Healthsystemmanagement_Nepal

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Question: Critically appraise the district health system of Nepal.
WHO has defined a health system as “all organizations, people and actions whose primary
intent is to promote, restore or maintain health”. Health system encompasses all the
individuals and authorities that provide preventive, curative and rehabilitative health
services not merely hospitals and nursing homes.(1) The major aim of health system is to
improve the population health, to provide social and financial risk protection, to improve
efficiency of health services and to maximize autonomy and control to allow people to
make choices. The six block of health care system as purposed by WHO are service
delivery, health workforce, information, medical products and technologies, financing and
leadership and governance.
Constitution of Nepal 2015 defined Nepal as a federal democratic republic organized
around 3 levels of Government-Federal, Provincial and Local level. The constitution
presents basic health care services as a fundamental right. Henceforth, our country is
divided into 7 provinces ,77 districts and 753 local levels (including 6 metropolitans,11
submetropolitan,276 municipalities and 460 rural municipalities). The impact of new
system of governance in every administrative sectors of nation is inevitable. Health system
is no exception. Previously DPHO/DHO, now health division of municipality is the
functional unit of our national health system.
Simply, a district health system includes the interrelated elements in the district that
contribute to health in homes, educational institutions, workplaces, public places and
communities, as well as in the physical and psychosocial environment. Some of the
components of a district health system are Health office, district hospitals; health centers;
community, neighborhoods and households; Private health sector, NGOs and mission
health services. Due to the recent implementation of federal system the state of confusion
exists which has led to the situation where health system is being run by both DHO and
Municipality. The situation has been further complicated by the fact that the power is being
gradually handed to Municipality by District Health Office.

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Most of the programs are already passed down to municipality while some of the programs
are still under Health Office. These include programs like Immunization programs, Cold
chain maintenance and training programs like FCHV training, HMIS training, etc.
In the present context of historic transition towards institutionalization of Federal
Democratic Republic, decrease in geographical size and area of local body have a
significant implication to reach services to people provided at local level. It has a potential
benefit to provide equal access to government provided services to all rural and urban
population. The health offices in districts used to manage services and manage all health
facilities but now roles and responsibilities of health offices are not clear. Health office are
now under Provincial government (Ministry of social development) and are just working
as role of mediator between provincial and local government. (2)
Figure 1: Representation of role of Health office in federal context
On the contrary, all power and authorities are transferred to local level government but in
current context, local governance poses a major challenge with limited staffs and skills to
manage health programs. Health sector are overshadowed by other administrative units
which are currently functional under municipality office. The coordination among the three
levels of government has been major issue in health sector. Programs remain
unimplemented or partially implemented due to the federal government’s failure to transfer
power, with clarity, to the provincial and local governments.(3)
Federal Government
Provincial Government
Local government
Health office

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The transformation of government from centralized to federal has led to effective supply
of resources from provinces and brought a new wave in health sector reform. Thus, proper
implementation, good governance and accountability is crucial.
Transition from unitary to federal system of government poses major challenges in the
organization of health system. Municipality health system is entirely a new concept in the
health system. It has major differences from preexisting district health system. The fate of
present health office and other government bodies and the associated challenges
surrounding transformation are of major concern. SWOT analysis on the transition from
District health system to Municipal health system as a functional unit of health system is
as below:
Strengths
 Increased access to health care facilities.
 Decreased reliance on central government for funds/budgets.
 Decreased working area.
 Better identification of health problems within the municipality.
 Increased efficiency in identification, planning and response to epidemiological
breakdown. Strengthening of procurement operation, maintenance and
management of all biomedical and auxiliary equipment’s.
 Local people as stake holders who have better idea about existing problems in
municipality, cordial relationship with local people.
 Increased people participation.
Weaknesses
 State of confusion/delimit between DHO and Municipality.
 Lack of proper orientation to health workers regarding their duties/working limits,
extent of involvement.
 Lack of definitive ideas on recording and reporting and recipients of those records.
 Difficulty in managing changes in health care organization during the transition
period.
 No distinct timeframe on the transition and its subsequent impact on delivery of
health services.

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Opportunities
 Launching of popular health programs becomes easier in light of autonomy and
independence of local government.
 Attractive proposition for private sectors to invest and become more involved at
local level.
 Training to health professionals can be conducted at local level thus minimizing
the associate expenditure which was previously conducted at central level.
Threats
 Ignition of dissatisfaction, public unrest and even disintegration as a consequence
of failure to keep up with people' expectation from the new system.
 Overshadowing of health unit by other administrative units within municipality.
Health sector might not be on the top of priority list.
Overall Problems and issues in district health system of Nepal
The problems and issues of health service management at the district and grass-root level
in Nepal are as follows:
i. Problems and issues in provision of preventive and community health services
 The numbers and location of community level facilities (HPs, and PHCCs)
are based on administrative areas, which do not adequately reflect needs.
 There is a lack of effective supervision and monitoring mechanisms
especially at grass-root level facilities.
ii. Problems and issues in provision of curative services
 The resources available to district hospitals often bear no relation to the size
of the facility, service population (clinical, technical and administrative
staff): medical supplies, equipment and facilities.
 There are extensive staff vacancies in hospitals.
iv. Problems and issues in inter and intra sectoral coordination
 There is no effective mechanism to assure coordination at district and grass-
root levels. The existing formal coordination committees (e.g. HFOMC.)
are not functional in several districts and grass-root levels.
v. Problems in logistics management
 Stock outs and overstocks exist due to inadequate procurement planning,
lack of an inventory control system and insufficient resources to satisfy
demand.
 Storage space and conditions are not always managed due to a lack of
resources, use of rented facilities and lack of supervision.

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vi. Problems in information management
 Reporting is often delayed and incomplete.
 Data is often non-reliable and inconsistent
Conclusion
The impact of new system of governance in every administrative sectors of nation is
inevitable. Health system is no exception. There will be major implications on health
system on account of ongoing transition. It is expected that the federal system of
governance will address the major loopholes and aid to bolster the current health system.
The access to health services is expected to be at the doorsteps of people residing in a
particular municipality. Maternal mortality, child death due to diarrhea, ARI, severe
malnutrition which are of prime national concerns is expected to decline in the forthcoming
days. However, it will certainly be met with many challenges. This should not derail the
smooth transition of health system and should not be met with trepidations among people.
Recommendations
 Proper hierarchical relationship and division of work between three layers of
government.
 The role of health office should be clearly specified; health office should be
mobilized on programme monitoring, evaluation, supply chain management.
 The presence of current human resource in health seems inadequate to act as a
bridge between municipality and district health office. The increment in number of
staffs either in contract or permanently might be of help to address this issue.
 It is vital to ensure that health sector does not become overshadowed by other
administrative units which are currently functional under municipality office.
 Regular supervision of health related activities of all health facilities present in the
district is essential.

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References
1. Key components of a well functioning health system.
2. Thapa R, Bam K, Tiwari P, Sinha TK, Dahal S. Implementing federalism in the
health system of Nepal: Opportunities and challenges. Int J Heal Policy Manag
[Internet]. 2019;8(4):195–8. Available from:
https://doi.org/10.15171/ijhpm.2018.121
3. Science C. Health Care delivery system in Malaysia. 1999;