and the launch of a new web-based Health
Infrastructure Information System (HIIS) with GIS mapping were all supported by NHSSP. This
information is already being used to prioritise a number of new construction projects on the basis
of such factors as accessibility, population, availability of suitable land, morbidity and the
condition of current facilities.
The introduction of a new building works (infrastructure) e-bidding system with support from
NHSSP is estimated to have reduced the average price of new contracts by 12%, resulting in
around £3.4 million savings in the first year of its introduction alone. Further savings are
projected from the introduction of standardised, integrated designs for new health facilities –
while these guidelines cost around £30,000 to develop, they are expected to reduce the average
per metre construction cost by an estimated 16%.
Constraints The critical issue here is the sustainability of this support in the absence of
appropriate counterparts to take this work forward and ensure tools and systems are updated
and maintained. In particular, civil engineers are required at MD to maintain engineering
standards and plan for future infrastructure projects. They are also required to work with DUDBC
to establish quality assurance procedures for timely completion of high-quality health
infrastructures.
4.2.3
Strengthening the use of evidence in planning and strategy development for EHCS and
broader planning processes
TA contribution Embedded TA is seen by stakeholders to play a critical role in building capacity
(especially in FHD/CHD) to use evidence for policy and planning. The value of having embedded
expertise in DoHS in terms of strengthening the organisational culture and capacity to
understand and use data for developing pragmatic and context-specific strategies is evident.
NHSSP support has ensured that HMIS data can now be disaggregated to allow better assessment
of health sector performance and to better develop and implement targeted programmes for
underserved population groups. The provision of data to the divisions as part of the AWPB
process has also encouraged use of data across the sector at central level. A practice of analysing
evidence before the AWPB process was adopted in 2012/13 for using sector evidence to review
progress made under NHSP-2 and to set priorities, targets and baselines for NHSS. Surveys have
also been streamlined and reviewed to ensure that critical data for decision-making and
measuring progress of the health sector strategy is available. Lack of accurate burden of disease
data however, limits the ability to conduct truly needs-based planning.
There is evidence that the MoHP is incorporating evidence into policies in key areas such as
integrating the Aama and 4ANC incentive programmes; in the progress made in terms of
improving access to speciality care (i.e. caesarean sections) through improved functionality of
CEONC services; piloting of the Hospital Quality Improvement Process which is now to be scaledup to 10 districts with budget allocated to support this; strategies to address overcrowding in
12
referral hospitals including developing centres of excellence within selected strategic birthing
centres; improving MNH programming and monitoring in underserved remote areas with a
strong GESI element and the expansion of new approaches to family planning to reach
underserved populations.
Constraints Data is primarily used for reporting to the central level with little analysis at lower
levels for programme planning. Issues with data quality persist in a system where facility level
data collection and reporting is paper based and use of data is largely limited to central GoN.
There is also considerable scope to strengthen the architecture of health information systems
across the sector to create linkages across different data sources and improve data quality.
4.2.4
Improved implementation of Aama
TA contribution The increased support in the area of maternal and new-born health through the
‘Aama’ maternity incentive programme which evolved out of the DFID-funded Nepal Safer
Motherhood Project (NSMP) is valued by GoN. NHSSP has contributed to improved
implementation and governance of Aama, increasing institutional deliveries across all ethnicities
and castes. NHSSP worked closely with FHD to conduct rapid assessments to strengthen
governance of Aama and other DSF schemes and developed tools to monitor implementation of
Aama funds which are regularly updated and analysed for planning and budgeting at FHD. The
FHD has increasingly taken a lead in this process but requires support from TA to implement the
assessments and analyse the findings to better reflect the unit costs of Aama (e.g. at different
level of facilities, transportation incentives by regions) in future revisions, particularly, as
additional new-born services are added and a broader social health protection framework is
developed by MoHP and to contribute learning from Aama to develop the capacity of MoHP to
consolidate many demand side financing schemes under a social health protection framework.
Constraints Whilst access to maternal and new-born services has increased there are concerns
about the quality of care provided – and of lack of access to specialist life-saving services, such as
C-section, amongst some underserved groups. Quality of care continues to suffer as a result of
high number of unfilled positions (STS), high stock-out of drugs (STS) and poor skills of SBAs.
Ensuring not only delivery but effective delivery, as demonstrated by progress against a set of key
quality indicators is a focus for NHSS.
4.2.5 Gender Equality and Social Inclusion
NHSSP TA has provided a significant contribution to establishing an institutional structure to
communicate and support the introduction of GESI into the system; provision of tools and,
capacity enhancement to build skills on concepts, principles and application of GESI guidelines of
staff at MoHP, DoHS, RHDs and DHO/DPHOs. GESI has been incorporated in the National Health
Policy Review, HRH strategic plan, Urban Health Policy, NHSP-2 implementation plan, JAR report
and mainstreamed in AWPBs of departments and centres. Integration of GESI in social
mobilisation activities of Ministry of Federal Affairs and Local Development has also been piloted.
GESI interventions including Social Service Units (SSUs) One Stop Crisis Management Centres and
social audit have been piloted and scaled-up with support from NHSSP. A multi-sectoral response
to GBV at district level has also been supported by NHSSP.
A rapid assessment of health and governance social mobilisation programmes has been
undertaken and operational research is underway to explore the institutional and social factors
that underpin exclusion from social mobilisation programmes, non-participation of women and
poor and excluded groups in local governance structures and processes and why some groups are
13
not well-served by health services. Progress on gender and social exclusion remains fair with
survey data indicating that the differentials in mortality between difference castes and ethnic
groups and wealth quintiles is slowing declining.
Constraints Sustaining the progress made in this area is a key challenge moving forward.
Significant differences by socioeconomic group, caste and ethnicity still persist and as Nepal
moves towards universal coverage it is essential that the focus on GESI is sustained. Ensuring that
GESI has the correct institutional home moving forward for planning and delivery is essential to
ensure that the progress made by NHSSP in mainstreaming GESI continues.
4.2.6
Health policy and planning
TA contribution DFID TA was designed to focus largely at the central level in terms of supporting
the GoN with drafting the NHSS (now approved by cabinet), successfully supporting the GoN to
lead the JAR process, preparing a draft of the Public Private Partnership Policy (draft) and
developing the National Health Policy. NHSSP is also seen by DPs to have strengthened GoN’s
leadership of JCMs/JARs.
District Health Planning Guidelines were prepared and piloted in one district but convincing
districts of the utility of district plans when there is no response from the centre to these plans
was a challenge.
Constraints GoN expressed frustration at the lack of two-way dialogue facilitated by the
JCM/JARs with it seen largely as a forum for EDPs to ask questions of the GoN. The administrative
burden placed upon the GoN was also raised as an issue.
While TA inputs in this area were delivered effectively the centralised planning and budgeting
system and a lack of flexible finance at the regional and district levels, continues to limit the
ability of the health system to respond to local needs and contexts. There is very little flexibility
for districts to plan and spend according to their needs. While there are many partners (bilaterals, multi-laterals, NGOs) providing support for decentralized planning at district level, there
has been a lack of will within the MoHP to devolve certain authorities and financial decisionmaking.
4.3
4.3.1
Moderate progress
Human resources for health
TA contribution Whilst some of the building blocks for strengthening HRH were established with
support from NHSSP, a lack of political will within Government limited broader HRH reform and
substantive improvements to HRH systems and planning. NHSSP provided support to the HRH
strategic plan – which was approved by the cabinet at the end of 2012 after excessive delays but
has not yet been adopted in practice. NHSSP also supported development of a costed M&E
framework and human resource projections based on the plan. An HRH profile covering both
public and private sector workers was also completed, with support from NHSSP, as well as
workforce plans and projections to inform decisions about the design of services, staff training
and to inform strategic engagement with the private sector. HRH activities across DoHS and MoHP
were mapped to identify bottle necks, gaps and overlaps between departments and functions. An
institutional assessment of NHTC was completed with support from NHSSP to support its strategic
development as the identified body supporting all in-service training in Nepal.
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The area of human resources has seen less progress in large part due to the failure to pass an
Amended Health Services Act until the end of 2013. This resulted in a recruitment freeze to
sanctioned posts in the health sector. In response, DFID did not include this in the ToR for the
second phase of TA except if drawn down through TARF by GoN.
Constraints Although a significant number of posts were filled in 2014 the lack of a strategy to
ensure that the recruitment is based on merit or that deployment is strategic with skills matched
to posts has limited progress in this area. While GoN officials have been relatively open to joint
working in areas such as strengthening of M&E and accounting systems, procurement and
financial management, there has been less engagement in the area of human resources.
Furthermore, HR is a public sector wide issue and political will and reform is required beyond the
health sector.
4.4
Added contribution of TA beyond the logframe
NHSSP’s advisers are recognised by both GoN and DPs across the sector as engaging in activities
that go far beyond work plan requirements on a daily basis including responding at short notice
to requests, providing high level strategic guidance and taking on additional areas of work. There
were also broader operational or organisational shifts in terms of ways of working seen to be
attributable, at least in part, to NHSSP that were highlighted by those interviewed for this review.
Embedded TA well positioned to respond to rapidly emerging needs The post-earthquake
response by NHSSP phase 214 demonstrates how embedded TA is able to rapidly respond to
support the GoN with emerging situations. NHSSP worked with the GoN to rebuild its health
systems to provide health services and support to affected people. The contribution of NHSSP
has been invaluable, shifting work plans to support a range of activities including needs
assessments, data collection, coordination, recovering planning, information management and
supply of emergency medicines and equipment. NHSSP advisers worked closely with their
ministry counterparts through various post-earthquake thematic ‘clusters’ and working groups to
provide technical support for urgent activities including designing and carrying out multi-sectoral
post disaster needs assessments (PDNA) and planning in affected districts and preparing daily
and weekly district level status updates. The initial need assessments, followed up with more indepth technical assessments, helped the GoN to project total recovery costs across the country.
Prior to this, NHSSP also took on support to the GoN to implement family planning pilots to
expand access to remote areas after an earlier DFID contract to a service provider was cancelled.
In addition, NHSSP responded to the drive to rationalise the frequency/number of surveys and
instead of providing support to Nepal Household Survey (HHS) and STS, NHSSP helped develop
the National Health Facility Survey (NHFS).
NHSSP infrastructure advisors carried out assessments on building safety - this task continues,
along with the planning and supervision of repairs and reconstruction and responding to
numerous information needs from the many agencies seeking to provide effective support. This
was an area of support was highlighted by GoN and development partners interviewed in this
review as being critically important to the transition and recovery effort.
NHSSP has strengthened organisational culture and capacity within the MoHP/DoHS for reform
In addition to strengthening the structures, systems, tools and skills that facilitate an improved
health system, NHSSP is seen by development partners to have supported a stronger
14
This refers to the initial support provided as part of NHSSP Phase 2 and not as part of the separate Transition and
Recovery Programme.
15
bureaucratic cadre with a desire to drive reform and a broader way of thinking beyond vertical
programmes.
NHSSP has strengthened TA as a ‘process’ within the health sector Development partners
reported that NHSSP has contributed to strengthening the model of delivery of TA across the
sector from a discrete activity or output with limited dialogue to an iterative ‘process’ between
the GoN and the TA provider(s).
NHSSP facilitates effective contributions from other TA actors The embedded NHSSP Advisers
were seen by stakeholders to play a critical role in supporting the effectiveness of other TA
contributions across the sector. NHSSP was seen to provide a welcoming ‘hub’ of knowledge/’a
reference point’; skills and experience of the health system and GoN ways of working, and play a
critical role in helping to coordinate and encourage partnership. Other TA partners reported
valuing the closeness that embedded advisers have to GoN counterparts and their ability to
influence and advise the GoN on a day-to-day basis. DPs felt that the presence of embedded
advisers helps to facilitate and progress their TA contributions within the health sector and
examples provided include information systems, surveys, family planning. Part of this is
attributed to the strengthening of working through technical working groups (i.e. M&E TWG,
safer motherhood sub-committee, family planning sub-committee, PFM and Audit committees)
that NHSSP/DPs support, but is also due to the informal relationships that the advisers have
fostered with development partners across the sector. See Annex 6 for details of collaboration
between NHSSP and other partners.
Embedded TA supports GoN to build partnerships with other DPs/NGOs at district level to
support scale-up/implementation of GoN strategies Embedded TA is seen to play a critical role
in leveraging support from development partners to implement GoN approaches at district level.
The value of having embedded TA within FHD to provide the technical support to guide
implementation and to link with the GoN system was recognised by development partners and
advisers. In the case of USAID a model has evolved whereby USAID’s project-based approach to
financing allows them to invest in pilot interventions that, when successful, can be mainstreamed
into the health system with support from DFID and other DPs that provide sector budget support.
Good examples include the treatment of Acute Respiratory Infection (ARI) by community
volunteers, the community based new-born care programme and the family planning pilots. See
Annex 6 for details of collaboration between NHSSP and other partners.
NHSSP has supported establishing effective mechanisms and process for multi-sectoral working
NHSSP has been instrumental in promoting effective multi-sector working on a range of areas of
work, most notably in relation to the development of integrated GBV guidelines. With support
from NHSSP a lead Ministry was identified to champion GBV and through setting-up an effective
steering committee and technical working group the active involvement of the Ministry of
Finance and Ministry of Local Development was secured. The integrated guidelines were drafted
and are awaiting approval.
DFID TA contributes to effective partnership working and a mature SWAp through building and
fostering relationships with GoN and development partners The relationship between DFID,
NHSSP, other DPs and the various sections of the MoHP appears to have been relatively strong
throughout NHSP-2 despite concerns raised by both GoN and DPs about unrealistic and
unreasonable expectations of GoN by DPs (given the proportion of health sector budget
contributed by DPs).
16
Embedded TA programme has provided DFID with additional influence and is seen to represent
value for money The embedded technical assistance programme would appear to represent
particular VFM, providing a mechanism not only to support the GoN in a relatively flexible and
supportive manner, but a pathway through which DFID has been able to exercise significantly
more influence than it might through direct pooled funding to the SWAp alone (particularly given
the DFID contribution represents just 8% of the total spend in health). At this critical juncture for
the future of the SWAp, DFID should ensure this relationship and influence is sustained.
4.5 Conclusions on sustainability and recommendations for further TA across thematic areas
Stakeholders see the strength of DFID TA to be at the core systems reform and policy level.
Stakeholders recommended that DFID prioritise TA in the areas of: procurement and
infrastructure, public financial management and EHCS. These will remain major priorities for the
sector with no foreseeable significant technical assistance being provided by other TA agencies
on these areas . DFID TA is seen by other development partners and GoN to be best placed to
drive forward long-term reform in these areas.
Other areas of support where DFID TA is seen as important in the next phase include HRH, health
policy and planning, M&E and further support to GESI interventions/GBV response. DFID should
continue to actively coordinate with other agencies or NGO partners and build upon their
respective comparative advantages to ensure that TA inputs are coordinated across partners to
support the NHSS (USAID, GIZ, STC).
Infrastructure Support to the broader infrastructure planning, compliance to existing standards,
and timely completion of planned infrastructure continue to be paramount as Nepal responds to
the damage caused by the earthquakes. Lack of skilled human resources combined with the need
to strategically rebuild and repair infrastructure and medical equipment in earthquake affected
districts means that continued support in this area is viewed as critical by GoN and EDPs.
Transactional TA is required to move forward with urgent construction and repair as well as
transformative TA to institutionalise and strengthen systems and build capacity of MD and
DuDBC to ensure that health infrastructure is developed as per plans and standards.
PFM With acceptance of TABUCS across the sector to track expenditures; the ministry is also
keen to capture revenues collected by health facilities and utilise the eAWPB modules within
TABUCS to improve the efficiency of health planning at the district and central level. Further,
NHSSP will need to continue to support the MoHP and DoHS to implement and build capacity to
for internal control guidelines to reduce and clear budget irregularities. There will also be further
work required to ensure that TABUCS is compatible with the Line Ministry Budget Information
Systems (LMBIS) as Ministry of Finance is requesting other ministries to utilise the platform to
capture revenues by line ministries.
Procurement The support provided by NHSSP on procurement is widely recognised by the GoN
counterparts and other development partners, and, at least in the short term, there will continue
to be capacity substitution to support LMD to develop procurement documents until it has
appropriate cadres in place with procurement expertise. GoN counterparts and EDPs recognise
the critical role of TA to support reform of procurement and logistics systems responsible for
forecasting, tendering, contracting and supply chain processes. Procurement expertise to lay
foundations for establishing a procurement centre as proposed in the NHSS will be essential in
the next phase. Indications from USAID are that they will expand their support to supply chain
management and Logistics Management Information Systems (LMIS) in the near future.
Human resources for health Although Phase 2 did not provide TA to this area stakeholders see
this as a critical area requiring TA. Although this has proven challenging in the past, GoN
counterparts recognise the need for reform to ensure that effective systems are in place to
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support the move to federalism. Development partners emphasised that addressing this issue is
critical to sustainable improvements to the health sector. EDPs felt that DFID embedded TA, with
the close, trusted and effective working relationships established between advisers and the
ministry and the relationship DFID has had with Government over time, is well-positioned to
support this area of work. It was recommended that DFID should develop a dialogue with the
MoHP around HR and explore options for moving forward in this area. There is a need to better
understand barriers towards a more rational approach to health workforce planning and for the
development and maintenance of a transparent and rational approach to healthcare worker
recruitment, training and deployment. Joint agreement between the GoN and the partners on
the reforms needed in the sector, highlighting the role of the GoN and development partners to
realise the reform, should be established to ensure human resource planning and strategy is
realised.
Health policy and planning Support to strategic planning in the sector is also seen as critical by
stakeholders. Although there have been considerable improvements, planning continues to be
ad-hoc, not sufficiently evidence-based, and centralized. Tackling the mismatch between topdown planning and local needs leading to unrealistic budget submissions will strengthen the
planning process.
The earthquake transition and recovery programme, provides an opportunity for the next phase
of DFID TA to build upon learnings from delivering TA support at district level across the 14 worst
affected districts. Furthermore, moving ahead with federalism with newly created provinces,
provides opportunity to engage with the health ministry on functions and structures for various
levels of GoN and to support the process of devolved planning and decision-making. Plans for a
new organizational structure envisaged under federalism could allow additional staffing and
training to support this.
When a federal structure is agreed, it will have a significant impact, on health service delivery.
This should be taken into account in the design of future TA, particularly since the GoN is still
operating in a highly centralised planning and budgeting environment. Planned transition to a
federal state and devolved responsibility for health services could result in a deterioration in the
quality, and scope, of service delivery, in particular to the poor and excluded. Continuing to
support FHD/MD to improve quality through the scale-up and consolidation of QI systems like
HQIP will be critical as will continued support with translating evidence into strategies and
approaches to improve the scope of services and increase access amongst the poor and
underserved and coordinating with implementation partners to support scale-up.
M&E The support provided by NHSSP to strengthen access to quality routine data is highly valued
by the sector and is seen as critical to help facilitate the TA planned by other EDPs such as GIZ.
Capacity has been enhanced in MoHP and DoHS but with further routine information system
strengthening planned and limited capacity across the sector there is still a valuable role for the
routine technical expertise provided by embedded TA – especially in use of data for planning and
decision-making at all levels of GoN. In addition, TA is recommended in the NHSS and by advisers
to support development and implementation of a capacity strengthening plan with NHRC to
synthesize and promote the use of evidence including exploring potential relationships with
academic partners (international/local) and strengthening the link with Public Health
Administration and Monitoring & Evaluation Division (PHAMED) at MoHP.
GESI Ensuring that the sector addresses GESI in policy and planning and that underserved and
vulnerable groups are accessing services as Nepal moves towards Universal Coverage is critical.
Targeted programming for hard-to-reach or remote areas as being supported by NHSSP currently
is needed to ensure access to services amongst these populations. Increased funds to execute
18
plans at the district level where local context can be better considered and underserved
populations better served is essential.
Demand-side financing – Aama NHSS calls for harmonising the Aama programme within a
broader framework of social health protection, and further developing modalities for involving
private sector institutions in Aama implementation through state non-state partnerships. NHSSP
will support FHD to better reflect the unit costs of Aama (e.g. at different level of facilities,
transportation incentives by regions) in future revisions, particularly, as additional new-born
services are added and a broader social health protection framework is developed by MoHP. TA
is required to draw lessons from Aama, to contribute learning to develop the capacity of MoHP to
consolidate many demand side financing schemes under a social health protection framework.
The GoN has shown strong commitment in implementing health insurance and the Ministry of
Finance continues to set aside money for implementing insurance.
Specific recommendations for each thematic area are set-out in Annex 5
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5
LESSONS LEARNED FOR DELIVERING SUSTAINABLE TA
This section presents an overview of the lessons learned from NHSSP over five years for
delivering TA. Findings are structured around five key areas: 1) ensuring focus of TA deliverables
is relevant, appropriate and aligned to GoN priorities 2) ensuring the delivery model for TA is
appropriate 3) working within GoN systems and structures 4) working with GoN to ensure
systemic barriers are addressed from the outset and 5) working closely with development
partners to create an enabling environment for TA.
5.1
Ensure focus of TA deliverables is relevant, appropriate, aligned to GoN priorities and has
senior level buy-in
New systems were best embraced or owned by the GoN when developed alongside GoN,
aligned to their priorities, and when there is an incentive for those using the system i.e. reduces
workload and increases efficiency. Acknowledging the reality of the political economy and
striking the right balance between reform and pragmatism and when designing innovations is
important to ensure buy-in and sustainability. Recognising potential disincentives to comply with
a system and addressing them where possible through awareness raising and system design is
important.
TA is most effective at driving technical innovations in terms of systems and tools that enhance
working practices and show results Feedback from stakeholders indicates that TA has been most
effective at driving technical innovations, in terms of tools and systems, that enhance working
practices, improve efficiency/effectiveness and show demonstrable results. GoN counterparts
cited the many examples of tools and systems developed and implemented with support from
NHSSP (e.g. TABUCS, eAWPB, HMIS strengthening, Social Audit, SSUs, HQIP, Aama and GESI).
GoN ownership at a senior level helps to drive forward change The capacity of TA to secure buyin to a process, system or strategy is critical to driving forward reform. For example, improved
financial management and subsequently, improved budget absorption rate of the ministry was
desired by key senior leadership within the ministry. This led to a discussion and agreement on
the concept note for TABUCS. Strong leadership by MD, and the health minister, to de-politicise
the planning new infrastructure led to the site-selection criteria and guidelines. The Population
Division Chief was critical in supporting the GESI agenda and the Secretary acting as Chair for the
GESI Steering Committee which also raised the profile of this issue across the sector. In contrast,
there has been a lack of political will centrally to decentralise and devolve power, thus
decentralisation efforts stalled despite development partner interests.
5.2
Ensure the delivery model for TA is appropriate
Embedded TA is seen as accountable to GoN, which fosters trust and increases influence of
advisers to advocate for sustainable change DFID TA is seen by stakeholders as being
accountable both to the UK DFID and the MoHP which is seen as important in influencing GoN
and on receptiveness to TA. NHSSP are viewed as being aligned to GoN priorities, trusted and
integrated, ‘able to gauge expectations of GoN and move accordingly’ and were seen to act as a
conduit between DFID and the GoN as well as other development partners with a TA mandate.
Using evidence to drive policy decisions and strategy development leads to sustainable change
Supporting the generation of evidence through HMIS, surveys or pilots, and use of evidence to
20
inform planning or develop strategies has been a key element of NHSSP’s approach. This has
been used by NHSSP TA to influence and advocate to GoN counterparts and has led to better use
of evidence within the GoN resulting in a strengthened organisational culture in some divisions
(e.g. FHD, CHD, PPICD), increased understanding and consideration of GESI and the development
of context specific approaches to ensure that the underserved have access to EHCS. The
challenge moving forward is ensuring that this filters down to district level planning and strategy
development/implementation.
Direct sector budget support, flexibility and responsiveness of DFID TA is highly valued by GoN
The relationship between GoN and DFID is reported to have been strong through NHSP-2 due to
the direct contribution to NHSP-2 through sector budget support (rather than project-based
financing) and support to NHSSP TA. MoHP staff particularly value DFID’s continued commitment
to predictable pooled funding and provision of high performance advisers with an overall ‘can do’
attitude. Contracting based on payment-based deliverables and DFID’s ‘flexible and responsive’
approach to supporting TA is highly valued across the sector. Embedded NHSSP TA is seen by
stakeholders to have flexibility to respond to the day-to-day requests and inputs required and
valued by the GoN.
The flexibility that the Technical Assistance Response Fund [TARF] provides is highly
appreciated by GoN (i.e. developing National Health Policy and Health Act; supporting
emergency needs post-earthquake in preparing standards for pre-fabricated buildings, etc.). Up
to June 2015 the TARF had received 26 proposals of which it had funded 22 and the £500,000
allocated is on track to be spent by the end of Phase 2. In having access to, and control over, a
flexible and responsive technical assistance fund MoHP is better able to respond to changing
circumstances and fill programming gaps. Accordingly the TARF has served as a rapid response
tool and safety net that is highly valued by MoHP. It is recommended by stakeholders to include
such a fund in future MoHP AWPBs to institutionalise its provision under PPICD.
Although recognised as a useful tool for GoN, concerns were raised by other stakeholders outside
of GoN including the rate at which consultants can be paid under this fund being pegged too low
to attract the skills required for certain areas of work; that the fund reinforces bad practice as it is
open to the same contracting-related challenges that are endemic across the GoN and that the
types of activities being funded by TARF were routine activities (trainings) that should have been
planned by MoHP during AWPB process.
Appropriate team composition is critical with size, mix of expertise, experience and age across
the advisers all impacting effectiveness of TA delivery The smaller team in Phase 2 is seen as
being easier to navigate by other development partners and to have an appropriate mix of team
members in terms of experience and maturity. The team brings high-level expertise; skilfully
works with and navigates the system whilst maintaining a healthy distance when needed. ‘TA
needs to be able to negotiate GoN expectations and personalities and develop appropriate
strategies’. High levels of expertise of Nepali Advisers make them highly valuable to GoN
counterparts, and they are often called upon to perform duties beyond their ToR (e.g. write
speeches for the Minister, the Secretary and other high level officials; support NHRC in nationwide survey design, analysis, and joint publication of articles; developing of engineering drawings
for hospitals etc.,).
Building and supporting a coherent team of advisers strengthens the TA approach Embedded
advisors are exposed to challenges that those providing TA outside of GoN are less likely to
experience. Ensuring that advisers feel they are part of a supportive and cohesive TA team helps
advisers to respond to pressures and navigate the political economy of GoN. Cohesiveness is built
21
on longevity and relationships of trust and NHSSP has benefitted from advisers who have been
involved through both phases and have good relationships with both GoN and within the team.
5.3
Work within GoN systems and structures
Ensure TA is positioned at appropriate level within GoN structure In Phase 1 TA was provided to
the five regions within the Regional health Divisions. Whilst some positive developments as a
result of TA were reported, the effectiveness of the TA effort was limited by the lack of autonomy
held by the regions resulting in incomplete ownership of programme planning, implementation
and evaluation (as recognised by DFID in the TOR for Phase 2). Learning lessons from this
experience when structuring future TA programmes around new federal structures as they
emerge is critical to ensure that TA is positioned appropriately to achieve optimal results.
Strengthening and working through Technical Working Groups supports consensus,
coordination, harmonisation of TA and partnerships resulting in sustainable change A critical
process for driving forward reform identified across the stakeholders has been strengthening and
working through Steering Committees and Technical Working Groups. SCs and TWGs provide an
opportunity to advocate/influence, agree on a way forward/strategy across divisions/partners,
coordinate inputs to an area of work, provide quality assurance and to keep work on track and to
an agreed timeline. Despite the high number of SCs/TWGS across the sector these are largely
seen by stakeholders as effective mechanisms to drive change.
5.4
Work with GoN to ensure systemic barriers are addressed from the outset
Agree with the GoN from the outset detailed capacity enhancement plan, including GoN
commitment to stable posts, and an exit strategy for TA The system is not currently able to
absorb capacity enhancement sufficiently in certain divisions. High staff turnover, frequent
transfers or lack of sanctioned posts is a challenge across the sector raised by GoN, development
partners and advisers. For example, lack of procurement and bio-medical expertise in LMD has
delayed the capacity of development efforts by NHSSP to implement standard procurement
procedures and implement bio-medical specifications. Lack of civil engineering expertise has
hampered capacity development for building standards at the Management Division and
coordination within DuDBC in quality assurance and timeliness of construction. Within FHD,
whilst the GoN has allocated budget to scale-up HQIP across 10 districts a member of staff is not
available to facilitate the scale-up, with a similar situation faced with the potential scale-up of
piloted family planning approaches.
In a climate of frequent transfers, high turnover and unfilled posts; building tools and systems is a
sensible approach to strengthening the health sector. Ensuring new systems can be managed and
monitored effectively moving forward is key to long-term sustainability. There is recognition by
GoN that this is a joint responsibility of GoN and TA, that this should be negotiated and agreed
from the out-set to ensure posts are filled to enable capacity building efforts to materialise.
Agreeing with the relevant division a TA plan with a timeframe for support; the type of TA to be
provided and whether this should change over time (i.e. from transactional to transformational
etc.); requirements from the GoN to ensure effective CE and sustainability (e.g. counterpart in
post for agreed period of time) and an exit strategy based on this agreed plan is seen to be a
critical component of effective embedded TA. Plans and exit strategies should be reviewed on an
on-going basis to ensure that factors hindering effective capacity enhancement can potentially be
addressed.
22
Working with GoN to identify the correct institutional home is key to effective CE and
sustainability Where an appropriate division is identified to lead results the potential for longerterm sustainability is seen to be greater. For example, PHCRD, the focal division for free care, is
seen to be an appropriate institutional home for social audits resulting in confidence about its
sustainability. In contrast, GESI is housed at the Population Division in the ministry with little
influence in the overall policy and planning for the sector, the mandate for which is with the
PPICD which raises concerns about whether GESI will be adequately built into planning processes.
(See Annex 4 for specific details of where institutional home of an area of work has hindered
capacity enhancement across each work stream).
Support GoN to issue multi-year contracts to enable scale-up of interventions and service
delivery Lack of multi-year contracts has hindered, for example, the scale-up of EAP resulting in
fragmented inputs by NGOs and compromising the quality of programme implementation. This
has also been an issue when contracting health workers (i.e. ASBA), severely disrupting
availability of C-sections at district hospitals during the early months of the new fiscal year when
the budget is released late.
5.5
Work closely with development partners to create an enabling environment for TA
Aid effectiveness and harmonisation across the TA sector needs strengthening to ensure
continued GoN receptiveness to TA Efforts have been made in the past to harmonise TA efforts
and to ensure alignment to GoN strategies. A TA/TC committee at the MoHP was established
during NHSP-2 and drafts of Joint Technical Assistance Arrangements (JTAA) were also floated
but didn’t materialise. GoN and some EDPs felt that EDPs should more clearly communicate their
plans for TA to GoN moving forward. The GoN is increasingly sensitive about the growing volume
of TA delivered by an expanding and diverse set of partners, which it finds difficult to manage.
GoN feel that disproportionately large amounts of TA are available in areas that are of interest to
partners or protect their financial investment (i.e. public financial management, procurement),
while there is limited TA in other key areas of GoN priority (i.e. drug control, quality of care, etc.).
These factors could contribute to tensions between EDPs and the GoN, act to reduce
receptiveness to TA and hinder future TA efforts.
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6
RECOMMENDATIONS FOR FUTURE TA IN TRANSITION TO NHSS
DFID TA is seen by both GoN and EDPs to provide a critical contribution to the sector.
Recommendations for future areas of TA to support NHSS, based on feedback from the
stakeholders interviewed and previous reviews of NHSP-2 and NHSSP TA, are summarised in
Table 3 below. Detailed recommendations across the thematic areas covered by NHSSP are
provided in Annex 5.
Sustain a dual focus on strengthening central systems and supporting districts to ‘build back
better’ The review suggests that in view of the transition and recovery from the earthquake as
well as the planned move to federalism, it is critical that DFID TA sustains a dual focus on
maintaining central level systems support in key areas (infrastructure, procurement, PFM, EHCS)
whilst focusing on district level strengthening of health systems and services and decentralised
planning and budgeting.
Ensure equitable access to and functionality of quality essential health services
The aspiration to ‘build back better’, supported by DFID’s TA to Recovery and Transition
programme, will support strategic transition to recovery and restoration of systems and
contribute to expanded availability and functionality of essential health services.
This will require, for example, TA to work with Government to ensure that infrastructure
assessments inform designs and plans that meet short-term emergency needs as well as longer
term strategic rebuilding efforts. TA should continue to provide valuable support to the careful
sequencing of infrastructure repairs, with procurement, EHCS and financing activities, to ensure
that buildings, supplies and services are in place in a coordinated and timely manner.
The impact of the federal structure on health service delivery should be taken into account in the
design of future TA, particularly since the GoN is still operating in a highly centralised planning
and budgeting environment. Planned transition to a federal state and devolved responsibility for
health services could result in deterioration in quality, and scope, of service delivery, in particular
to the poor and excluded. Continuing to support FHD/MD to improve quality through the scaleup and consolidation of QI systems like HQIP will be critical as will continued support translating
evidence from pilots into strategies and approaches to improve the scope of services and
increase access amongst the poor and underserved.
Strengthening district planning and implementation systems
TA has a critical role at central and district levels to support transition to longer-term health
systems planning in line with NHSS and federalism and to ensure that all the components of
rebuilding and strengthening the health system are delivered with an evidence-based and
coordinated approach across partners.
TA support has and will continue to provide, through the T and R programme, valuable evidence
that can be used to inform delivery of NHSS. Support to district planning and implementation to
build back better systems and services and through the strategic prioritisation of health services
will provide valuable lessons to inform planning for decentralisation in the move to a federal
structure. For example, implementation lessons and assessment of costs of care for expanded
family planning services or for people with post-earthquake injuries and psychological trauma will
help inform planning for services. Expansion of service availability in select districts through
contracted NGOs will be developed, implemented and monitored in a coordinated fashion for
efficient provision within a district health systems framework and will provide valuable learnings
24
for expanding relationships with NGOs to meet unmet needs and address gaps in service
provision at district level identified in NHSS.
Federalism provides an opportunity for critical reform in core areas
NHSS and federalism present opportunity for reform of existing systems within the new
structure. TA should engage with the ministry on functions and structures and support the
process of devolved planning and decision-making. Continuing to improve the sector’s planning
processes where the centre provides the priorities and targets and districts plans and implements
through provision of flexible block grants to districts is critical. Further TA support to MoHP
budget management and delivery is critical to ensure better absorption of current allocations and
negotiation for greater investments.
In addition to critical capacity substitution to support routine procurement, GoN counterparts
and EDPs recognise the critical role of TA to support GoN to lay the foundations for procurement
reform.
Federalism and NHSS also provide an opportunity for much needed HR reform to ensure that
effective systems are in place to support a more transparent rational approach to health
workforce planning, recruitment, training and deployment.
Harmonising social health protection NHSS calls for harmonising the Aama programme within a
broader framework of social health protection, and further developing and piloting modalities for
involving private sector institutions in Aama implementation through state non-state
partnerships. TA is required to draw lessons from Aama and to contribute learning to develop the
capacity of MoHP to consolidate demand side financing schemes under a social health protection
framework.
25
Table 3: Recommendations for next phase of TA
NHSS
Outcomes15
Rebuilt and
strengthened
health
system: HRH,
Infrastructure,
Procurement
and Supply
chain
management
Recommendations for continuation of current TA support
Recommendations for emerging areas of TA support
HR: DFID removed HR from Phase 2 with the exception of demand-led support to
be provided through the TARF upon request from GoN.
HR: Feedback from GoN and EDPs indicate that this is seen to be a critical area for
further DFID TA due its perceived effectiveness at influencing and working on core
systems at a strategic/policy level, closely aligned to GoN. The 2014 Aide
Memoire includes a MoHP commitment to build upon the 2011 Human Resources
Strategy and an organisation and management survey has been conducted. TA
support to strengthen production, deployment and retention of human resources
including improved data on workforce distribution and support to the devolution
of HR management to subordinate authorities is required. Influencing HR planning
may, be a slow one but it will be an important aspect of TA support to NHSS if
good performance, further efficiencies and the value of TA to GoN are to be fully
realised. Other DPs did not indicate intention to provide TA to this area.
Procurement: GoN counterparts and EDPs recognise the critical role of TA to
support reform of procurement and logistics systems responsible for forecasting,
tendering, contracting and supply chain processes. Procurement expertise to lay
foundations for establishing a procurement centre as proposed in the NHSS will
be essential in the next phase. Indications from USAID are that they will expand
their support to supply chain management and Logistics Management
Information Systems (LMIS) in the near future.
Infrastructure: A priority area for GoN, identified in their strategy and in
discussions, is improving capacity of management of health infrastructure and
medical equipment at LMD and at decentralised levels. KfW has recently awarded
TA to strengthen capacity at regional levels to maintain bio-medical equipment,
which will be coordinated through the Management Division within the Physical
Asset Management (PAM) unit.
Procurement: GoN counterparts and EDPs felt that this is a critical area for
further TA to institutionalise tools and systems, strengthen capacity and develop
IT systems to support timely and transparent procurement. Transactional TA has
been requested by GoN as technical procurement and bio-medical expertise is
lacking to institutionalise tools and systems.
Improved
quality of care
at point-ofdelivery
Infrastructure: Lack of skilled human resources combined with the need to
strategically rebuild and repair infrastructure and medical equipment in
earthquake affected districts means that continued support in this area is viewed
as critical by GoN and EDPs. Transactional TA is required to move forward with
urgent construction and repair as well as transformative TA to institutionalise and
strengthen systems and build capacity of MD and DuDBC to ensure that health
infrastructure is developed as per plans and standards.
Budget has been allocated to scale-up HQIP in 10 districts but FHD & MD currently
lack capacity to provide required support. TA is needed for a time-bound period
to work alongside identified FHD staff to develop capacity with a clear exit
strategy in place to ensure sustainability. Advisers felt that TA is well-positioned
to support the GoN and to work with partners to develop a consolidated QI
system for the health sector. It was recognised that there are many DPs working
in this area and so communication across partners to coordinate support, and
support GoN to work towards a consolidated system is seen as critical.
15
Improving quality at the point of service delivery is seen as a critical area for
further TA support by all stakeholders to support the GoN to establish minimum
standards and build capacity; to develop, implement and monitor regulations to
accredit health institutions and to establish QA mechanisms for medicines,
supplies, lab services and equipment. TA to develop an independent body for
quality assurance and accreditation and to strengthen capacity of the National
Public Health Laboratory and drug regulatory authority or the Department of Drug
Administration (DDA) are highlighted in NHSS. TA could also play a critical role in
The following outcomes are not included in the recommendations as TA was not provided in NHSSP and was not identified as priority areas moving forward into the next phase by the stakeholders
interviewed in this study: Improved healthy lifestyles and environment and Strengthened management of public health emergencies
26
Equitable
distribution
and utilization
of health care
services
supporting the GoN on licensing and monitoring the quality of care of the private
sector and strengthening healthcare waste management.
A critical area of support identified by the adviser, GoN counterparts and in NHSS
is to strengthen referral across the system.
TA support is required to sustain and expand access to EHCS and further progress
reductions to inequities in health outcomes. TA should continue to support
MoHP/DoHS to develop client-centred strategies, support context specific
planning and potential scale-up of the interventions based on evidence. For
example, gains made in provision of district level CEONC services require further
TA to substitute for on-going lack of capacity in FHD to support this.
Improving utilisation, hence health outcomes, of underserved population groups
requires devolution of planning and financial decision-making to sub-ordinate
authorities at district and lower levels, where these population groups can be
better served through targeted programmes.
Support will be needed to the ministry to develop formulas for distribution of
flexible funds to districts to cater to district health needs as well as national
priorities, including monitoring implementation of the flexible budgets.
Ensuring that GESI is built into the new federal structures and integrated into
planning will help to achieve equitable distribution and utilisation of health care
services. Support to strengthen and monitor GESI interventions (e.g. SSU) is also
required to ensure sustainability.
Continued support to expand OCMC to every district hospital and to roll-out GBV
protocols as per NHSS is required.
Strengthened
decentralised
planning and
budgeting
Improved
sector
management
It is acknowledged in NHSS and by GoN/EDPs that further TA to strengthen and
build capacity for harmonised evidence-based annual planning and budgeting is
required both at central level and at district level. This translates to further TA
support at the MoHP to develop Business Plans and the AWPBs that
operationalizes the NHSS and support Divisions and Centres to plan accordingly,
while also ensuring further flexible funds are provided to districts by MoHP. At
central level, support to establish a regulatory framework and monitoring
mechanisms will be important for delivering NHSS.
EDPs emphasised that NHSSP TA has focused primarily at central level, with other
partners working at district level. The earthquake transition and recovery
programme is being implemented across the 14 affected districts and will provide
learning to inform future work at district level. Coordination of DP inputs to
districts to support planning is critical when planning future TA inputs in this area.
The signing of the collaborative framework between the MoHP and the Ministry of
Federal Affairs and Local Development provide an opportunity for progress as will
the new arrangements introduced in the move to federalism. Pushing forward the
strengthening of state non-state partnership functions, particularly for service
delivery in remote or hard-to-reach areas, within PPICD, is also an area requiring
further focus moving forward.
PFM is seen by MoHP and EDPs as a core area of support for DFID TA. An NHSS
priority is to strengthen current practices on financial planning, auditing and
transparency and continued support to build capacity to improve, expand
The GoN recognises the need for specialist support to the restructuring across the
health sector as it moves to federalism with broad implications for the entire
heath sector.
27
and
governance
utilisation and manage TABUCS to ensure the system is fully institutionalised,
further roll-out of eAWPB software and strengthening audit clearance are seen by
GoN to be a critical to achieving this.
It is recommended that a review of TARF is undertaken to explore its
functionality, types of activities funded and governance, processes for monitoring
the quality of work delivered and whether any changes would be required were
this fund to be made available in the future.
Stakeholders also recognised the role that TA can play in supporting MoHP to
work with state non-state partners and enhance capacity in PPP.
Further short-term support to the social audit process to promote accountability
and ensure sustainability is also required.
Improved
sustainability
of health
sector
financing [HF,
PFM, DSF]
Improved
availability
and use of
evidence in
decisionmaking
processes at
all levels
Embedded TA could play a valuable role in supporting streamlining and
strengthening of governance mechanisms (JCMs/JARs) to encourage two-way
dialogue in response to concerns raised by GoN. Development partners
recommend that DFID/NHSSP support the GoN as it negotiates SWAp
arrangements for the next phase of financial support to the sector.
Ensuring that lessons from the Aama unit costing study and rapid assessments,
STS and NDHS are used to inform broader health financing and harmonisation
within the broader framework health social protection is seen as valuable by the
stakeholders.
Embedded TA is seen to provide a valuable role in supporting improved
availability, quality and use of evidence in decision-making. EDPs report that
partners are well-coordinated/ harmonised in this area, and this is partially
attributed to embedded TA acting as a focal point for communication. Capacity
has been enhanced in MoHP and DoHS but with further systems strengthening
planned and limited capacity across the sector there is still a valuable role for the
routine technical expertise provided by embedded TA – especially in use of data
for planning and decision-making at all levels of GoN. Other EDPs, such as
UNICEF, WHO and GIZ, are working with the GoN at the policy and district level in
developing and implementing health information system architecture, requiring
close coordination across DPs in this area should continue.
28
Priorities for the GoN in the next phase include developing a health financing
strategy and framework, strengthening resource allocation practices,
strengthening social health protection mechanisms and initiating a health social
security programme. Other EDPs, such as GIZ and WHO, will be supporting this
area of work so coordination across partners is critical. Pushing forward the
strengthening of state non-state partnership and purchasing functions,
particularly for service delivery in remote or hard-to-reach areas, within PPICD, is
also an area requiring further focus moving forward.
In addition to support to the GoN, TA is recommended by NHSS and advisers to
support development and implementation of a capacity strengthening plan with
NHRC to synthesize and promote the use of evidence including exploring potential
relationships with academic partners (international/local) and strengthening the
link with Public Health Administration and Monitoring & Evaluation Division
(PHAMED) at MoHP.
Annex 1: ToR
Annex 2: List of stakeholders interviewed
GoN Counterparts
Dr. Shilu Aryal, Safe Motherhood Focal Person, Family Health Division
Dr. Bhim Singh Tinkari, Director, LMD
Mr. Sagar Dahal, Chief, Health Sector Reform Unit, MoHP
Dr. Padam B. Chand, Chief Specialist, MoHP
Dr. Senendra Upreti, DG, DoHS
Dr. Bhim Acharya, MD
Development Partners
Dr. Jos VANDELAER, WHO Country Representative
Ms. Shanda Steimer, Director of Health, USAID
Dr. Asha Pun, Maternal Health Specialist, UNICEF
Ms. Franziska Fuerst, Team Leader, Health Financing (insurance), GIZ
Mr. Sudip Pokhrel, Freelance (formerly Health Policy and Planning Advisor NHSSP Phase 2)
Ms. Natasha Mesko, former Health Advisor, DFID
Dr. Manav Bhattarai, World Bank
Ms. Latika Pradhan, UNFPA, formerly AUSAID
NHSSP Advisers and Staff
Dr. Suresh Mehata, Research Advisor, NHSSP
Dr. Suresh Tiwari, Health Financing Advisor, NHSSP
Mr. Pradeep Paudel, M&E Advisor, NHSSP
Mr. Sitaram Prasai, GESI Advisor, NHSSP
Mr. Stuart King, Team Leader, NHSSP
Mr. Greg Whiteside, QA Advisor, NHSSP
Dr. Maureen Darang, EHCS Advisor, NHSSP
Dr. Rajendra, Family Planning Advisor, NHSSP
Krishna Sharma, Head of Programme Management
Ramchandra Man Singh, Advisor (NHSSP 1 only)
29
LIST OF REFERENCES
Central Bureau of Statistics. " Nepal Living Standards Survey 2010/11." Kathmandu, 2012.
Central Bureau of Statistics. "Nepal Multiple Indicator Cluster Survey 2014 Key Findings."
Kathmandu, 2014.
Ministry of Home Affairs. Disaster Risk Reduction Portal. http://www.drrrportal.gov.np/ Accessed
15 June, 2015.
Council for Technical Education and Vocational Training. “Technical and Vocational Education and
Training Development Journal.” Vol 1(10). Bhaktapur, 2010.
Ministry of Health and Population, New ERA, and ICF International Inc. "Nepal Demographic and
Health Survey 2011." Kathmandu: Ministry of Health and Population, New ERA, ICF
International Inc., 2012.
Ministry of Health and Population. "Nepal Health Sector Programme I (2004-2009)." Kathmandu:
GoN of Nepal, 2004.
Ministry of Health and Population. "Nepal Health Sector Programme II (2010-2015)." Kathmandu:
GoN of Nepal, 2010.
Ministry of Health and Population. "Nepal Health Sector Strategy (2015-2020)." Kathmandu: GoN
of Nepal, 2015.
GoN of Nepal. “Constitution of Nepal (2015).” Kathmandu: GoN of Nepal, 2015.
WHO, UNICEF, UNFPA, The World Bank, and United Nations Population Division. "Trends in
Maternal Mortality: 1990 to 2013." Geneva, 2014.
‘Formulation of Capacity Development Framework FRP – S&P – 2008-136’ by Oxford Policy
Management, May 2009.
REFERENCES
Beer M, Organisational Change and Development. Goodyear Publishing, Santa Monica Ca, 1980.
Dickinson C, Global Health Initiatives and health systems strengthening: the challenge of
providing technical support. HLSP Technical Approach Paper, June 2008.
Ministry of Finance, 2010, Joint Evaluation of the Implementation of the Paris Declaration, Phase
II, Nepal Country Evaluation.
Oxford Policy Management, Formulation of Capacity Development Framework FRP – S&P – 2008136, May 2009.
Oxford Policy Management, Developing Capacity? An Evaluation of DFID funded Technical
Cooperation for Economic Management in Sub-Saharan Africa. Synthesis Report EV667, DFID,
2006.
Potter C and R Brough, Systemic capacity building: a hierarchy of needs. Health Policy and
Planning; 19(5), 2004.
UNDP capacity assessment methodology – user guide, Feb 2008.
30
Annex 3: Capacity pyramid
• Performance capacity: Are the tools, money, equipment, consumables, etc. available to do the
job? A doctor, however well trained, without diagnostic instruments, drugs or therapeutic
consumables is of very limited use.
• Personal capacity: Are the staff sufficiently knowledgeable, skilled and confident to perform
properly? Do they need training, experience, or motivation? Are they deficient in technical skills,
managerial skills, interpersonal skills, gender-sensitivity skills, or specific role-related skills?
• Workload capacity: Are there enough staff with broad enough skills to cope with the workload?
Are job descriptions practicable? Is skill mix appropriate?
• Supervisory capacity: Are there reporting and monitoring systems in place? Are there clear lines
of accountability? Can supervisors physically monitor the staff under them? Are there effective
incentives and sanctions available?
• Facility capacity: Are training centres big enough, with the right staff in sufficient numbers? Are
clinics and hospitals of a size to cope with the patient workload? Are staff residences sufficiently
large? Are there enough offices, workshops and warehouses to support the workload?
• Support service capacity: Are there laboratories, training institutions, bio-medical engineering
services, supply organizations, building services, administrative staff, laundries, research facilities,
quality control services? They may be provided by the private sector, but they are required.
• Systems capacity: Do the flows of information, money and managerial decisions function in a
timely and effective manner? Can purchases be made without lengthy delays for authorization?
Are proper filing and information systems in use? Are staff transferred without reference to local
managers’ wishes? Can private sector services be contracted as required? Is there good
communication with the community? Are there sufficient links with NGOs?
• Structural capacity: Are there decision-making forums where inter-sectoral discussion may
occur and corporate decisions made, records kept and individuals called to account for nonperformance?
• Role capacity: This applies to individuals, to teams and to structure such as committees. Have
they been given the authority and responsibility to make the decisions essential to effective
performance, whether regarding schedules, money, staff appointments, etc?
Annex 4: NHSSP logframe indicators - TA contribution, assessment of sustainability and
recommendations
Separate logframes were developed for NHSSP 1 and 2 to measure performance and the results
are summarised in tables x to x below. Impact, outcome and output indicators are included in the
logframes. This section provides a review of progress against outcome and impact indicators
whilst section 4 reviews discusses progress across the outputs for each of the thematic areas.
Progress against programme logframes has been assessed annually by DFID during its annual
reviews of NHSP-2 with changes to indicators and targets made as required.
31
Table 1: NHSSP Phase 1 & 2 logframe impact indicators
Impact
Indicator
Baseline
NHSSP 1: 2010
Milestone 1
(2011)
Milestone 2
(2012)
Target 2015
Comment on
performance
Phase 1 2010 – 2013
Increased utilisation of
essential health care services
especially by women, the poor
and excluded
Diarrhoea cases among under-5
children treated with Zinc & Oral
Rehydration Solution (ORS).
6.6% zinc (rural)
67.6% ORS &
zinc
45.6% ORS
Planned: 7%
25%
40%
Skilled attendance at birth (% and
number of births and by lowest and
second wealth quintiles)
8.2% (poor)
Planned: 12%
(poor)
Achieved
(NB. HMIS data
used instead of DHS
data which is not
yet available)
No data
Data source: DHS 2011 & DHS
2015
Achieved:
95.3% (HMIS
2013)
20% (poor)
25% (poor)
85%
85%
83%
(2006)
85%
Baseline NHSSP
2: 2013
45.3%
Milestone 1
(2014)
Planned: 53%
Milestone 2
(2015)
60%
On track
2.2%
Achieved:
Planned: 1.6%
56.4%
<1%
Data not available
Phase 2 2013 – 2015
Increased utilization of health
services, and improved health
and nutritional behaviour of
the people of Nepal
% of deliveries conducted by a
skilled birth attendant
Obstetric direct case fatality rate
(%)
Data source: HMIS
1
Table 2: NHSSP 1 logframe outcome indicators
Outcome Indicator
Milestone (2013)
Progress Summary of Activities
Challenges/lessons learned
Strengthened health system to increase access to sustainable, quality EHCS for poor women and underserved populations
% of districts with at
least one health
facility providing all
CEONC signal
functions 24/7 (100%
of districts = 75)
Baseline: 44% (33 districts)
Planned: 68%
Achieved:
72% (54
districts)
Fully met
NHSSP worked with FHD to:
% of health facilities
that have undertaken
a social audit as per
MOHP guidelines in
the last FY
Absorption rate of
committed funds for
the health sector
% of sanctioned posts
that are filled
Baseline: 0
Planned: 15%
Achieved: 15%
(236/4010 facilities in 22
districts)
Baseline: 80%
Planned: 86%
Achieved: 97%
Baseline: 77% doctors,
89% nursing staff
Planned: 88% doctors,
88% nursing staff
Achieved: 63% doctors,
83% nursing staff
Not met
Not met
NHSSP supported:
- development of Human Resource Strategic plan
% of health facilities
with no stock-outs of
listed free drugs in all
four quarters
Baseline: N/K
Planned: 80%
Achieved: 23%
Not met
NHSSP focused on strengthening
procurement systems and planning
-increase CEONC allocations in AWPBs
-develop plans to expand C-section training sites
-advocate for increase in sanctioned posts
NHSSP funded CEONC mentor to work with CEONC
providers to overcome barriers to service provision
-Absence of multi-year contracting impacts
functionality and continuity of CEONCE services
-Availability of trained CEONCE providers esp. for
semi-remote/remote areas
Training MBBS doctors in advanced SBA skills and
CEONC mentoring interventions greatly enhance
availability of CEONC services
NHSSP supported:
-development of Social Audit guidelines
-implementation of 236 social audits
- evaluation of Social Audits in Palpa and
Rupandehi
Fully met
2
central
Delay in approving Health Services Act has
affected recruitment
Strategies in HRH strategic plan not implemented
to impact recruitment numbers
Decisions on staff transfers and recruitment are
primarily made at the central level with limited
authority devolved to lower level authorities
Table 3: NHSSP 2 logframe outcome indicators
Outcome Indicator
Milestone (2015)
Progress
Summary of Activities
Challenges/lessons learned
Increased and equitable access to quality essential health services
% of the population
living within 30minutes travel time to
a health or sub-health
post
% of deliveries by
Caesarean Section (CS
rate)
Baseline: 50%
Planned: 80%
Latest data: 62% (NLSS
2010/11)
On track
Fully met
% districts with at
least one public facility
providing all CEONC
function
Baseline: 5.8%
Planned: 4.5%
Latest data: 6.7% (HMIS
2013/14)
Baseline: 67% (50 districts)
Planned: 76% (57 districts)
Latest data: 84% (62
districts)
% of children, under
five with pneumonia,
who
receive
antibiotics
Baseline: 42.1%
Planned: 50%
Latest
data:
(2013/14)
Fully met
but
continuity
of
services is
a
challenge
Not on
track
Many of the doctors working in these facilities
have temporary contracts. Budget is often
released 3-6 months after beginning of FY when
many of these contracts are unpaid, hence CEONC
functions are unavailable during the same
months.
41%
Health policy and Planning
Table 4: NHSSP 1 progress against output indicators, challenges & lessons Health Policy and Planning
Output
Indicator
Milestone
(2013)
Progress Summary of Activities/ comments on progress
3
Challenges/lessons learned
Output 7: PPICD has a clearly defined and functional role as the focal point of the planning and policy process for the health sector
PPICD led and
implemented the
JAR process
PPICD updated
and
disseminated the
National Health
Policy and the
nationally agreed
Planning
Guidelines for
Health
PPICD staff
lead
preparation
for the JAR
and the
completion
and sign off of
the final JAR
report
National
Health Policy
disseminated;
the Planning
Guidelines for
Health
developed
and piloted
Achieved
PPICD led on the JAR 2013 preparation and
implementation which resulted in an Aide-Memoire that
was signed within weeks of the JAR completion.
PPICD staff are very busy in the months leading up to the JAR
due to GoN reviews and find it difficult to do the necessary
work to prepare the JAR.
The JAR 2013 was considered by many to be the most
successful so far.
Partly
met
Supported drafting of the National Health Policy endorsed in 2014.
It is difficult to convince districts of the utility of district plans
when there is no response from the centre to district plans
District Health Planning Guidelines were drafted by MD
for use by DHOs. All DHOs and some of their partners
were oriented on the guidelines which were piloted in
one district.
Further experience of using the planning guidelines is needed
Health Facilities Operations Manual produced
Table 5: NHSSP 2 progress against output indicators, challenges & lessons Health Policy and Planning
Output Indicator
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
Output 3.1: Draft NHSS document [Milestone 2015: Final draft of NHSP-3 accepted by MoHP and forwarded to Cabinet by January 2015]
3.1.1 Support to Strategic
planning for NHSS
Achieved
-NHSSP advisers contributed to working groups and
provided feedback on draft documents
3.1.2 Support the development of
the 5-year (2015-2020) NHSS
Achieved
-NHSSP supported GoN with process and drafting of
NHSS along with consultant funded through TARF and
other consultants
-NHSS endorsed in October 2015 but much longer
process than anticipated
3.1.3 Strengthen state non-state
Not on
- SNP policy not yet endorsed
4
Earthquake resulted in delays to process
partnership (SNP) functions with
PPICD
track
- NHSSP support pilot of a Performance Based Grants
(PBGs) framework with 7 public and private hospitals
operated by non-profit sectors
Table 6: Health Policy and Planning – TA contribution, assessment of sustainability and recommendations
TA Contribution
Sustainability
 The JAR is a significant event for the partners and the GoN. The GoN is clearly in the lead to set the  Planning and implementation are weak within the
agenda, discuss, and negotiate priorities with donor partners.
ministry at all levels of GoN. Typically, programmes
 Under the guidance of PPICD, the reports published for the JAR are primarily written by Advisers. Each
and priorities are designed at the centre and line-item
report is reviewed and signed off by PPICD before it shared with other stakeholders.
budgets are sent to the districts to implement
 Local Health Governance Strengthening Programme (LHGSP) was piloted by the ministry between 2010
according to these designs. There is very little
and 2012 to improve decentralised governance. The pilot was supported by USAID, GIZ and NHSSP, the
flexibility for districts to plan and spend according to
lessons of which were drawn into the Collaborative Framework agreement between Ministry of Health
their needs.
and Population and Ministry of Federal Affairs and Local development in 2014.
 There are many partners (bi-laterals, multi-laterals,
 NHSSP worked closely with the Ministry to develop the National Health Policy which was endorsed in
NGOs) providing support for decentralized planning at
2014. The national health policy is widely accepted by the sector and its aspirations are operationalised
district level; however, there is a lack of will within the
through the NHSS (2015 – 2020) which prioritises decentralised planning and budgeting. There is however,
MoHP to devolve certain authorities and financial
no evidence in guidelines for policy parameters in planning, nor any evidence of pilots based on this new
decision-making.
policy.
 There is ambivalence among senior officials in the
 The NHSS has been prepared and was endorsed by cabinet in October 2015. The earthquake provided
ministry for partnership arrangements in the future,
further opportunities to reflect on future needs for the highly affected districts and improved disaster
particularly in light of the World Bank initiated,
preparedness and response. The lessons have been incorporated into the NHSS. The NHSS M&E
Disbursement Linked Indicators (DLIs).
framework has been developed and implementation plan is in the process of being developed.
 In terms of strengthening state non-state partnership functions within PPICD NHSSP supported the
Ministry by preparing a draft of the Public Private Partnership Policy. While this is still in draft stage, the
Ministry, with technical expertise from NHSSP initiated piloting a Performance Based Grants (PBGs)
framework with 7 public and hospitals operated by non-profit sectors, which provides lessons for further
developing contracting framework.

Recommendations
5



There are opportunities to work with the Ministry to develop planning processes from identifying and communicating priorities for the sector at the start of the AWPB
process by PPICD, to better alignment and resourcing of decentralized plans.
The new constitution enshrines federalism with newly created provinces, which provide an opportunity to fully engage with the health ministry on functions and
structures for various levels of GoN and to support the process of devolved planning and decision-making.
NHSSP can play a role to facilitate discussions between the donors and the GoN and develop revised partnership arrangements for the SWAp and its instruments for
the new sector programme, NHSS.
Procurement and infrastructure
Table 7: NHSSP 1 progress against output indicators, challenges & lessons Procurement and infrastructure
Output Indicator
Milestone
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
(2013)
Output 6: MoHP and the Ministry of Physical Planning and Works (MPPW) have the capacity to develop and implement procurement in accordance with the procurement
arrangements for the health sector during the implementation of NHSP-2
6.1
Recommended
standards &
procurement
documents for
best practice
adopted and
applied
Development of
an Operations
Manual
Achieved
Goods and services: drafting of an operations manual
Building works: integrated construction designs discussed, updated
and revised. The updated designs include blood supply units, SSUs and
OCMCs. Facilities are now designed to suit different levels of
population and ecological zones
Standard bidding process for building works prepared by NHSSP was
agreed by the WB, was uploaded to the DUDBC website and printed
Proper use of standard designs, site selection
and design types.
Encouraged use of Google based HIIS to
locate new health infrastructure
Adherence to designs by contracted entities
Provided orientation on the infrastructure
bidding process to contractors in coordination
with the WB
6.2:
Transparency &
disclosure
measures
implemented
6.3:
Transparency –
Complaints &
Dispute
a: Annual
procurement
plans published
Achieved
NHSSP supported: the Consolidated Annual Procurement Plan (CAPP)
for 2013/14
The Plan is not fully consolidated as the MoHP has little appetite for
such.
Divisions changing their orders and quantities
mid-procurement
100% of tender
notices
published on
the MoHP/
Achieved
100% of tender notices were published on LMD’s website
100% of Bidding Documents, Contract Notices and Reasons for Failure
were regularly published on LMD’s website
Confusion created by the WB asking DUDBC
not to go for e-bidding
6
Resolution
MPPW website
50% of bidding
documents
available for
download from
e-bidding server
Not met
Available for all the National Competitive Bidding (NCB) which
includes more than 90% of the bids. International Competitive Bidding
(ICB) was not completed due to the WB’s objection.
To maintain the momentum to introduce ebidding
Table 8: NHSSP 2 progress against output indicators, challenges & lessons procurement and infrastructure
Output Indicator
Progress
Summary of Activities/ comments on progress
Challenges/lessons learned
Procurement
Output 1.1: Logistics Management Divisions (LMD’s) capacity for transparent and timely procurement [Milestone 2015: 80% of ICB and NCB documents quality assured]
1.1.1 Increase LMDs capacity to conduct
Mostly on
-CAPP approved for 2014/15 and 2015/16
CIAA investigations into irregular
procurement and contract management in a
track
procurement practices make LMD
transparent, timely and accountable manner in
officials
reluctant
to
sign
line with procurement guidelines and CAPP
procurement documents
1.1.2 QA procedures for annual procurement
plans and bid documents established and
disseminated with approval by DFID and LMD
Unlikely to
be achieved
1.1.3 Support improvements in systems,
procedures and processes for procurement and
contract management
1.1.4 Strengthen linkages between procurement,
contract management and finance through an
electronic contracts management system
On track
1.1.5 Enhance value for money in procurement
practices by improving LMD knowledge of
supplier market for procured goods
Mostly on
track
1.1.6 Expand capacity of LMD to effectively
ensure quality goods procured through the use of
On track
(but
On track
-All documents received by advisers were reviewed but not all
documents are sent by LMD for review
Required QA standards not being met where documents aren’t
submitted for review
-On-going updates made to Contract Management System (CMS)
-Capacity enhancement delivered in procurement, contract
management and supply chain management
NHSSP supported:
- Demand forecasting and delivery information reporting system
developed, software piloted, reviewed and rolled out in central
and regional warehouses and divisions (not at district level)
NHSSP supported:
- Development of specification bank, which establishes standards
for wide-ranging healthcare products. These specifications are
being used by LMD for procurement. The VFM case study on
LMD’s technical specification bank showed a minimum return of
£2.6 to every £1.0 invested in developing the bank.
-Many more specifications added to system but constant
updates and additional specifications required
7
Many documents – mostly NCBs –
slated for QA review were
approved by LMD without review
Districts failed the pilot and so
have been excluded from roll out
plan
- Lack of bio-medical engineers at
LMD has made capacity
development difficult
- A system to add and review
specifications is lacking
Failure to keep it up-to-date as a
result of staffing shortages
technical specification bank and appropriate use
of biomedical engineers
sustainability
in medium
term
doubtful
given
constraints)
-Biomedical engineers visited hospitals to promote use of bank
and coached LMD counterparts in appropriate post-shipment
inspection including rejection procedures
No sanctioned biomedical
engineers in LMD make mediumterm sustainability a problem
Infrastructure
1.3 Availability of Standards and Criteria for Expansion of health Infrastructure [Milestone 2015: HIIS updated to show land and physical status of 2,400 (80%) of
existing Sub Health Post buildings]
1.3.1 Support rationalisation and coordination of
On track
NHSSP supported:
Non-compliance of district
procurement planning for infrastructure
- preparation of the infrastructure procurement plan for 2014/15 authorities with land selection
(including maintenance)
and capacity building of MD/DUDBC for timely construction and
guidelines as a result of pressure
quality of health infrastructure
from local communities and other
- standard drawings for various levels of health facilities
GoN entities
- development of site selection guidelines for building of health
infrastructures; MD to apply approved criteria for site selection
- preparation of ToR for assessment and preparation of master
plans for upgrading referral hospitals
1.3.2 Improve monitoring of health infrastructure
projects by strengthening the Health
Infrastructure Information System (HIIS)
On track
Institutionalising the process of infrastructure planning is a key
objective of NHSS
-HIIS used to prioritise locations of new buildings, track condition
and maintenance requirements
-Training to district technical staff
8
Staff and financial resources
insufficient to fully institutionalise
HIIS (estimated to take 2 – 3
years from Sept 2014)
Relationship between MD and
DUDBC needs to be sustained to
ensure effective planning and
implementation
Table 9: Procurement – TA contribution, assessment of sustainability and recommendations
TA Contribution
 NHSSP has been engaged in developing tools and systems to improve the
overall procurement process.
 The following tools were introduced within LMD by NHSSP Advisers :
 Specifications bank – houses >1000 specifications for healthcare
products procured by LMD
 Contract Management Systems – a web-based system that links contract
management system to inventory management system
 Web-based e-bidding process – an e-bidding system for e-bidders to
deliver their bids electronically
 The following systems were introduced by NHSSP Advisers in LMD:
 Consolidated Annual Procurement Plan (CAPP) - a single procurement
plan for the needs of all divisions under Department of Health Services
 International Competitive Bidding (ICB) – a procedure to request for
international bids based on international norms and practices
 National Competitive Bidding (NCB) – a procedure to request for national
procurement of based on international norms and practices.
Sustainability
 Lack of technical procurement and bio-medical expertise within the MoHP and
frequent transfers have made capacity development difficult.

There is a broad consensus that a procurement reform is needed at the MoHP
and a concept note has been widely agreed. The drive to decentralization may
help the realization of the procurement reform agenda as the pressure grows to
support the changes.

The NHSSP team has developed multiple tools and systems to facilitate
procurement processes, which still require continued TA presence to be
effectively utilized by LMD.

Multiple software platforms: Specification Bank, e-bidding, Contract
Management Information System operate as silos and don’t have effective
linkages. This increases transaction costs for LMD to manage, maintain, conduct
trainings, and other associated opportunity costs.
Recommendations
Key areas of TA include supporting:








negotiation and implementation of procurement reforms that are amenable to the GoN and donors
institutionalise the National Competitive and International Competitive Bidding, including QA procedures within LMD
consolidate LMD IT systems including LMIS, IMS, CMS, technical specifications bank and finance
continue development of Contract Management System (CMS)
develop IT systems for procurement monitoring and planning, supplier database and expand utilisation of e-bidding
build capacity of LMD for equipment certification, regularly review utilization and de-commissioning of equipment, including LMD’s capacity to support health
facilities to manage them
work with LMD to develop a system to add, review, or upgrade specifications of health products in the specifications bank
bar code pharmaceutical batches with identifiers, expiry date etc. for tracking through the warehouse and distribution system
Table 10: Infrastructure – TA contribution, assessment of sustainability and recommendations
TA Contribution
Sustainability
 The site selection guideline – a scientific approach to infrastructure  The MD should have an engineer to oversee infrastructure planning and
1


development – is being utilized by the MD for health infrastructure planning
and by DuDBC on land acquisition.
Various standards for buildings have also been developed by NHSSP, which are
now being used by the MD. These standards are being used for competitive 
bidding processes by the DuDBC and have helped in better understanding of
health sector’s needs by DuDBC.
Health Infrastructure Information System was developed with support from 
NHSSP with GIS mapping capabilities. This is currently being used to justify
construction for infrastructure planning during the AWPB process.

construction. While there are now building standards for wide range of health
facilities, there are no counterparts with the required skill-set at MD delaying
capacity building efforts.
A system to add, review and upgrade standards is required. There are some cases
where DuDBC has altered designs of health facilities without any discussions with
MD.
There are further needs to develop capacity of DuDBC for monitoring and quality
assurance of the entire infrastructure development process. This is partly due to
lack of necessary budget for this purpose but also because the staff do not have
the needed expertise.
The HIIS system has been developed by local external consultants. There isn’t
capacity within the MD to update and upgrade the software and fully utilize its
functions, partly because there are no counterparts with the required skill-set at
MD
Recommendations
Key areas of TA include supporting:





Institutionalisation of engineering standards and other guidelines, including site selection criteria, at MD/DoHS of health facilities and development of a system to
review, update, and add engineering standards.
Build capacity of MD/DoHS to jointly plan, monitor and implement health sector infrastructure with DuDBC.
MD/DoHS and DuDBC to develop and implement quality assurance measures to further improve quality and timely construction of health care facilities.
Build capacity of MD/DoHS to update, utilise and manage Health Infrastructure Information Systems (HIIS).
MD/DoHS to build capacity of decentralized units to update and utilise health infrastructure data in HIIS.
2
Public financial management /health financing (Aama)
Table 11: NHSSP 1 progress against output indicators, challenges & lessons PFM/Health Financing
Output Indicator
Milestone (2013)
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
Output 4: MoHP and DoHS have the capacity to develop and implement a transparent and sustainable supply and demand-side financing framework
4.2 Functional
Health Financing
expertise in MoHP
and DoHS
Consensus built with
MoHP and key
stakeholders on core
components of the
HF strategy
Achieved
MoHP and EDPs agreed to develop a HF strategy and
the World Bank prepared an outline. NHSSP provided
technical inputs through the Benefit Incidence Analysis
(BIA), Budget Analysis Report and Household Survey.
MoHP prioritised the implementation of the
National Health Insurance Programme (NHIP)
which slowed progress preparing HF strategy
Achieving consensus on final design of NHIP
4.2 Implementation
of systems to
provide regular
monitoring and
information of DSF
schemes
Analysis of the effect
of free care and
Aama on service
utilisation trends
Achieved
Institutionalisation of the RA in subsequent years.
Effective analysis of the excel databases.
4.3: Improved
systems to ensure
timely and accurate
reporting of
expenditure
e-AWPB expanded
to a further 1-2
regions
NHSSP supported:
- institutionalisation of RA in FHD with FHD including a
budget line in its AWPB. FHD director served as the
principal author on RA reports.
-Integrated excel database for the Aama and 4ANC
schemes and a separate excel database for Uterine
Prolapse data were created to record expenditure and
progress of these DSF schemes. Databases updated
regularly and information used for planning, budgeting
and policy level decision making.
- integrated M&E framework of DSF schemes including
Aama with 4ANC, Uterine Prolapse and FP developed
NHSSP supported:
-preparation of TABUCS to help capture expenditure on
programme activities and prepare good quality and
timely financial monitoring reports (FMRs)
-preparation of a web-based planning and accounting
system with the flexibility for use in offline mode
-pilot completed for TABUCS in 11 selected cost centres
Achieved
Table 12: NHSSP 2 progress against output indicators, challenges & lessons PFM/health financing (Aama)
1
Generation of quarterly reports based on an
integrated M&E framework.
M&E framework needs to be rolled out across the
country. The capacity of regional and district level
health facilities to implement the framework needs
to be strengthened.
Issues related to data storage and security are a
concern for MoHP.
Building the capacity of MoHP officials at all levels.
Output Indicator
Milestone (2015)
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
PFM
Output 1.2: Timeliness of budgeting and financial reporting [Milestone 2015: TABUCS generated financial reports covering 100% of cost centres and linked to eAWPB
and FCGO databases]
1.2.1 Improve budgetary control by
On track - Roll-out to all cost centres completed
TA required to expand its utilization and improve
supporting roll-out of TABUCS nationally
- TABUCS now accounts for around 76% for all
data analysis at various levels
and build capacity of MoHP to effectively
expenditures from 287 cost centres, has been linked to
Intermittent non-functionality of the software
manage and use TABUCS
eAWBP and has improved governance and transparency needs to be addressed
of expenditures across the system
TABUCS use as planning tool and to capture
- software is well accepted by MoHP and it is seen as a
revenues from hospitals through user-fees which
key tool to improve absorptive capacity
remains unrealized
- Technical audit initiated to explore non-functionality of No capacity in MoHP currently to build and
software issues
manage software currently
1.2.2 Capacity of MoHP cost centres to deal
On track NHSSP supported development and roll-out of Internal
Failure of staff to comply
with audit queries and provide financial
Control and Audit Clearance Guidelines to all 287 cost
Limited funds to train staff
reports built
centres and preparation of audit queries. In July 2014
Establish dedicated audit clearance units?
39% of audit queries had been cleared.
1.2.3 Support wider PFM programmes by
Achieved NHSSP supported updated FMIP and Procurement
PFM committee in DoHS should be established
providing inputs on issues including
Improvement Plan [PIP], implementation of plans,
Comprehensive PFM framework should be
fiduciary risk (and supporting Financial
preparation of second Financial Monitoring Report
developed
Management Improvement Plan [FMIP]
governance structures)
Health financing/Aama
3.1 Aama delivery unit cost identified
3.3.1 Review the Aama programme
Achieved NHSSP supported:
Harmonising Aama with broader social health
-annual review of Aama programme
protection framework
-rapid assessments of Aama
-presentation of findings to FHD
3.3.2 Conduct unit cost analysis of Aama
Achieved NHSSP supported:
FHD may lack resolve to revise programme based
-design and implementation of cost
on findings from costing study
3.3.3 Develop Aama FHD plan of action
On-going Activities to draft the action plan based on the Aama
and/or review Aama guidelines
rapid assessment, unit cost analysis and DSF review to
improve implementation and draw out policy level
recommendations are on-going.
2
Table 13: PFM – TA contribution, assessment of sustainability and recommendations
TA Contribution
 Absorptive capacity of ministry has increased during the NHSP-2 period,
while the absorption rate hasn’t notably increased (JAR 2013/14, Fin.
Mgmt. Report)
 Regular audit findings by Office of Attorney General (OAG) as a
percentage of audited expenditure have fluctuated from 5.8% (2010/11)
to 13.8% (2012/13) (JAR 2013/14, Fin. Mgmt. Report)
 Substantive efforts are needed to clear the audit backlogs of MoHP
carried forward since 1972, which the MoHP has committed to clearing
(JAR 2013/14, Fin. Mgmt. Report)
 Most audit queries in the NHSP-2 period have been due to noncompliance with legal provisions, weak internal financial control and
weak budget implementation. (JAR 2013/14, Fin. Mgmt. Report)
 From 2010 to date NHSSP has supported the GoN with the design,
development, implementation and roll-out of the Transaction Accounting
and Budget Control System (TABUCS).
 TABUCS now accounts for around 76% for all expenditures of Ministry of
Health and Population from 284 cost centres, has been linked to eAWBP
and has improved governance and transparency of expenditures across
the system.
 The software is well accepted by the Ministry of Health and Population
and it is seen as a key tool to improve absorptive capacity.
 In addition, NHSSP has also established a system for responding to audit
queries and has built capacity of MoHP staff to prepare audit status
reports.

Recommendations
Key areas of TA include support to:



Sustainability
 Although the system is fully functional, with MoHP staff equipped to use the
system for accounting expenditure, it is anticipated (by senior GoN officials and
the Advisor) that further TA will be required to expand its utilization and improve
data analysis at various levels (e.g. DHO, DoHS, MoHP).
 There are also some issues related to intermittent non-functionality of the
software. A technical audit has been initiated and the findings are expected
shortly.
 TABUCS has the potential to be used as a planning tool as well with an inbuilt
module for e-AWPB, which currently isn’t widely used. It also has in-built features
to capture revenues from hospitals through user-fees which remains unrealized
and presents further opportunities for the sector to gather revenues from
hospitals through greater awareness of user-fees being collected and accounting
for those fees in future budget / grant allocations.
 On the technological side external consultants are hired by NHSSP to build and
manage software required to maintain TABUCS as there isn’t capacity within the
MoHP currently.
Improve utilization of TABUCS at MoHP and DoHS, including supporting DoHS to follow-up on trainings and skills to utilize at decentralized cost centres.
build capacity of MoHP, DOHS and decentralized units to analyse expenditure data.
better integration and utilisation of e-AWPB and revenue generation modules into TABUCS.
3


development and implementation of a software improvements based on technical audit currently being undertaken.
build capacity of MoHP to manage and maintain TABUCS software and develop inter-linkages with other information systems (i.e. HURIS).
Table 14: Health financing/Aama – TA contribution, assessment of sustainability and recommendations
TA Contribution
 NHSSP supported FHD with rapid assessments of demand side financing. The FHD has increasingly
taken a lead in this process but requires support from TA to implement the assessments and analyse
the findings. These have supported FHD to strengthen governance of the Aama programme.
 NHSSP has worked with FHD to develop excel databases to monitor progress of expenditures for
various demand side schemes, including Aama, 4 ANC and uterine prolapse. The databases are
regularly updated and analysed for planning and budgeting at FHD – with support provided by NHSSP.
 An integrated M&E framework of DSF schemes including Aama with 4ANC, uterine prolapse and FP
was developed. The updating and analysis of the framework relies on TA provided by NHSSP and
further strengthening is required at central level and at district level health facilities.
 In phase 2, NHSSP an important step forward was taken by FHD which included the cost of contracting
independent consultants to conduct the Aama annual review with guidance from Phase 2 TA rather
than PHASE 2 paying for all of the review which was an important first step that needs continuing.

PHASE 2 also provided technical support to FHD for the Aama unit cost study, which was shared on
June 8th with stakeholders. The final report is pending.
 An action plan for Aama is to be developed considering the cost of additional new-born services being
added to the free care and the Aama unit cost analysis.
Sustainability
 NHSS calls for harmonising the Aama programme
within a broader framework of social health
protection, and further developing modalities for
involving private sector institutions in Aama
implementation through state non-state partnerships.
There are opportunities to work with FHD to better
consider the unit costs of Aama (e.g. at different level
of facilities, transportation incentives by regions) in
future revisions, particularly, as additional new-born
services are added to the free care and a broader
health protection framework is developed by MoHP.
 Further TA is required to enhance the capacity of the
FHD to take increase ownership of the activities that
have relied on TA including the rapid assessments and
monitoring progress of DSF schemes.
 It is advised to work toward a broader health financing
strategy, consolidating health sector demand-side
financing mechanisms, free-care, health insurance
Recommendations
Key areas of TA include supporting:



the MoHP to develop and implement a health financing strategy that consolidates various demand side financing schemes, free care and social health insurance;
MoHP/FHD to develop next generation Aama considering lessons from Aama unit cost study, national surveys and rapid assessments undertaken by FHD, including
Aama into social health insurance; and,
build capacity of FHD to take ownership of Aama Rapid Assessments and monitoring of demand-side financing schemes.
4
Monitoring and evaluation
Table 15: NHSSP 1 progress against output indicators, challenges & lessons Monitoring and Evaluation
Output
Indicator
Milestone (2013)
Progress
Summary of Activities/ comments on progress
Challenges/lessons learned
Output 5: MoHP has the capacity to strengthen and effectively use an information system to support planning and delivery of quality EHCS
5.1: HMIS
functioning
effectively and
informing local
area planning
and monitoring
across Nepal
5.2 Additional
monitoring
data not
covered by
HSIS generated
a) Strategies to strengthen
HMIS successfully scaled up
across all 75 districts
Achieved
NHSSP supported:
-MD with revision of HIMS indicators, recording and
reporting forms
-supported field testing of the revised HMIS and training
-strong commitment from divisions, centres and
development partners to support implementation of the
revised HMIS.
b) The DoHS annual report
published within three
months of the FY end with
improved analysis and
interpretation of data
Not
achieved
Some improvement was seen in the quality of the DoHS
annual report in terms of its analysis, interpretation and
presentation. However, publication of the report within
three months after completion of the FY was not
achieved.
Facility survey
Achieved
NHSSP supported:
-completion of Service Tracking Survey/facility survey and
report provided
Institutionalisation of the STS due to its
complexity and cost
Involvement and ownership of the STS by the
divisions and centres. Seek institutional home
for future surveys within MoHP
Capacity of GoN counterparts to manage the
STS
Table 16: NHSSP 2 progress against output indicators, challenges & lessons, Monitoring & Evaluation
Output Indicator
Milestone (2015)
Progress
Summary of Activities/ comments on progress
Challenges/lessons learned
Indicators 2.1: Monitoring and evaluation (M&E) framework for strategic plan developed and evaluation tools institutionalised in MoHP [Milestone 2015: NHSP 3 M&E
framework developed with consistency in data source across indicators and time]
5
2.1.1 Support the integration of the MoHP
and DoHS MIS by developing a unified coding
system
2.1.2 Support the roll-out HMIS to ensure
quality data and promote better use of data
(including disaggregated data)
On track
NHSSP supported development and roll-out of
unified coding system
On track
2.1.3 Support the generation of primary
information for NHSP-2
On track
NHSSP along with partners supported:
-system design, developing software, and building
capacity to maintain the system, implementation
of DHIS2 at district, compendium of indicators for
districts
-strengthening of medical records system in public
hospitals
-Revised HMIS to be used for this purpose
-NHSSP coordinated with EDPs to support
preparation of draft NHSS document, M&E strategy
and results framework
See 2.1.5
2.1.4 Improve availability and use of
evidence/data for planning and policy design
by strengthening information sources
2.1.5 Support generation and analysis of
primary information for NHSP-2 and to inform
NHSP-3
On track
NHSSP supported:
-Service Tracking Survey 2013 finalised and shared
at regional reviews with support from NHSSP
-development of tools for 1st Nepal Health Facility
Survey in 2015 and survey underway
-planning the Nepal Burden of Disease study
-further analysis of the NDHS data
-M&E plan for remote areas MNH access project
6
Electronic system roll-out at facility level required to
significantly improve data quality - funding not
currently available to enable this
Table 17: Monitoring and Evaluation – TA contribution, assessment of sustainability and recommendations
TA Contribution
 NHSSP 1 & 2 provided technical assistance to strengthen the Health
Management Information System and the generation and use of
primary information for NHSP-2 and NHSS design.
 A strategic and comprehensive programme of HMIS TA has been
delivered to support MoHP/DoHS to:
 review the HMIS/HSIS and develop a way forward for
strengthening
 strengthen indicators and tools for routine data collection &
data quality assurance
 develop software system to host HMIS data and user manuals
 build skills across the system to support roll-out to district
level online data entry
 develop a data quality assurance (DQA) system (underway)
 develop an integrated results framework for the new Nepal
Health Sector Strategy 2015-20120 (NHSS 205-2020)
 Phase 1 provided to support the roll-out of service tracking surveys
including tools to replicate the studies and building skills within the
responsible divisions.
 Phase 2 supported the harmonisation of surveys across the Ministry
resulting in the Nepal Health Facility Survey.
 NHSSP helped to strengthen GoN systems that utilise data for
evidence-based planning by supporting compilation of key findings
of national level surveys and supporting their use in preparing the
AWPB.
 NHSSP has also supported MoHP and NHRC with the development
of survey tools for nation-wide surveys (e.g. NCD STEPS survey), use
of disaggregated data for the AWPB, analysis and publication of
papers in academic journals.
Sustainability
 Despite significant advances, further system strengthening is required to ensure quality data
is provided by the HMIS for NHSS 2015-2020 and that this data is utilised to supplement the
evidence base for policy and planning.
 GoN is supportive of an integrated HIS and online system and strengthening utilisation of
data for monitoring and planning is an NHSS priority.
 PHASE 2 & partners on behalf of the MoHP/DoHS has moved to help reduce error and
improve data quality through the roll-out of DHIS2 for data entry at health facility but so far
the process is not fully functional – and there isn’t a budget currently allocated by the MoHP
to further support this.
 Moving to an electronic system at health facility level and establishing a data quality
assurance system are priorities to help address data quality issues.
 A cost analysis is currently underway (GIZ) to assess the savings to be made over time once
an electronic system is established at all levels.
 Integrating the DQA system (developed by USAID) into the GoN system is needed to ensure
sustainability.
 Better utilisation of data is required at all levels of the system. Typically, GoN officials
continue last year’s activities rather than analyse available data/information and plan based
on evidence – although support to FHD and CHD has led to improved use of evidence for
context-specific planning and design of strategies and approaches to respond to the needs
of specific target populations.
 Frequent staff transfers and shifting the institutional home of surveys within the Ministry has
hindered capacity enhancement efforts. Whilst the Ministry has the tools to implement
surveys; the technical skills to manage the process and utilise the results for decision-making
need further development.
 NHRC (& recently established Knowledge Management Section) is seen as a critical recipient
of TA with less frequent movement of staff, better institutional memory and better skills as a
result. Strengthening of NHRC technical capacity in research design, analysis and research
communications is needed, as are systems to support data repository.
Recommendations
Key areas of TA include supporting:

A review of the health information system architecture including a roadmap for greater system integration.
1




Development of a plan for roll-out of electronic data entry at health facility level including advocating for budget allocation.
Integration of DQA process into the GoN system.
The M&E TWG to review the institutional homes of the surveys.
Development of a capacity strengthening plan with NHRC including exploring potential relationships with academic partners (international/local) and strengthening the
link with Public Health Administration and Monitoring & Evaluation Division (PHAMED).
2
Essential Health Care Services
Table 18: NHSSP 1 progress against output indicators, challenges & lessons EHCS
Output Indicator
Milestone (2013)
Progress Summary of Activities/ comments on progress Challenges/lessons learned
Output 1: DoHS/regions have capacity to deliver quality and integrated essential health care services (EHCS), especially to women, the poor and underserved
1.1: Districts have
Strategic
options
to Achieved NHSSP supported:
Poor quality of care at referral hospitals
improved tools, skills
reduce overcrowding of
- a study to assess the effects of increased
and systems to
CEONC referral hospitals
demand for institutional delivery care in
Work with MD and PPICD to include MoF grants in
provide functional
agreed with FHD and
tertiary facilities in 2012
the infrastructure procurement plan to ease the
CEONC services
actions included in the
- FHD to plan and budget activities to overcome overcrowding situation
2013/14 AWPB.
overcrowding in 10 referral hospitals
1.2: Evidence
generated for
strengthening
maternal, neonatal
and child health
service delivery,
including outreach to
underserved groups.
AWPBs
aligned
for
implementation
of
strategic guidelines for
under-served
and
unreached populations in
10 districts.
Achieved
NHSSP supported innovations to strengthen
service delivery for underserved groups in four
areas:
1. Integration of FP with EPI service provision.
Based on the study findings, the GoN has
committed to rolling out the integration of
services more widely.
2. Strengthening district referral systems:
29 health facility in-charges were trained in
obstetric first aid. FHD plans to provide this
training to a further 100 health workers
(paramedics).
3. Strengthening the delivery of PNC:
supporting health workers to provide more
systematic and comprehensive PNC
counselling.
4. Strengthening the availability of
comprehensive abortion care (CAC) in the two
pilot districts
Table 19: NHSSP 2 progress against output indicators, challenges & lessons EHCS
1
Absence of vaccinators
Absence of multi-year contracting
Ensure FHD develops monitoring tools for referral of
obstetric complications.
Shortage of staff, language problems, lack of family
awareness of importance of PNC – QI and national
campaign needed to raise awareness
Poor capacity of the training sites; frequent transfer
of trained staff; the need for tailor made monitoring.
Approaches that suit the specific needs of remote
areas are required instead of the blanket approach
used at present.
Output Indicator
Progress
Summary of Activities/ comments on progress
Output 2.2: Quality of Care in maternal health services
2.1.2 Support the
On track NHSSP supported:
development of a system
(and scale- -The QA & ITWG to agree on HQIP, develop a suitable monitoring mechanism
and tools for monitoring and up planned - preparation of guidelines on use of hospital grants incorporated in MD’s budget
managing the quality of
& budget for 1st time
maternal, neonatal and child allocated)
- HQIP pilots in two districts completed
health (MNCH) in health
Scale-up of HQIP planned in 10 districts & budget allocated (not yet released)
facilities
2.1.2 Support the
On track
NHSSP supported:
implementation of
-developing action/monitoring plans including implementation timeline,
strategies to address
monitoring indicators and reporting templates for 3 referral hospitals
overcrowding in tertiary
- evaluation of strategies for overcrowding undertaken to influence
facilities
thinking/priorities
-establishing strategic birthing centres in Banke district
FHD budget allocated in 2014/15 to fund improvements to referral hospitals
2.1.3 Support effective
On track
NHSSP supported:
implementation of
-developing a monitoring framework to track CEONC fund utilisation
comprehensive obstetric and
-developing operational guidelines
neonatal (CEONC) funds
-expansion of CEONC services to additional hospitals
2.1.4 Support review,
planning and budgeting of
FHD/CHD and others
On track
2.1.5 Support to disseminate
study findings on integration
of FP services in EPI clinics
On track
2.1.6 Support the design and
preparation of remote areas
MNH pilot in Taplejung
district
On track
NHSSP supported:
-finalisation of the AWPB and business plan
-workshop on interim FP support plans
-pilot approaches implemented in 3 districts
-strengthening SBA training in line with SBA policy and training strategy
NHSSP:
-prepared pulse report and posted on social media
Scale-up planned in hill and mountain areas and remote areas with support from
UNFPA and H4L
NHSSP:
-developed study design and tools and supported implementation of the pilot
including IP training for 55 health facility staff and 3-days HFPMOC training course
-supported launch of EAP activities in 5 VDCs and supported revision of EAP
implementation guidelines for community mobilisers
2
Challenges/lessons learned
FHD lack staff to support scale-up
QI indicators need to be incorporated
into NHSS monitoring framework and
plans
Support to HR to enable strengthening
and expansion to new sites
Hospital development committees need
strengthening to ensure sustainability
of service provision
Develop strategy to reach post-partum
women for integrated EPI/FP services in
Terai districts
2.1.7 Support for the design
and preparation of new born
care support through SCI
(Save the Children
International)
On track
-independent M&E agency appointed to assess HF activities, EAP implementation,
VDC support to HFs and SBA deployment
NHSSP provided support to SCI to implement in three districts including
finalisation of rapid assessment tools and implementing the assessments
Table 20: EHCS – TA contribution, assessment of sustainability and recommendations
TA Contribution
 Embedded in FHD, the NHSSP Advisers have provided day-to-day valuable
support to FHD and CHD to develop and utilise a strategic evidence base to
design and test strategies to tackle barriers to delivering quality MNCH and FP
services to the poorest and those in remote areas.
 A key achievement of Phase 1 was seen to be the discussions and action
agreed by the GoN as a result of the CEONC study which:
 provided valuable evidence to support the need for strengthening
CEONC provision and the allocation of GoN funds for this purpose
 contributed to improving functionality of the CEONC fund 16
 supported introduction of CEONC mentors
 leveraged support from other partners to strengthen CEONC provision
 contributed to the number of districts with CEONC provision increasing
from 33 (2010) to 54 by 2013 and 61 by mid-July 2015
 NHSSP also worked with DoHS to use evidence emerging from pilot studies
(e.g. remote areas in Taplejung district, the Save the Children International
pilot on new-born care support etc.) to support ‘context-specific planning’.
 A critical area of on-going work is on improving quality of care at strategic
birthing centres – with the current focus on developing strategic birthing
centres as ‘centres of excellence’.
 The Quality Improvement Process [HQIP] for maternal health services has
been established in two hospitals with a monitoring and reporting mechanism
Sustainability
 There are a number of threats to the sustainability of CEONC provision:
 The number of districts providing CEONC dropped from 61 in mid-July to 49 by the
end of July 2015 - largely as a result of delays to the release of CEONC funds to
cover salaries for CEONC providers.
 The sustainability of the fund, which emerged as a temporary measure [‘a band
aid’] was questioned by the DoHS on the basis that salaries should be included in
MoHP budget and not direct from FHD;
 Without this fund or increases in sanctioned posts with sufficient remuneration
for CEONC trained health workers, the continuity and expansion of CEONC
provision is threatened.
 FHD’s capacity to provide oversight and monitor the Fund in the longer-term.
Appointing a qualified clinician with the requisite management skills and
experience, willing to accept a civil service salary will be a challenge.
 Whilst HQIP has been well-received by hospital staff and has budget allocation to
scale-up in 10 districts there are concerns about its sustainability:
 FHD & MD lack capacity currently to provide the support required to scale-up
to a further 10 districts
 Capacity of counterparts was built during the pilots but these staff have since
been transferred and/or not replaced
 The budget for scale-up has not yet been released.
 The family planning approaches piloted with support from NHSSP have been
16
This fund started in 2008/9 and is intended to support staff hiring, purchase of equipment, drugs and supplies, repair operation theatre and information dissemination in selected low
Human Development Index (HDI districts). It specifically allows for the hiring of private sector team for the provision of Caesarean section (CS) services through short-term contracts.
3







created to link the hospitals to the centre. NHSSP has provided support
directly to the hospitals to establish this process. Subsequently FHD has
allocated funds to scale-up HQIP in 10 districts this financial year.
NHSSP has supported implementation of 3 family planning pilots to increase
access to LARCS and other FP services amongst unreached populations in
remote areas and demonstrated increases in CPR have been reported. This
was an add-on to NHSSP’s work plan that NHSSP agreed to take on in response
to an urgent request from DFID.

Although not captured in the logframe indicators, Phase 1 also contributed to
strengthening delivery of immunisation services where an immunisation
coordinator supported CHD to improve the use of routine immunisation and
supervision /monitoring data in low coverage districts with the aim of
increasing coverage. NHSSP also contributed to the development of health
sector strategy to address Maternal Under nutrition.
well-received by the GoN and are to be implemented across selected districts [e.g.
scale-up of EPI/FP integration in 3 districts]. These approaches will also be rolledout as part of the Earthquake T&R programme across selected affected districts
(funded by DFID and USAID [TBC]). Detailed implementation guides have been
developed by NHSSP to enable replication in other districts and FHD staff has
been involved in district coordination meetings, however the role of TA is seen as
critical to support initial implementation.
Embedded TA was seen to play a critical role in leveraging support from other
development partners to support implementation of GoN approaches at district
level. However, the value of having embedded TA within FHD to provide the
technical support to guide implementation and to link with the GoN system was
seen as invaluable - whether being implemented by GoN or other development
partners.
Recommendations
TA is still needed to take HQIP to scale as FHD has committed the funds within their AWPB but doesn’t have the prerequisite technical support to deliver on this
commitment. For future TA, FHD should ensure they have prerequisite in built staff or funds to contract adequate staff to work alongside TA with a clear exit strategy in
place.
Consolidating lessons learned into a single strategy for QI in hospitals. Other partners such as Jhpeigo, Nick Simmons and GIZ are implementing QI interventions and
embedded TA is well-placed to support DoHS to develop a consolidated system.
Further support to DoHS to use research evidence and pilot implementation lessons to develop strategies to improve access to quality health services of underserved
populations. Examples include strengthening referral within the GoN system to ensure that women are able to access emergency C-section; strengthening quality of
care in referral hospitals and to explore the potential for working with the private sector in remote areas.
Lessons from the Aama unit costing study and rapid assessments as well as data from the Service Tracking Surveys and NDHS should also be used to better design the
next generation of Aama programme.
For family planning further support to the DoHS to learn lessons from the pilot, support context specific planning and potential scale-up of the interventions will be
required.
4
Gender Equality and Social Inclusion
Table 21: NHSSP 1 progress against output indicators, challenges & lessons GESI
Output
Indicator
Milestone
(2013)
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
Output 3: MoHP and DoHS have systems, structures and capacity to implement the GESI strategy
3.1 AWPBs
integrate GESI,
reflecting the
GESI strategy
AWPBs show
increased
resourcing for
GESI activities
Achieved
3.2 A leadership
and coordination
structure in place
to drive
implementation
of the GESI
strategy
A GESI district
coordination
structure
established
with TOR and
membership
in 20 Districts
Achieved
- Population Division, PHCRD, FHD and CHD made
significant investments in GESI-related programming in
2013/14
-TA worked with divisions to help staff identify how GESI
could be integrated into their programmes
Ensuring continued focus on GESI in successive AWPBs
-The Institutional Structure Guidelines for
mainstreaming GESI approved
-GESI Steering Committee was formed with the Health
Secretary as chair and meetings to be held twice a year
-DoHS GESI Committee was formed in December 2011
to meet once a year
-One official was nominated as the GESI focal person by
each division and centre
-TWGs were formed in all five regions in 2012 and
oriented on their roles.
-TWGs were formed in 70 districts with meetings held
Ensuring level of commitment to institutionalising GESI across
ministry
Ensuring institutional structure for mainstreaming GESI fully
functional
-GESI Section was established in the Population Division,
reflecting the growing level of commitment to
institutionalising GESI seen across the Ministry.
Ensuring GoN fully owns and adopts the business plan format
during AWPB
Business plan format invaluable in ensuring GESI-related
activities were identified, planned and budgeted
Strengthening the skills needed to apply the GESI framework
down to health facility level
Provide a regular budget for TWG meetings and the
implementation of GESI Operational Guidelines in order to
keep the GESI institutional structure fully operational.
Ensure the adequate provision of TA.
Table 22: NHSSP 2 progress against output indicators, challenges & lessons GESI
Output
Indicator
Milestone
(2015)
Progress Summary of Activities/ comments on progress
1
Challenges/lessons learned
Output 3.2: Refocused and sustainable Equity and Access Programme (EAP) [Milestone 2015: Model piloted in one district and learning and recommendations shared]
3.2.1 Technical strengthening,
expansion and improved
sustainability of the EAP
On track
NHSSP supported implementation of integration of feasibility study in
two districts
If integration is endorsed a one year pilot is proposed in first year of
NHSS
LGCDP unwilling to implement
recommendations from the assessment
3.2.2 SSUs piloted across 8 zonal
and referral hospitals and an
institutional home for SSUs
established
On track
NHSSP supported:
-revised SSU guidelines based on study results (approved)
- SSUs piloted in 8 districts
-an institutional home has been established
-governance mechanisms to ensure transparency of free care to
target groups have been introduced
NHSSP provided technical backstopping support to hospitals
Delayed budget release to SSUs affect ability to
operate
3.2.3 Scale-up of social audits
based on lessons learned from
piloting
On track
NHSSP supported:
-Social Audit guidelines developed, piloted and revised and AWPB and
EDP funding was allocated for mainstreaming
-Social Audits scaled up based on lessons learned from piloting
Quality assurance required to ensure effective
process and planning
3.2.4 Pilot OCMCs and develop
multi-sectoral response to GBV at
district level
On track
NHSSP supported:
-implementation of OCMC in 15 districts and evaluation conducted
-capacity building on GBV conducted with police
-coordination across sectors for preparation of Integrated National
GBV Guidelines
Institutional basis for GESI needs strengthening
More support required to institutionalise
On-going support to build structures, tools and
skills to support multi-sectoral response to GBV
needed
Table 23: GESI – TA contribution, assessment of sustainability and recommendations
TA Contribution
 Phase 1 supported:
 establishing an institutional structure to communicate and support the
introduction of GESI into the system (GESI steering committees, focal
persons at each level, institutional structure guidelines approved);
 provision of tools (GESI operational guidelines to support
implementation of the strategy, integration of GESI into core in-service
curriculum, disaggregating HMIS data); and,
Sustainability
 Whilst considerable progress was made in institutionalising GESI the sheer scale of rolling
out the guidelines across the country and capacity building while retaining and adequate
focus on capacity building at facility level was challenging. Creating partnerships and
coordinating with EDPs in project districts for capacity building at facility level helped to
facilitate this.
 For OCMC, insufficient functional coordination across ministries and with EDPs and civil
society at both the central and district levels hindered district level capacity to roll-out
2







capacity enhancement to build skills on concepts, principles and
application of GESI guidelines of staff at MoHP, DoHS, RHDs and
DHO/DPHOs.
GESI has been incorporated in the National Health Policy Review, HRH
strategic plan, Urban Health Policy, NHSP-2 implementation plan, JAR
report and mainstreamed in AWPBs of departments and centres.
Integration of GESI in social mobilisation activities of Ministry of Federal
Affairs and Local Development has also been piloted.
Social Service Units (SSUs), to facilitate the provision of free and
partially free of cost health care services to target group patients, have
been piloted in eight hospitals. With support from NHSSP:
 an institutional home has been established within the Ministry;
 governance mechanisms to ensure transparency of free care to
target groups have been introduced (e.g. on-going roll-out of
HMIS in the pilot hospitals); and,
 PPPs have worked well.
One Stop Crisis Management Centres, to provide hospital based
integrated support to survivors of GBV, have been piloted in 15
hospitals with support from NHSSP and an impact assessment
completed.
A multi-sectoral response to GBV at district level has been supported
by NHSSP including developing:
 umbrella guidelines for GBV services (on-going);
 a national GBV protocol for health providers (on-going);
 a training manual; and,
 monitoring and reporting system (on-going).
Social Audit guidelines were developed, piloted and revised and AWPB
and EDP funding was allocated for the mainstreaming of this approach
across the country. Social Audits have now been scaled up based on
lessons learned from piloting with support from NHSSP and are
effective at leveraging VDC and community resources, improving the
health facility environment, increasing opening hours, raising
awareness of and access to entitlements and increasing women and
poor people’s participation in accountability efforts.
A rapid assessment of health and governance social mobilisation





interventions. However, OCMC is part of the National Action Plan led by the Prime
Minister’s office and will remain a priority for GoN meaning that support to improving
coordination is required.
For GBV, work is currently underway to build the institutional structures, tools and skills
to ensure system responsiveness.
For SSUs there have been a number of challenges to sustainability including
 weak hospital management and governance;
 ‘lack of teeth’ of MoHP to hold hospitals accountable threatening transparency and
sustainability;
 hospital management reluctant to accept SSU-related service provision as a core
responsibility;
 resistance among some hospital staff due to strong accountability mechanisms that
may limit opportunities for irregular fund use and nepotism;
 lack of recognition amongst some hospital staff of the importance of providing SSU
services to the poor and marginalised;
 lack of multi-year contracting and delays in budget transfers have impacted on
contracted NGO services.
Improving governance at the frontline and overcoming political economy issues around
hospital management are critical to ensuring sustainability.
Scaling up Social Audits has proved challenging due to:
 the politicisation of contracting of NGOs;
 lack of interest or motivation of health staff; and,
 limited capacity of PHCRD.
However, sustainability of Social Audits looks promising with around half of districts now
covered although insufficient funds are received to cover all health facilities in the
districts. PHCRD is seen to be an appropriate institutional home for Social Audits and
there is an incentive to sustain it in terms of the budget received and the financial
benefits (TA/DA) to PHCRD staff when conducting training and monitoring visits. Factors
hindering sustainability include:
 maintaining the quality of social audits and ensuring the full process is completed
 the responsiveness of the health sector including DHOs in recognising social
auditing as an effective means by which to improve health services;
 poor communication and monitoring from the centre;
 insufficient flexible financial resources at the local level to plan and implement
activities;
3
programmes has been undertaken and operational research is
underway to explore the institutional and social factors that underpin
exclusion from social mobilisation programmes, non-participation of
women and poor and excluded groups in local governance structures
and processes and why some groups are not well-served by health
services.


Social Auditors’ capacity to conduct social audits with understanding and
motivation; and,
 EDPs support to district facilitation not being sustainable in the long-term.
A critical evidence-base will have been developed during NHSSP to inform future
design/strengthening of social mobilisation programmes. A key issue hindering EAP was
the inability to issue multi-year contracts with EAP NGOs fragmented inputs and
compromised the quality of programme implementation.
Recommendations
 Supporting better GESI integration in the planning process with the institutional home moved to PPICD from Population Division. Supporting the MoHP to move towards
decentralised planning and devolution of authority in planning, budgeting and implementation to district - and as the country move towards federalism - to the federal
units.
 SSUs: there are a number of on-going areas of work including:
 continuing to influence the medical superintendents to ensure they functionalise and are supportive of measures to increase transparency;
 rolling-out the MIS;
 support to sustaining the PPP modality; and,
 support review of feasibility of expanding SSUs to embrace coordination and monitoring of other hospital based social protection programs and health insurance
models based on the results from the process evaluation.
 Social Audit:
 support to streamline and ensure sustainability based on results from the process evaluation;
 explore direct contracting of NGOs by RHD, especially in poor governance districts;
 improve the enabling process including strengthening selection guidelines for NGOs;
 explore the scope and design for integration of health social auditing by local GoN.
 Social mobilisation programmes:
 support to turn these learnings from assessment into pilots to support inclusive health development;
 to help operationalize the collaborative framework between MoHP and MoFALD;
 to harmonise social mobilisation programmes and demand-side accountability approaches and mechanisms; and,
 to strengthen VDC engagement with HFOMC and health providers and VDC resource utilisation.
 OCMC: Support is needed to operationalize the monitoring and reporting systems for OCMCs.
 GBV: supporting the development of structures, tools and skills is essential including;
 developing joint annual district GBV plans across sectors;
 supporting harmonisation of GBV committees at district level;
 further support to the police to improve their response;
 further integration of GBV into health services (e.g. through training of health professionals);
 strengthening of MWCSW to lead coordination of GBV services; and,
4

a GBV case follow-up system needs to be developed.
Human Resources for Health
Table 24: NHSSP 1 progress against output indicators, challenges & lessons HRH
Output Indicator
Milestone (2013)
Progress Summary of Activities/ comments on progress
Challenges/lessons learned
Output 2: MoHP has capacity to develop and implement an effective HRH Strategy
2.1 HRH Strategic Plan
developed and used
to guide annual work
plans and regularly
updated.
Evidence of
implementation of the
strategies for the
recruitment of nurses at
hospitals and doctors at
PHCC in all five regions
Partially
achieved
- HRH strategic plan was approved by the MoHP and the
Cabinet in 2012 (2011 milestone) and has been used to
influence planning and budgeting in the AWPB (2012
milestone)
- Progress made in developing interconnected
strategies and related activities to facilitate recruitment
and equitable distribution of health workers, primarily
through better recruitment and deployment systems,
but little implementation actually took place and there
was limited recruitment
-MoHP owns the HRH Strategic plan and stakeholders
were engaged and educated on strategic approaches to
HRH. Discussions on HRH now better informed.
Recognition that new HRH initiatives need to be in line
with plan.
Priority activities need to be translated into
the AWPB on an annual basis
2.2: Staffing
projections available
to inform training
plans.
Projections completed and
agreed and used to inform
planning for pre-service
training
Achieved
NHSSP supported:
-development of a plan and projections for Nepal’s
health workforce were developed
-completion of HRH profiles for the GoN to use in
Delays in receiving the HRH assessment data
and concerns over quality
Continuous monitoring through the
STS/other HR information systems needed to
encourage MoHP to address the challenges
5
designing services and planning staff training
of translating recruitment plans into action
to improve staffing levels
Table 25: HRH – TA contribution, assessment of sustainability and recommendations
TA Contribution
Sustainability
 The HRH strategic plan was approved by the cabinet at the end of 2012 after excessive delays. The costed M&E framework was  This area of work was not
developed and human resource projections were made based on the plan.
included in PHASE 2.
 An HRH profile covering both public and private sector workers was also completed as well as workforce plans and projections to
inform decisions about the design of services, staff training and to inform strategic engagement with the private sector.
 HRH activities across DoHS and MoHP were mapped to identify bottle necks, gaps and overlaps between departments and
functions.
 An institutional assessment of NHTC was completed to support its strategic development as the identified body supporting all inservice training in Nepal.
 The area of human resources has seen less progress in large part due to the failure to pass an Amended Health Services Act
which resulted in a recruitment freeze to sanctioned posts in the health sector for more than 4 years. The Act was finally passed
in late 2013 meaning that recruitment against all sanctioned but unfilled posts could commence.
 Although it was hoped that the formation of a new Parliament post-national elections would create a more stable political
environment this has not been the case and the level of staff turnover seen in the civil service continues to be high.

Recommendations
 Now the freeze on recruitment has been lifted, ensuring that human resources are appropriately allocated across the system is seen as a critical area for TA support by
Advisors and development partners.
 Support to implement the HR strategic plan as also defined in NHSS to strengthen the HR system including further devolution of deployment and transfer authorities to
DHOs and RHD and addressing the issue of deployment of staff to remote areas is considered critical.
 Improve the function of HuRIS (Human Resource Information Information Systems) and other human resource information systems to maintain an updated database
on health workers in Nepal, including the private sector
 Working with the TWG and other stakeholders through the annual AWPB cycle to ensure that the strategic plan is adequately reflected in the AWPB moving forward is
seen as an important area for further support.
6
Annex 5: Specific recommendations by NHSSP thematic areas
Procurement
Conclusions
 There is broad consensus across the sector including within GoN that a procurement reform is needed.
 Decentralization may help realization of the procurement reform agenda as the pressure grows to
support change.
 Tools and systems developed by NHSSP require continued TA presence to be effectively utilized.
Limited capacity enhancement due to lack of technical procurement and bio-medical expertise.
 Procurement experts and bio-medical engineers are needed to professionalise procurement and
improve capacity to manage bio-medical equipment
 Linkages between multiple software platforms are required to increase system efficiency.
Recommendations
Further TA is recommended to:





Support negotiation and implementation of procurement reforms that are amenable to the GoN and
donors
Support critical human resources gaps in procurement that will work towards institutionalising tools
and systems developed in NHSSP 1 and 2 (including biomedical engineers and procurement experts)
(National and International Bidding procedures, Contract Management System (CMS), e-bidding
processes, QA within LMD)
Build capacity of LMD to manage and increase adoption of e-bidding and processes for equipment
certification, to regularly review utilization and de-commissioning of equipment and strengthen
capacity of LMD to support health facilities to manage them
Support LMD to build IT systems for procurement monitoring and planning; a supplier database; a
system to add, review, or upgrade specifications of health products in the specifications bank; bar
code pharmaceutical batches with identifiers, expiry date etc. for tracking through the warehouse and
distribution system
Review diverse tools and systems to develop effective linkages/consolidate (i.e. linking of technical
specifications bank with competitive bidding processes, finance, LMIS, IMS, CMS).
Infrastructure
Conclusions
 Progress made strengthening tools and systems e.g. building standards, HIIS.
 In MD counterparts not in place to oversee infrastructure planning and construction and system not in
place to upgrade standards.
 Limited capacity in MD to upgrade and fully utilise HIIS.
 DuDBC capacity for monitoring and QA of infrastructure development process needs to be
strengthened.
Recommendations
Further TA is recommended to:





support institutionalisation of engineering standards and other guidelines, including site selection
criteria, at MD/DoHS of health facilities
build capacity of MD and DuDBC to develop a system to add or review standards, and quality
assurance and timely construction of health infrastructure
build capacity of MD/DoHS to jointly plan, monitor and implement health sector infrastructure with
DuDBC
build capacity of MD/DoHS to improve utilisation of Health Infrastructure Information System (HIIS) to
add new facilities built, upgrade or review status, and for selection of new sites for health facilities
MD/DoHS to build capacity of decentralized units to update and utilise health infrastructure data in
HIIS.
1
Public Financial Management
Conclusions
 Absorptive capacity of ministry has increased during the NHSP-2 period, while the absorption rate
hasn’t notably increased
 Substantive efforts are needed to clear the audit backlogs of MoHP which the MoHP has committed to
clearing
 Most audit queries in the NHSP-2 period have been due to non-compliance with legal provisions, weak
internal financial control and weak budget implementation
 TABUCS now accounts for around 76% for all expenditures from 284 cost centres, has been linked to
eAWBP and has improved governance and transparency of expenditures across the system.
 Software is accepted by MoHP and it is seen as a key tool to improve absorptive capacity.
 Intermittent non-functionality of the software needs to be addressed using results from technical
audit.
 TABUCS use as planning tool (eAWPB) and to capture revenues from hospitals through user-fees
remains unrealized.
 TA required to expand its utilization and improve data analysis at various levels.
 No capacity in MoHP currently to maintain and manage software.
Recommendations
Further TA is recommended to:








Support the ministry to implement the Financial Management Improvement Plan, its internal control
and audit clearance guidelines; to strengthen the newly formed Audit and PFM committees, and to
develop simplified reporting templates for financial monitoring reports (FMR)
Improve functionality of TABUCS by developing and implement a software improvements based on
results from technical audit and financial rules and regulations
Improve utilization of TABUCS at MoHP and DoHS, including supporting DoHS to follow-up on trainings
and skills to utilize at decentralized cost centres
Build capacity of MoHP, DOHS and decentralized units in financial management, particularly analysing
expenditure data and responding to audit queries
Better integrate and support utilisation of e-AWPB and revenue generation modules into TABUCS
Build capacity of MoHP to manage and maintain TABUCS software and develop inter-linkages with
other software (i.e. HURIS).
Work with MoHP to reduce audit queries and budget ‘irregularities’
Work with MoHP to improve budgeting process by better incorporating MTEF principles
Health Policy and Planning
Conclusions
 Planning and implementation are still weak within the ministry at all levels of GoN.
 There is very little flexibility for districts to plan and spend according to their needs.
 There has been a lack of will within the MoHP to devolve certain authorities and financial decisionmaking although plans are underway to explore arrangements for federalism.
 There is a lack of a unified voice and ambivalence among senior officials in the ministry for partnership
arrangements in the future, particularly in light of the World Bank initiated, Disbursement Linked
Indicators (DLIs).
Recommendations
 Support MoHP to re-structure itself in-line with the federal structure
 Work with the Ministry to develop planning processes by identifying and communicating priorities for
the sector at the start of the AWPB, and through better alignment and resourcing of decentralized
plans
 Support consolidated planning at ministerial, departmental, provincial level, considering disaggregated
data produced by HMIS and surveys
 Support consolidation and streamlining of review processes in the sector (i.e. merge national review
conducted by DoHS with Joint Annual Review, reduce number of vertical programming reviews, etc.)
 NHSSP/DFID should facilitate discussions between the donors and the GoN and develop revised
2

partnership arrangements for the SWAp and its instruments for the new sector programme, NHSS.
Improve the contracting capacity within the MoHP to better utilise the private sector to deliver critical
services in remote or hard-to-reach areas
Health financing/Aama
Conclusions
 Management of DSF schemes need to be strengthened in MoHP
 A health financing strategy is needed given the wide range of DSF, free care, and health insurance
 FHD needs continued support to conduct Rapid Assessments and monitor expenditures of Aama funds
 Private sector needs to be utilised to implement Aama through state, non-state partnerships.

Recommendations
Further TA recommended to:



Support the MoHP to develop and implement a health financing strategy that consolidates various
demand side financing schemes, free care and social health insurance;
Support MoHP/FHD to develop next generation Aama considering lessons from Aama unit cost study,
national surveys and rapid assessments undertaken by FHD, including Aama into social health
insurance;
Build capacity of FHD to take ownership of Aama Rapid Assessments and monitoring of demand-side
financing schemes.
Monitoring and Evaluation
Conclusions
 HMIS architecture requires further strengthening.
 Several EDPs are working collaboratively in this area with NHSSP seen to play a critical role. GoN is
supportive of an integrated HIS and online system.
 Plans underway to roll-out data entry to health facility level in selected districts, but limited funds have
been secured by MD for further roll-out.
 Integration of DQA system into GoN required for sustainability.
 Improved use of evidence for context-specific planning and design of strategies and approaches in FHD
and CHD but better utilisation of data is still required at all levels of the system.
 Whilst the Ministry has the tools to implement surveys, frequent staff transfers and shifting the
institutional home of surveys has hindered capacity enhancement efforts. Surveys are largely funded
by DPs.
 NHRC is seen as a critical recipient of TA with less frequent movement of staff, better institutional
memory and better skills as a result.
Recommendations
 Working alongside MoHP and other development partners, embedded TA is seen to provide a valuable
role in supporting/facilitating the required developments to the HMIS/HIS including:
o a review of the health information system architecture including a roadmap for greater
system integration;
o developing of a plan for roll-out of electronic data entry at health facility level including
advocating for budget allocation;
o integrating of DQA process into the GoN system.
 TA is also recommended to support development of a capacity strengthening plan with NHRC including
exploring potential relationships with academic partners (international/local) and strengthening the link
with Public Health Administration and Monitoring & Evaluation Division (PHAMED).
3
Essential Health Care Services
Conclusions
 Embedded TA seen to play a critical role in building capacity in FHD/CHD to use evidence for policy and
planning, leveraging support from development partners to implement GoN approaches at district
level, to provide technical support to guide implementation and to link with the GoN system.
 Concerns over sustainability of CEONC fund and continuity of service provision. FHD’s capacity to
resource post to provide oversight and monitor the Fund in the longer-term will be a challenge for
DoHS.
 HQIP well-received by hospital staff and budget allocated to scale-up in 10 districts but concern about
sustainability. FHD & MD lack capacity currently to provide the support required to scale-up to a
further 10 districts..
 Family planning pilot approaches well-received by GoN. These approaches will also be rolled-out as
part of the Earthquake T&R programme across selected affected districts (funded by DFID and USAID
[TBC]). TA is seen as critical to support scale-up. Skilled staff to support this not currently available in
FHD.
Recommendations
Further TA is required to:
 Take HQIP to scale as FHD has committed the funds within their AWPB but doesn’t have the
prerequisite technical support to deliver on this commitment. For future TA, FHD should ensure they
have prerequisite in built staff or funds to contract adequate staff to work alongside TA with a clear exit
strategy in place.
 Consolidate lessons learned into a single strategy for QI in hospitals. Embedded TA is well-placed to
support DoHS to develop a consolidated system.
 Continue support DoHS to use research evidence and pilot implementation lessons to develop
strategies to improve access to quality health services of underserved populations including
strengthening referral within the GoN system to ensure that women are able to access emergency Csection; strengthening quality of care in referral hospitals and exploring the potential for working with
the private sector in remote areas.
 Ensure that lessons from the Aama unit costing study and rapid assessments as well as data from the
Service Tracking Surveys and NDHS are used to better design the next generation of Aama programme.
 Further support DoHS to learn lessons from the family planning pilots, support context specific planning
and potential scale-up of the interventions.
Gender Equality and Social Inclusion
Conclusions
 NHSSP supported structures, tools and capacity building to enable GoN to mainstream GESI but the
scale of institutionalising GESI is a challenge.
 OCMC is a priority for GoN but requires support with coordination at central and district levels to rollout effectively.
 Extensive support is required to ensure build the institutional structures, tools and skills to ensure
system responsiveness for GBV.
 Sustainability of SSUs continues to be hindered by weak management and governance at central and
hospital level, resistance among hospital staff, lack of multi-year contracting and delays in budget
transfers impacting contracted NGO services.
 Social Audits are likely to be sustainable due to PHRCD being an appropriate and motivated lead.
Threats to sustainability include EDP support to district facilitation not being sustainable, insufficient
flexible financial resources at the local level to plan and implement activities and PHRCD capacity to
promote Social Audit as an effective means by which to improve health services and to monitor
effectively.
 A critical evidence-base will have been developed during NHSSP to inform future design/strengthening
of social mobilisation programmes. A key issue hindering EAP was the inability to issue multi-year
4
contracts which for EAP NGOs fragmented inputs and compromised the quality of programme
implementation.
Recommendations
Further TA is required to:

Support better GESI integration in the planning process as MoHP moves towards decentralised
planning and devolution of authority in planning, budgeting and implementation to district. Move
institutional home to PPICD from Population Division.
SSUs:




continue to influence the medical superintendents to ensure they functionalise and are supportive of
measures to increase transparency;
roll-out the MIS;
support sustaining the PPP modality; and,
support review of feasibility of expanding SSUs to embrace coordination and monitoring of other
hospital based social protection programs and health insurance models based on the results from the
process evaluation.
Social Audit:




support streamline and ensure sustainability based on results from the process evaluation;
explore direct contracting of NGOs by RHD, especially in poor governance districts;
improve the enabling process including strengthening selection guidelines for NGOs;
explore the scope and design for integration of health social auditing by local GoN.
Social mobilisation programmes:




support to turn these learnings from assessment into pilots to support inclusive health development;
to help operationalize the collaborative framework between MoHP and MoFALD;
to harmonise social mobilisation programmes and demand-side accountability approaches and
mechanisms; and,
to strengthen VDC engagement with HFOMC and health providers and VDC resource utilisation.
OCMC: support with operationalising the monitoring and reporting systems for OCMCs.
GBV: support development of structures, tools and skills including;






developing joint annual district GBV plans across sectors;
supporting harmonisation of GBV committees at district level;
further support to the police to improve their response;
further integration of GBV into health services (e.g. through training of health professionals);
strengthening of MWCSW to lead coordination of GBV services; and,
a GBV case follow-up system needs to be developed.
Human Resources for Health
Conclusions
 An HRH Strategic Plan was developed and approved during Phase 1.
 HRH was not included in PHASE 2.
 HRH is seen to be a critical area requiring strengthening moving forward.
Recommendations
 Now the freeze on recruitment has been lifted, ensuring that human resources are appropriately
allocated across the system is seen as a critical area for TA support by Advisors and development
partners.
 Support to implement the HR strategic plan to strengthen the HR system including addressing the
issue of deployment of staff to remote areas is considered critical.
5
Annex 6: Joint active collaboration with partners beyond GoN
Agencies
Activities
H4L, UNICEF, SAVE.
QA of new HMIS tools.
USAID, UNFPA, WHO.
NFHS design and tools.
WHO, USAID, UNFPA.
Burden of Disease scoping study.
All major EDPs.
NHSP-3 design and results framework.
GiZ, UNFPA, H4L+ (7 total).
Social auditing review and implementation
Under PHCRD.
Local NGOs.
SSU transparency and accountability.
Asia Foundation.
GBV training.
WHO. H4L, UNFPA.
GESI training for NHTC trainers.
UNFPA, WHO, JHPIEGO, DFID, Centre
for victims of torture.
GBV/OCMC
H4L, Hera, PSI, UNFPA, USAID, RTI.
Friends of LMD meetings.
WB/DFID/KFW/USAID.
Procurement Reform.
WB, NSI
RAMP
SAVE
CB-ICMNCI
USAID/H4L/UNFPA
FP pilots in four districts
GiZ
New MNH programme
UNFPA
Costed five year implementation plan for FP
development
NSI
CEONC support and strengthening of district
hospitals
H4L,GiZ,WHO,NSI
Quality assurance/improvement system
USAID
Capacity building in PFM
PFMA-CA
Public Financial Management & Accountability work
plan re. MoHP functions & plan
WB/KOICA/GiZ
Social protection (formerly health insurance) and
FMR Implementation Progress Report
Table X: Summary of Value for Money (VfM) studies, findings and utilisation
Study description
Key findings
Assessing VfM for
introducing
electronic annual
work planning and
Led to significant economies of scale and improved efficiencies:
-estimated saving per user of one month’s salary per year (£200) set against a cost
of intervention of £1000 per user implies a payback period of 5 years
-halved the amount of time spent on planning cycle
6
budgeting (e-AWPB)
-improved accuracy, avoidance of duplication and improved management
decisions
Assessing VfM for ebidding and
integrated designs
for the construction
of health facilities
E-bidding in 2010/11 had reduced the average price of new contracts by 12%
leading to projected savings of £3.4 million in the year
Average construction cost per square metre can be expected to reduce by around
16%
The £3 million of savings generated in the 1st year alone exceeds to £85K cost of
the two programmes
Integration of
Expanded
Programme on
Immunisation and
Family Planning
Clinics: Value for
Money study
Integration of
payment process for
Childbirth Incentives
(4ANC and Aama
transport Payment)
Integration of FP into EPI clinics is highly cost-effective in terms of DALYs saved
Integrated clinics need to be maintained throughout the district for at least 10
years for costs per new FP user to fall towards the benchmarks
The total amount of annual efficiency savings were estimated to be £5350-7050
per year equivalent to a rate of return on the cost of introducing changes of 15 –
22%
Other benefits of introducing changes not costed in this model include nursing
time released and more auditable and transparent administrative system
7