HRI Report 2_HFMSP

This publication is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The
contents are the responsibility of the Partnership for Maternal and Neonatal Health Project, HealthRight International in partnership with Mother and Infant Research
Activities (MIRA), and do not necessarily reﬂect the views of USAID or the United States Government.
STRENGTHENING
HEALTH FACILITY
OPERATION AND
MANAGEMENT
COMMITTEES
TO IMPROVE MATERNAL
AND NEWBORN HEALTH STATUS
IN
PERIPHERAL HEALTH FACILITIES OF ARGHAKHANCHI, NEPAL
Partnership for Maternal and Neonatal Health
an Innovation of the Child Survival and Health Grants Program

STRENGTHENING HEALTH FACILITY
OPERATION AND MANAGEMENT
COMMITTEES TO IMPROVE MATERNAL
AND NEWBORN HEALTH STATUS IN
PERIPHERAL HEALTH FACILITIES OF
ARGHAKHANCHI, NEPAL
Study Team members
Chandra Rai 1
Hari Rana 2
Mohan Paudel 3
Dr. Dharma Shrna Manandhar 4
Jyoti Shrestha 5
Dhruba Adhikari 6
August 2013
1
Project Director/Country Representative, HealthRight International
2
Training and Operation Coordinator, HealthRight International
3
Monitoring and Evaluation Coordinator, HealthRight International
4
President, Mother and Infant Research Activities (MIRA)
5
Research Coordinator, Mother and Infant Research Activities (MIRA)
6
Research Ofﬁcer, Mother and Infant Research Activities (MIRA)

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iMC to im
HealthRight and Mother and Infant Research Activities (MIRA) would like to express gratitude towards
District Health Ofﬁcer Dr. Yam Bahadur Basnet, and District Health Ofﬁce Arghakhanchi team for their kind
co-operation, encouragement, and collaborative efforts to implement the Health Facility Management
Strengthening Program (HFMSP) with HealthRight and Mother and Infant Research Activities (MIRA).
Special thanks go to the health staff and Health Facility Operation and Management Committee
(HFOMC) members from Thada Primary Health Care Centre, Narapani Health Post (HP), Pokharathok HP,
Subarnakhal HP, and Siddhara HP. HealthRight also would like to thank all of the respondents who spent
their valuable time during the interview and documentation process.
Special thanks goes to the National Health Training Centre, Nepal, Family Health Program II, and Nepali
Technical Assistance Group, for providing the training materials, trainers, and technical support to the
program.
This project was immplemented with funding support from the United States Agency for International
Development (USAID) through the Child Survival Health Grants Program. HealthRight would like to express
gratitude to USAID in Nepal and Washington.
Finally, especial thanks go to Ms. Sangita Bista and Jen Leigh, independent consultants for data collection,
report writing, and editing of this process document report.
Acknowledgements

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 ii
CB-NCP Community Based Maternal Newborn Care Package
DDC District Development Committee
DHO District Health Ofﬁce
EC Electoral Constituency
FCHV Female Community Health Volunteer
FGD Focus Group Discussion
GoN Government of Nepal
HF Health Facility
HFMSP Health Facility Management Strengthening Program
HFOMC Health Facility Operations and Management Committee
HP Health Post
HW Health Worker
KII Key Informant Interview
MIRA Mother and Infant Research Activities
MNC Maternal and Newborn Care
MNH Maternal and Newborn Health
MoHP Ministry of Health and Population
NGO Non Government Organization
NHTC National Health Training Centre
OR Operations Research
PHCC Primary Health Care Center
PHC-ORC Primary Health Care - Out Reach Clinic
QI Quality Improvement
SHP Sub Health Post
VDC Village Development Committee
Acronyms

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iiiMC to im
Table of Contents
ACKNOWLEDGEMENTS.........................................................................................................................................i
ACRONYMS............................................................................................................................................................ii
TABLE OF CONTENTS...........................................................................................................................................iii
EXECUTIVE SUMMARY........................................................................................................................................ iv
1. INTRODUCTION............................................................................................................................................1
1.1 Background.............................................................................................................................................1
1.2 National Policy Context ..........................................................................................................................1
1.3 Health Facility Management Strengthening Program Approach........................................................2
1.4 Scope Of Study........................................................................................................................................3
1.5 Objectives Of The Study..........................................................................................................................3
2. METHODOLOGY............................................................................................................................................4
2.1 Study Design...........................................................................................................................................4
2.2 Study Site................................................................................................................................................4
2.3 Data Collection.......................................................................................................................................4
2.4 Data Analysis..........................................................................................................................................4
3. ACHIEVEMENTS AND FINDINGS................................................................................................................5
3.1 Capacity Development Of Health Facility Operation And Management Committees.......................5
3.2 HFOMC Capacity Assessment Findings.................................................................................................6
3.3 Communication, Coordination, and Support.......................................................................................7
3.4 Planning, Implementation, and Monitoring..........................................................................................9
3.5 ResourceMobilization...........................................................................................................................13
3.6 Essential Medicine and Equipment....................................................................................................14
3.7 Human Resources Management........................................................................................................15
3.8 Physical Infrastructure.........................................................................................................................16
3.9 Good Governance.................................................................................................................................17
4. OPPORTUNITIES FOR SCALING UP AND SUSTAINABILITY....................................................................18
5. LESSONS LEARNED..................................................................................................................................19
6. CHALLENGES AND CONSTRAINTS..........................................................................................................20
7. RECOMMENDATIONS...............................................................................................................................21
REFERENCES......................................................................................................................................................22

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iv
Executive Summary
This report describes the process of the Health Facility Management Strengthening Program (HFMSP)
implemented by Mother and Infant Research Activities (MIRA) in partnership with HealthRight International
and the District Health Ofﬁce of Arghakhanchi. HFMSP was a capacity building process with the Health
Facility Operation and Management Committees (HFOMCs) of ﬁve peripheral health facilities, to help them
identify, prioritize, and solve health problems by utilizing local resources to improve maternal and newborn
health, and increase community facility linkages.
HFMSP was implemented as one intervention of Operations Research (OR) conducted in electoral
constituency two of Arghakhanchi District. The OR was designed by HealthRight International under the
USAID funded Partnership for Maternal and Neonatal Health Program, and implemented from 2010 to
2013. Eighteen district trainers and 57 HFOMC members were trained using a package from the National
Health Training Centre, Ministry of Health and Population that included three days of basic training, two
follow up reviews, and monthly monitoring visits by district trainers.
The objective of this report is to explore and document the HFMSP process and activities, achievements,
challenges and constraints, and lessons learned for institutional retention and future sharing with relevant
stakeholders. Changes in the capacity of the HFOMCs were investigated, in terms of institutional capacity
and committee empowerment, health facility management, and status of health service provision and
utilization. Both quantitative and qualitative methods were utilized, including a review of safe motherhood
HMIS data and meeting minutes, key informant interviews, focus group discussions, and observation of the
participating health facilities.

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 vMC to im
Key findings:
The HFOMCs’ capacity to manage the health facilities and health programs was increased. Average
assessment scores increased by about 50% between basic training and the second follow up, with none of
the HFOMCs scoring below 78% at second follow up.
The HFOMCs are encouraging regular participation of all members in a newly established series of
regular meetings to discuss community health issues, action plans, and findings of supervision visits. The
meetings are helping to build stronger relationships among members. They have also established a system
for communicating in case an emergency meeting must be called.
There is increased coordination between the HFOMCs and DHO and other stakeholders involved in
supporting the health facility.
Each of the HFOMCs has developed periodic and annual plans for the last three fiscal years and have
implemented them accordingly.
The committees have been working to identify communities without access to health services through
social mapping and supervision of outreach clinics. To respond to the needs of these communities, the
HFOMCs have resumed outreach clinics, established static clinics, changed the sites of outreach clinics,
conducted awareness campaigns, supported community screenings, and held health camps.
HFOMCs have developed and implemented a schedule for monitoring and supervising the health
facilities, PHC-ORCs, and Epi clinics using the provided supervision checklist.
The HFOMCs have increased resource generation for health facility management by coordinating with
the VDC, DHO, forest users groups, community groups, and leaders. They have also initiated their own
income generating activities like introduction of a users’ fee scheme, renting HF resources, selling unused
HF resources, and planting banana and coffee plants. They also manage a bank account for the HF income.
HFOMC management of medicine and equipment has improved, including coordination with DHO to
ensure regular supply of medicine and equipment, especially for birthing centers and newly established
static clinics, and preparation for potential outbreaks.
Human resources management has improved. The majority of newly generated resources have been
used to expand staffing. Increased focus has been placed on motivating staff, including development of a
performance appraisal and recognition system including certificates and financial incentives.
HFOMCs have made notable advances in the development, expansion, and maintenance of the physical
infrastructure at their HFs, based on needs identified through supervision.
In every HF visited, the citizen charter, along with the HFOMC annual work plan and names of HFOMC
board members with photos, was displayed.

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 1MC to im
1. INTRODUCTION
1.1 Background
HealthRight International implemented the Partnership for Maternal and Neonatal Health (PMNH)
Project in Arghakhanchi and Kapilvastu districts of Nepal from September 30, 2009 to September 29,
2013. The main goal of the project is to contribute to reducing maternal and newborn morbidity and
mortality in the project districts by increasing and sustaining utilization and quality of community and
facility based Maternal and Newborn Care services. HealthRight International is also implementing
Operations Research in Arghakhanchi district in collaborative partnership with Mother and Infant
Research Activities (MIRA), a non-governmental organization (NGO) in Nepal. The PMNH Project
implemented the Community Based Newborn Care Package (CB-NCP), use of misoprostol at
community level for prevention of postpartum hemorrhage, and Chlorhexidine for prevention of cord
infection district-wide in both project districts. MIRA conducted OR comparing the outcomes of those
interventions along with the outcomes from the addition of a health facility management strengthening
program, a maternal and newborn care (MNC) quality improvement (QI) process, and maternal and
neonatal near miss and death review process with basic equipment support, which were implemented
in electoral constituency two (EC 2).
Table 1: Arghakhanchi district demographics
Categories Population
Total Population 246,569
Children under five 30,773
Women of reproductive age (15- 45) 65,867
Expected Pregnancies per year 6,738
Source: Estimated Target Population for 2010/2011, Annual Report, DHS 2009/2010
Arghakhanchi district contains 42 Village Development Committees (VDCs), with one district hospital, two
Primary Health Care Centers (PHCCs), eight Health Posts (HPs) and 31 Sub Health Post (SHPs). The district
has a total population of 246,569, of which 65,867 are women of reproductive age.
The OR intervention area in EC 2 includes one PHCC, four HPs and 18 SHPs. The Health Facility
Management Strengthening Program (HFMSP) was implemented with the objective of increasing
community and facility linkages by strengthening partnerships between health facilities and communities
in managing public sector health services through active involvement of Health Facility Operation and
Management Committees (HFOMCs). The HFMSP was implemented in five health facilities of the OR
area: Thada PHCC, Siddhara HP, Subarnakhal HP, Pokharathok HP, and Narapani HP. By implementing
the HFMSP, the project envisions improved knowledge, skills, and accountability of HFOMC members,
and improved community involvement in health facility management and governance resulting in timely
identification and addressing of community maternal and newborn care needs by cross sectorial resource
mobilization, which commonly results in increased utilization of MNC services.
1.2 National Policy Context
The Government of Nepal’s (GoN) vision for health and development focuses on self-reliance,
community participation, and involvement of the private sector and non-governmental organizations
(NGOs). In 1999, GoN passed the Local Self-Governance Act, which led the Ministry of Health and
Population (MoHP) to decentralize health services management to local bodies (1). The main thrust
of the initiative is to make the community legally responsible for and technically capable of managing
local health facilities and health programs (2). Decentralization enables the community to participate

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 2
in managing health services and bring services closer to people’s homes (3). MoHP began the
decentralization process in 2002. By 2006, 1,433 HFs in 28 districts had been handed over to local
bodies (4).
Under the decentralization policy, HFOMCs are formally constituted as the responsible bodies for overseeing
overall management of the health facilities (5). Each HFOMC consists of nine to thirteen representatives
from the village development committee or municipality. In order to foster social inclusion and ensure
everyone has a voice in health facility management, membership includes the health facility in-charge, the
village development committee chairperson and elected members, school teachers, Female Community
Health Volunteers (FCHVs), and dalit (disadvantaged caste) and women members. The committee members
are selected through public meetings and general consensus. Some are selected by virtue of their posts,
and the rest are nominated by other members of the committee at a public meeting (6). Presently, however,
there is a lack of locally elected bodies, making it difficult and in some cases unfeasible to form the
committees according to national guidelines.
HFOMCs are supposed to manage the human resources, physical infrastructure, medicines and equipment,
funds, and health programs at the local level. The National Health Training Center (NHTC), MoHP developed
a standard package (including participant’s handbook, trainer’s guideline, and operating guidelines)
to build the capacity of the health facilities and HFOMCs through a series of orientations and trainings.
It is expected that once the HFOMCs assume full ownership of local health facility management, the
committees will meet at least once a month at their health facilities and discuss the health issues brought
by different community groups, identify local health problems, prioritize them, develop and implement
action plans, and mobilize local resources to solve the identified problems. Furthermore, they are to prepare
periodic and annual health plans, monitor and supervise health facilities, and review the progress of health
facilities periodically. The main source of funding for HFOMCs is a fixed budget, coming either directly
through the District Public/Health Offices or through the District Development Fund. HFOMCs also get funds
from their village development committees, non-governmental organizations, and the local community (6).
1.3 Health Facility Management Strengthening Program Approach
The HFMSP approach builds on the national decentralization policy, and aims to improve the health of
communities (focusing on marginalized and underserved people) by empowering the local community to
manage their own HFs and health programs. Salient features of this approach include:
Involving disadvantaged groups (e.g. dalits, janajatis, women) in health facility management decision
making
Delivering a complete package of interventions to develop knowledge and skills in managing health
facilities, rather than one-time events like trainings
Using simple, community friendly tools, guidelines and training methods
Focusing on building skills in organizational development, HF management, and health services
provision using a phased model
The HFMSP process worked over two years to build HF management capacity, through situational
assessments, a three-day interactive session, periodic review meetings, and monitoring visits.

Figure 1: The HFMSP Process
HFMSP Process
Self-assessment using standard tools
Monitoring visits in every monthly meeting of HFOMC
3 days
basic
training
6 months 6 months
2 days
review
meeting
1 day
review
meeting
HealthRight International coordinated with Nepal Family Health Program-II (NFHP), Nepali Technical Advisory
group (NTAG,) and NHTC prior to initiating HFOMC training in Arghakhanchi and arranged for their technical
assistance to conduct the training. Several rounds of meetings between NFHP-II, MIRA and HealthRight
International were held to discuss the training process, and selection of trainers. NHTC developed the
HFMSP training manuals in coordination with NFHP. Two facilitators from NTAG facilitated the trainings. MIRA
implemented the HFMSP at the selected ﬁve health facilities in close coordination with DHO, Arghakhanchi.
1.4 Scope of the Study
The study this report is based on sought to document how MIRA, in coordination with the Arghakhanchi
DHO, built the capacity of HFOMCs to improve Maternal and Newborn Health (MNH). It describes the steps
taken to build the capacity of HFOMCs to understand, document, prioritize, and develop solutions for
their problems. This report also presents some of the key activities and innovations that HFOMCs of ﬁve
peripheral health facilities have implemented to improve maternal and newborn health in their communities
and sustain their achievements. This document also notes some of the important lessons learned in
strengthening HFOMCs, as well as some constraints and challenges faced.
It is important for readers of this document to realize that this is not an evaluation of the Health Facility
Management Strengthening Program (HFMSP). Rather, it is meant to document the process of HFOMC
capacity building employed by the project and the HFOMCs’ efforts in improving quality and utilization of
maternal and newborn health using local solutions.
1.5 Objectives of the Study
The Objectives of the study documented in this report are:
Document activities undertaken to build the capacity of HFOMCs to identify, prioritize, and develop
solutions for their problems.
Document activities done by HFOMCs to improve maternal and newborn health through community
involvement and using local solutions.
Explore quality of MNH services and trends in service utilization.
Identify lessons learned and best practices of this process.

2. METHODOLOGY
2.1 Study Design
The study utilized both quantitative and qualitative methods. The research process comprised secondary data
review as well as primary data collection, conducted by an independent consultant over ten days in the field.
2.2 Study Site
Four of the five health facilities where HFMSP was implemented were visited by the consultant for this study.
These were Siddahara HP, Pokharathok HP, Subarnakhal HP, and Thada PHCC. These were chosen for HFMSP
with the aim of selecting relatively well performing committees, and to encompass variety in facility type.
2.3 Data Collection
The study employed both qualitative and quantitative methods of data collection. Consent to be included in
documentation was obtained prior to conducting interviews and discussions.
a) Document research: Review of official documents for government decentralization policy and self-
governance act 1999, and training manuals used for HFOMC capacity building.
b) Record review: Two types of records were reviewed. The three year data trend for safe motherhood
activities from 2010/2011 to 2012/2013 was reviewed. A detailed review of meeting minutes was also
done by developing a format to collect data about frequency of meetings, participation of dalit and female
members, and their activities to strengthen health program and health service delivery.
c) Key Informant Interviews (KIIs): Eight key informant interviews were conducted with a district health
officer, public health officer, research officer, chairperson, member secretary and members representing
dalits, janajatis, and women, to explore questions that were not answered by reviewing meeting minutes,
especially regarding the factors that enhanced management capacity, difficulties and challenges faced, and
future plans and perspectives for sustaining their efforts.
d) Focus Group Discussions (FGDs): Two focus group discussions were conducted in Thada PHCC
and Subarnakhal HP with members of HFOMCs comprising five participants in Subarnakhal and eight
participants in Thada. The HFOMC members discussed their thoughts on the HFMSP process, its
usefulness, and progress so far.
e) Observation: HFs were visited to observe cleanliness of HF, display of citizen charter, annual work plan
and name board of HFOMC members, etc.
2.4 Data analysis
Data generated from the record review and observations were entered into PC using MS Excel 2007.
Frequency tables and descriptive statistics were generated and used in the presentation of findings.
The interviews and discussions were audio recorded by Sony voice recorder, transferred to PC and
transcribed. The field notes from the observations and informal communications were also transferred
to a Word document to be used in analyses. The transcription was conducted in native language, Nepali
being the only language used to communicate with informants. Preliminary analyses of transcripts were
conducted throughout the data collection period to allow interview questions to be refined. A thematic
analysis of qualitative data was done. Themes were derived based on the roles and responsibilities of
HFOMCs as outlined by HFMSP.

3. ACHIEVEMENTS AND FINDINGS
Picture 1: HFOMC training exercise
3.1 Capacity Development of Health Facility Operation and Management Committees
To conduct HFOMC training, 18 district trainers from different sectors (DDC, Women Development
Office, DHO, MIRA and HealthRight International) were trained with trainers in February 2011 at DHO,
Arghakhanchi, with trainers from Nepali Technical Assistance Group (NTAG). The objective of training district
trainers was to prepare local people to train the HFOMCs and ensure sustainability of the program. Three
days of theoretical training and classroom demo sessions in the DHO training hall were followed by a three
day training for HFOMC members. The district trainers were divided into five groups and assigned one
HF for each group. Following the training of trainers, the participants, facilitators, and resource persons
traveled to their respective health facilities to conduct the three-day training to HFOMC members. A total
of 57 members from five committees received training, including 14 committee members from dalit and
disadvantaged groups, 12 women, and 5 FCHVs. On the seventh day, all district trainers returned to the
DHO training hall and shared their field training experiences. The master trainers provided feedback to all
trainers.
Content of the three day HFOMC training:
Decentralization process
Importance of Health Facility Management Strengthening Program
Healthy Life “our health, our responsibility”
Services available through health facility
Health facility management

Structure of HFOMC
Role and responsibility of HFOMC
Process to conduct HFOMC meetings
Self assessment of work of HFOMC
Social inclusion in health and process of social inclusion
Three year vision of health facility and HFOMC
Work plan of HF and HFOMC
After training, the HFOMCs were supported regularly with monitoring visits by the district trainers. In addition,
district staff from MIRA and HealthRight International and DHO supervisors played a key role in the monthly
monitoring visits to the health facilities. During the monitoring visits, district trainers observed, coached, and
facilitated HFOMC meetings. Information regarding gaps in knowledge and skills of HFOMC members were
collected, action plans were implemented, and supportive supervision and follow-up was provided.
After eight months (November 2011), a two day review was conducted, and another one day review was
held six months (June 2012) after that, in the same modality as the initial training. Review workshops
helped to address the gaps identified during monitoring visits. Further enhancement of knowledge and
skills in the areas of resource mobilization, program monitoring and supervision, good governance, need
assessments and plans developed during the review workshops.
3.2 HFOMC Capacity Assessment findings
The Health Facility Management Strengthening Program focuses on capacity development of HFOMCs. To
evidence change in HFOMC capacity, the approach included self-assessment of their capacity during the
initial three day training, and at the two follow up reviews. The self-assessments include three dimensions:
institutional capacity and committee empowerment; health facility management; and health service status.
Each dimension has a maximum score of 17 comprising a maximum aggregate score of 51. HFOMCs
achieving from 13 to 17 are considered to be performing well, 8 to 12 as fair, and less than or equal to 7
as performing poorly. Changes
in self-assessment scores
demonstrate changes in
HFOMC capacity.
The review of self-assessment
scores showed significant
improvement in their capacity
to manage institutional
development, health facility,
and health service status
presents the trend of changes
in HFOMC capacity during
the intervention (Fig 2). On
average, the aggregate score
increased from 35 percent at
baseline to 84 percent at 2nd follow up, with none of the health facilities scoring less than 78 percent.
In addition to the self-assessment findings, questions were included in the KIIs and FGDs to identify
perceived changes in HFOMC capacity. Most of the HFOMC members noted that the main change they
found in themselves was a feeling of ownership and belonging towards their HF.
3 days basic training
First follow up
second Follow up
Thada
Percentage
siddhara
Narapani
Suwarnakhal
Pokharathok
Average
of 5
HFs
100
90
80
70
60
50
40
30
20
10
0
Figure 2. HFOMC Self Assessment Score
84
63
33
37
25
24
35
35
41
80
86
78
90
84

“Earlier we did not care about the health facility and its services. This training developed
in us a feeling that this is our health facility and it is our responsibility to manage it. At
present, we are committed to providing quality services. We ensure the availability of 36
items of medicine in the HF. We have planted banana and coffee as income generating
activities for the health facility.”
-- FGD participant, Subarnakhal
“AtpresentwefeelresponsibletowardstheHF.Ifsomecomplaintsareheardinthecommunity
about service provision, we listen to them carefully and counsel them accordingly. We share
those complaints in the meeting to solve them.”
-- FGD participant, Thada
3.3 Communication, Coordination, and Support
According to the national guidelines, the HFOMC should conduct meetings on a monthly basis. It should
also develop action plans as needed, with the active participation of all members and consensus during the
decision making process.
Through the process of HFMSP implementation, the HFOMCs have indeed developed a system of having
regular meeting with active participation of all members, and all HFOMCs have ﬁxed dates and times for
their meetings. All HFOMCs completed the activities prepared in the plan of action developed during the
initial training. The HFOMC felt that developing new action plan as tedious work. Development of written
new action plans was found not into practice. However the new issues were discussed in the regular
meeting and recorded in the minutes. At present only annual plan is prepared.
The HFOMCs have established the practice of systematically keeping minutes of every meeting. Their
decisions are communicated through the network of FCHVs, mother’s groups, HFOMCs, social forums, and
sometimes through media (e.g.to announces availability of 24hour delivery service).
Provisions have been established for communicating with HFOMC members through the secretary in case
an emergency meeting must be called. The HFOMC of Pokharathok arranged a CDMA set and Siddhara has
set up a post paid sim and they have allocated funds for their management.
All of the HFOMCs held at least 60% of their scheduled meetings (range 60% -100%). Findings from
meeting minutes triangulated with KIIs and FGDs with HOMC members revealed that most HFs did not
hold meetings during the month of the national festival “Dashain and Tihar.” Thada was the only HF where
meetings could not be held three times due to lack of a required 51% of members present, over three ﬁscal
year (FY) periods. Similarly, there is a provision of monthly monitoring visits by district trainers during the
HFOMC meetings. Table 2 presents detail of HFOMC meetings and monitoring visits by district trainers.

Table 2 : Number (%) of HFOMC meetings held and facilitated by district trainers
Health facility
2010/2011
N=5 (months)
2011/2012
N=12 (months)
2012/2013
N=9 (months)
Meeting Held
Siddhara 5 (100) 11 (92) 7 (78)
Narapani 3 (60) 9 (75) 8 (89)
Subarnakhal 4 (80) 10 (83) 7 (78)
Pokharathok 5 (100) 9 (75) 7 (78)
Monitoring visits made by district trainers, among meeting held
Thada 4 (80) 6 (50) 6 (67)
Siddhara 2 (40) 4 (33) 5 (56)
Narapani 3 (60) 5 (42) 4 (44)
Subarnakhal 3 (60) 3 (25) 4 (44)
Pokharathok 3 (60) 4 (33) 3 (33)
“The main thrust is that, at present, we are well trained. Training developed in us a feeling
of ownership of our health facility. We understood the importance of regular meetings,
i.e, only through regular meetings can we understand the status of the health facility and
identify gaps so that we can take appropriate action.”
- FGD participant, Subarnakhal
There was improvement in the quality of meetings in terms of active participation of all members, decision
making by consensus, and division of roles and responsibilities. The training helped the HFOMC members
to better understand their roles and responsibilities, including the importance of regular meetings.
The HFMSP approach envisions active participation of female and Dalit members in the monthly meetings.
Female participation is above 50% for all HFs in FY2012/2013, except for Subarnakhal (table 3).
Table 3: Number (%) of Female and Dalit participation in meeting
Health facility
2010/2011
N=5 (months)
2011/2012
N=12 (months)
2012/2013
N=9 (months)
Female participation, among meetings held
Siddhara 5 (100) 9 (75) 5 (56)
Narapani 2 (40) 9 (75) 7 (78)
Subarnakhal 1 (20) 7 (58) 1 (11)
Pokharathok 5 (100) 9 (75) 7 (78)
Dalit participation, among meetings held
Thada 2 (40) 3 (25) 2 (22)
Siddhara 4 (80) 8 (67) 6 (67)
Narapani 1 (20) 4 (33) 6 (67)
Subarnakhal 4 (80) 8 (67) 4 (44)
Pokharathok 3 (60) 8 (67) 5 (56)

Though female and dalit representation has improved, there is still room for development of their capacity,
especially for those members who could not participate in the initial three day training. Pokharathok and
Narapani included dalit members in the committee only after the training, while Subarnakhal and Siddhara
included them on the very first day of training. Those members participated in the initial training were more
empowered. They were aware about their role of representation in the committee.
“We are here in the community to identify and bring health problems of our community
to the committee, discuss it and make people aware about health problems and services
available at the health facility and decisions made at committee.”
- Dalit Member, Siddhara
Most female and dalit members felt their capabilities have improved after being HFOMC members,
including increased ability to speak in a group, decreased feelings of hesitation and shyness, and increased
knowledge on health issues.
“This is the first time for me to be in a committee. Earlier I used to feel hesitation to speak in
a group. Being a member of HFOMC, I got the opportunity to learn new things and developed
the capacity to speak in a group, but still I feel hesitation to speak among the Health Facility
In-charge and other group of elite people in the committee. I haven’t tabled any agenda
items so far, but I along with dalit member did supervision of static clinic as delegated by
committee and presented the identified gaps. We are happy that gaps identified got priority
in the meeting and was solved.”
- Janajati Member, Pokharathok
3.4 Planning, Implementation, and Monitoring
Capacity building training of HFOMCs in all HFs has transformed them from dormant entities to active
stakeholders, increasing their sense
of belonging and motivation through
their active participation in planning,
implementation, and monitoring of
health facilities and health programs.
After only two years, there are some
impressive signs of success in the five
interventions HFs.
All HFs in the intervention area have
developed annual and three years
plans for the last three fiscal years and
created three year visions during the
training, with the active participation
of all members. Agendas during
planning are brought forward by HFOMC
members, regarding either health
issues of the community they represent or the findings of supervision visits. Agenda items are also brought
by the member secretary on topics identified during Ilaka (sub district) level or district level staff meetings, or
identified while reviewing health indicators. Health indicators with poor coverage are discussed and solutions
are sought. Discussion with HFOMC members revealed that those agendas that were urgent and can be
locally managed are fulfilled immediately; however, those less urgent, requiring large amount of funds like
ambulance service or construction of a new building are not completed within the planned period.
Picture 2: HFOMC members identifying marginalized groups in the
community through social mapping

Table 4: No. of PHC-ORCs resumed
Health Facilities PHC-ORCs resumed
Thada 3 (revitalized)
Siddhara 2
Narapani 2
Subarnakhal 1
All HFOMCs have identiﬁed the pocket areas in their community with poor access to HFs, through
community mapping and supervision of Primary Health Care – Outreach Clinics (PHC-ORCs). With an aim to
increase access to health services for these hard to reach communities, HFOMCs have been doing various
activities. For example, HFOMCs resumed and revitalized PHC/ORCs in their respective areas (table 4). It
is noteworthy that Siddhara and Pokharathok converted one PHC-ORC each to static clinics, so that these
communities can have regular access to health services. Other HFs (Thada and Subarnakhal) have brought
forward agendas for establishment of static clinics. These static clinics are providing services at the level
of Sub Health Posts (SHPs). In addition to the static clinics, DHO, at the request of the HFOMCs, has been
conducting health camps, uterine prolapsed screening camps, awareness campaigns, and family planning
camps at least once a year.
Similarly, HFOMCs have prioritized the maternal and newborn health program based on the review
of indicators. As such, they have identiﬁed the barriers to accessing services and have been involved
in creating an enabling environment for the
improvement of maternal and newborn health.
Their activities to improve MNH in the community
are noteworthy. At present 100 percent of the
intervention HFs are providing 24 hour delivery
services. Siddhara, Subarnakhal, and Narapani
started delivery service after the intervention period,
while Thada resumed it. With an aim to increase
HF delivery, Subarnakhal and Siddhara have been
initiated to provide an incentive of Rs.100 (about
1 USD) to FCHVs for bringing pregnant women to
deliver at the HF. In later part Subarnakhal has
increased incentive to Rs. 200 to FCHV for brining
pregnant woman to deliver at the HF. The provision of
incentives to FCHVs has been effective in increasing
HF delivery at Subarnakhal.
“Provision of incentive to FCHVs has helped in increasing institutional delivery. There were
about 3 to 5 deliveries per month which is very good in this small area. We also increased
the FCHV incentive from Rs. 100 to 200 to enhance its further effectiveness.”
Similarly, to promote institutional delivery and improve newborn health by preventing infection and
hypothermia, Thada has begun providing baby set (Nepali name daura, topi and suruwal set) to newborn babies
who deliver at the health facility. Pokharathok is also providing cloth wrappers for newborn babies born at the
health facility. Thada has been using a cost sharing mechanism for the bhoto topi sets, while Pokharathok has
been providing the wrappers free of cost.
Picture 3: Wrapper for newborns at HF

“The committees of EC 2 are gaining momentum in social mobilization for health service
promotion and utilization. We wanted to do something new, therefore we discussed it with
HFOMC members and health staff and finally decided to provide wrappers to newborns free
of cost. We have managed it from incentives received by the HF for institutional delivery,
therefore it is sustainable.”
- Member Secretary, Pokharathok
The committees identified difficult terrain, lack of transportation to the facility, and financial barriers
as important bottlenecks preventing women from delivering at the HFs. Considering the importance of
appropriate and timely referral to specialized care to improve the outcomes of mother and child during
pregnancy and labor, HFOMCs have arranged for stretchers, created an emergency reproductive health
fund, and established a maternity waiting home. Subarnakhal and Siddhara provided stretchers while
Pokharathok, Siddhara and Subarnakhal set up emergency reproductive health funds. The funds can be
used as a loan without interest so that women in need can afford transportation to reach an appropriate
center to receive care in time. HFOMCs of particular HFs have developed their specific guidelines to
implement the fund in a way that is easily accessible to the person in need.
“Emergency Reproductive Health Fund of Rs 20,000 (about 200 USD) has been created
at Siddhara. For the women convenience the total amount has been divided into three
places, Rs.10,000 at area nearby HF managed by HFOMC member, Rs. 5,000 each at Harre
and Laure village to be managed by FCHVs. Rs 1,500 is provided for transportation from
community to local HF and Rs 5,000 for referral from HF to higher center. Loan taken from
the emergency fund has to be returned within 15 days without any interest.”
- HFOMC chairperson, Siddhara
KIIs and FGDs with HFOMC members revealed that the stretchers and emergency funds have been used
extensively by the community. Table 5 presents the details about the amount of emergency reproductive
health fund, sources of fund, and its utilization.
Table 5: Emergency Reproductive Health Fund Mobilization
Health facility Amount Source No of times used
Pokharathok 29,000
FCHV’s fund, VDC,
community forest users
group
29
Siddhara 20,000
FCHV’s fund and HF internal
resource
3
Subarnakhal 15,000
FCHV’s fund and HF internal
resource
3
With an aim to address barriers like difficult terrain, lack of transportation, and lack of hotels and lodging
near the HF for accommodation of women and care takers to deliver at HF, Siddhara established a
maternity waiting home in one room of the HF building. The idea of the maternity waiting home is entirely
new in Arghakhanchi. The waiting home can accommodate one pregnant woman with two caretakers.
Establishment of the maternity waiting home is appreciated by the DHO, which envisions extending the idea
to other VDCs.

“We decided to establish maternity waiting home immediately after our decision to establish
birthing center because the HF is inaccessible to most of the communities. People need
to come from distant areas; we do not have transportation facility or the hotels where
people can stay. We have managed maternity waiting home in one room of HF building; we
can accommodate two care takers. We counsel pregnant mothers about it during ANC and
encourage them to come one or two day before EDD or as soon as abdominal pain starts.”
- HFOMC Chairperson, Siddhara
“Siddhara established a maternity waiting home, with a view to provide quality MNH
service. This is a very good initiative. HWs can closely monitor the health of mother and
baby during their stay at maternity home. This is very important to prevent newborn death.
DHO is exploring resources to strengthen waiting home of Siddhara and have a thought of
extending it to other VDCs by strengthening committees.”
-District Public Health Officer
`
Though the maternity home is of great importance in improving maternal and newborn health, its utilization
has not been as effective as anticipated. The HFOMCs have thought seriously about ways to increase
its utilization; they have been sharing about it in FCHV meetings to publicize it, have held community
interaction meetings, and are exploring resources to strengthen it.
“People do not feel comfortable staying here; they are not used to it as it is a new concept. As
it is a concrete building they fear being cold. Only three people have used it during summer
after its establishment. Our community has the culture of staying by a fire immediately
after delivery and during the postpartum period; this is not possible in our waiting home.
Therefore, people usually reside at the home of their relatives immediately after delivery
before going home. We need to make the room warm by provision of room heater to increase
its utilization which is not feasible at present due to lack of electricity. We are lobbying with
community leader for good capacity solar panel…we are ensured to get it in near future. We
hope with room heater people will be willing to use it.”
- Member Secretary, Siddhara
HFMSP activites resulted in
increased service utilization,
namely ANC visits and HF
delivery, yet there is still room
for improvement. All interviewed
HFOMC members, DHO, PHO
and research officer noted
that there has been a gradual
increase in utilization of available
maternal and newborn health
services. Figure 3 and 4 presents
the detailed picture of the
trend of utilization of ANC and
Health Facility delivery in the
intervention HFs.
Base line (Feb 010-Jan011) 2’nd year (Feb 012-Jan013)1’st year (Feb 011-Jan 012)
400
350
300
250
200
150
100
50
0
Figure 3. Four ANC visit status of Five HFMSP implemented HFs
157
137
129
43 37
70
25 40 44
16 29
68
28 37
46
269
280
357
Thada Siddhara Narapani TotalSuwarnakhalPokharathok

Apart from planning and
implementation activities, the
HFOMCs have made great
advances in their ability to
monitor and supervise health
programs. HFOMCs have
developed a system for regular
supervision through provision
of supervision schedules
with division of roles and
responsibilities for health facility,
EPI clinics, PHC-ORCs and
other national health programs
and campaigns, by using the
supervision checklist included
in the training manual. The
committees have found the supervision system very effective in identifying gaps. Committees present
the gaps identified during supervision in their monthly meetings and solve them on a priority basis. Some
examples are: after supervision, committees arranged for curtains at PHC-ORCs to maintain privacy for
antenatal checkups, procured furniture for the waiting area of ORCs, installed racks in the storeroom,
renovated staff quarters, and changed PHC-ORC sites. They also found health workers motivated and
focused on providing quality care after supervision.
“We realized the importance of supervision during first follow up review workshop. During
the workshop, we developed a supervision schedule and implemented it. We found it very
useful. Problems along with their causes are better identified through observation, which
also gives us the impetus to solve it as early as possible. At present we table most of our
agenda during our meeting from the findings of supervision visits.”
-Member Secretary, Pokharathok
3.5 Resource Mobilization
The HFMSP approach empowers committees to identify and mobilize community resources for
strengthening health programs and health services. Considerable improvement was observed in HFOMCs’
ability to generate and utilize resources, both cash and in kind. Resources were generated by coordinating
with DHO, DDC, VDCs, local forest users group, community groups, community leaders, and local NGOs, the
major source being the VDCs. All HFOMCs were able to allocate resources from their VDC for health facility
management and the trend is increasing (table 6).
Table 6: Resources generated by HFOMC
Health facility
Cash support from VDC
2010/2011 2011/2012
Thada 1,00,000 3,00,000
Siddhara 1,25,000 2,55,000
Subarnakhal 1,17,000 1,65,000
Pokharathok 151,000 2,56,000
Narapani 71,600 87,000
Total
Rs.5,64,600
(about USD 6,000)
Rs. 10,63,000
(about USD 11,400)
Thada
Siddhara Narapani TotalSuwarnakhalPokharathok
250
200
150
100
50
0
Thada
Siddhara Narapani TotalSuwarnakhalPokharathok
250
200
150
100
50
0
Figure 4. Health Facility Delivery status of Five HFMSP
implemented HFs
50 51 49 55
20
34
0 0 1 34
24
2
89
127
103
167
239

Some HFs have started their own income generating activities with a view to become independent. Thada
and Pokharathok HFOMC decided to collect user fees and developed a scheme for OPD charges and police
cases (for alcohol testing). It is also providing extended services like 24 hour emergency service using a
user fee scheme. This has helped in generating resources for the health facility as well increasing access
to services. HFOMCs have also used HF property for generating resources like renting out the canteen
(Thada), HF blocks (Subarnakhal), and selling unused HF property (e.g. firewood). Subarnakhal HFOMC
has planned for sustainable resource generation activities like planting cash crops (banana and coffee
plants). The cash generated by HFOMCs is mainly used to recruit local staff, as well as activities to motivate
HWs including FCHVs, renovation of infrastructure, and purchase of essential medicines and equipment.
HFOMCs have managed accounts in the names of the HFOMC secretary and chairperson, and deposit all
HF incomes into the account. Apart from cash support, HFOMCs have also received in-kind support like
construction of water supply tanks, latrines, placenta pits, buildings, land donations, and house rent.
“At present the HFOMC includes the VDC chairperson as HFOMC secretary. Other HFOMC
members like dalit, female, social worker, and school representative are also under the
network of VDC and play a major role in budget distribution during VDC council. The needs
of HFs are jointly prioritized during the meeting with active participation of all members.
The committee members play an active role in generating funds for the HF. Apart from
this, the forest users group of Siddhara has been helping the HF. The community group of
Narapani has bought 3 ropani land worth NRs, 3 lacs”.
- District Public Health Officer
3.6 Essential Medicine and Equipment
The HFMSP program entitles HFOMCs with the role of managing essential medicines and equipment
for smooth functioning of the health facilities. There have been significant changes in management of
medicine and equipment since the project began. Through regular supervision and interaction with HWs at
PHC-ORCs, EPI-clinics and HFs, they have been able to identify the gaps hindering smooth service delivery.
The identified gaps are solved through discussion at their regular meetings. HFOMCs have provided racks
for storing drugs, weighing scales, delivery beds, hospital beds, steel cupboards, solar arrays for light,
vacuum delivery sets, room heaters, bed sheets, and wrapper delivery sets. In addition, HFOMCs have
coordinated with DHO for regular supply of essential medicine and equipment for their HFs, especially for
their newly established static clinic. They have managed to ensure a regular supply of drugs from the DHO
for the static clinic, at the same level of supply as an SHP. The DHO has committed to provide essential
medicine and equipment for smooth delivery of service.
“We are happy with HFOMCs work of resuming PHC-ORCs, establishment of static clinics
and birthing centers. We encourage them for new innovations and have committed to
provide essential medicines and equipment for smooth delivery of services”
- District Health Officer, Arghakhanchi
The Siddhara HFOMC also identified the potential disease outbreaks that usually occur during rainy season
and have purchased extra medicines for their appropriate and timely management.
In depth interviews with the HFOMC chairperson and secretary revealed that shortages of medicines and
equipment have not hampered effective delivery of service. HFOMCs have been responsive to the gaps
identified by HWs and they try to manage it as soon as possible. This has resulted in the development
of trust and good relationships among HFOMC members and HWs. The support thus received has been
motivating HWs for smooth service delivery.

3.7 Human Resources Management
Human resources management is one of the crucial parts of a health care delivery system. The HFOMCs
have internalized the concept and have played an active role in human resources management. As such,
HFOMCs have been actively involved in recruiting the required staff. They have developed a system to
coordinate with the DHO for timely fulfillment of vacant posts well before potential transfer or departure of
current staff. HFOMC’s have also used a significant portion of the newly generated resources in recruiting
human resources. Table 7 illustrates the details of the HFOMCs’ efforts to recruit staff at a local level.
Table 7 Status of human resources recruitment by HFOMCs
Health facility Staffs recruited Source
Thada
1 ANM, 2 AHW, 1 Lab Assistant (La), 1
Office Assistant (OA)
ANM - DHO,
Siddhara 1 ANM, 2 AHW ANM - DHO, AHW - Committee
Narapani 1 ANM, 1 OA Committee
Subarnakhal 1 ANM, 1 OA ANM - DHO, OA - Committee
Pokharathok 2 ANM, 1 Ahw, 1 OA ANM - DHO, AHW & OA - Committee
Total 6 ANM, 5 AHW, 1 LA, 4 OA
Rs. 10,63,000
(About USD 11,400)
Though HFOMCs have made great advances in recruiting human resources at the local level, retention
of locally hired staff has remained a major challenge. All HFOMCs have to depend on VDC grants for
providing salaries to locally hired staff; therefore, their continuation depends on the availability of funds
and VDC priorities. The lack of a regular funding source was the main challenge for continuation. In order
to overcome the challenges, HFOMC began exploring options for local support, such as NGOs, Forest users
group, community groups, and leaders, but none of them were adequate.
HFOMCs of Siddhara and Pokharathok have developed systems of performance appraisal and motivational
activities based on appraisal to encourage HWs and FCHVs to provide quality services. The motivational
activities included cash prizes, certificates, and dosalla/swal. HFOMCs have also been regularly
encouraging HWs by providing financial incentives for HF delivery, conducting ORC clinics, providing blouses
and dhotis to office assistants, responding in a timely manner to problems shared by HWs, and verbal
encouragement.
Similarly, HFOMCs have been motivating FCHVs to attend their regular monthly meetings. FCHVs are
provided an incentive ranging from NRs.100 to 200 for attending each meeting. FCHVs of Siddhara and
Subarnakhal are also encouraged to bring women to the clinic for attended delivery with incentives. The
provision of incentives was effective, so for further encouragement, the incentive was increased to NRs.200
per women attended at the HF. FCHVs of Siddhara were also provided with motivational and educational
tour to other district for encouragement.
“Afterestablishmentofthebirthingcenter,withaviewtoincreaseHFdelivery,firstweprovided
incentive of Rs 100/FCHV/attendance to deliver women at HF. We found it effective and
realized that increase in HF delivery also means increase in resources to HF, as government
through HF is provided Rs 1000 per HF delivery….so for further encouragement we increase
the amount to Rs 200.”

Picture 4: Static clinic at Lamidamar
3.8 Physical Infrastructure
Availability of basic infrastructure is indispensable for smooth functioning of health service delivery and
serves as a strong basis for smooth
implementation of the health care system.
It is also essential for improving quality of
services, safety of staff and patients, and to
some extent works as a motivational factor
for health workers. HFOMCs are obliged
to maintain the basic infrastructure of the
HFs. As such, they have made noteworthy
improvements in the development,
expansion, and maintenance of physical
infrastructure at their HFs.
HFOMCshavedevelopedafeelingofownership
andbelongingwiththeirHFs.Asaresult,they
perceiveprotectionofHFpropertyastheir
responsibility.Theperceivedneedsfordevelopmentandmaintenanceofinfrastructureareusuallyidentifiedduring
meetingsandthroughsupervisionoffacilitiesandclinics.HFOMCshavebeenveryresponsiveinmanagingphysical
infrastructurethathasbeenidentifiedashavingneeds.SomeoftheHFOMCs’activitiesforinfrastructuredevelopment
andmaintenancearebrieflydescribedintable8below.
Table 8 HFOMC’s effort for Infrastructure Development and Maintenance
Health facility
Thada
Siddhara
Narapani
Subarnakhal
Pokharathok
Infrastructure development and maintenance
Solar array for light; placenta pit; heater for delivery room; maintenance of
lodgings
Furniture for birthing center and maternity waiting home; water tank for HF;
constructed building for static clinic
Purchased land for static clinic; water tap inside HF; made a waiting room in
the HF; bought gas set for sterilization; provided table, bed, and curtains in
each PHC-ORC clinic
New building for HF is under progress; purchased 14 stretchers; managed
curtains in ANC, delivery, and office rooms; purchased bed, pillow, and bed
sheets; construction of waiting room area
Cleaning of HF and surroundings; provided chairs, racks, and curtain to static
clinic; constructed one room and waiting area for static clinic; provided racks for
storeroom; partition and maintenance of lodging; solar arrays for birthing center

3.9 Good Governance
Good governance incorporates elements such as financial (internal and external) and social audits of
the health facility, display of the citizen charter, and social inclusion in health services. Audits (financial
and social) are important to understand the facility’s financial status and improve accountability and
transparency towards the community.
HFOMCs were encouraged to perform social audits during the second follow up review, however, the
practice of auditing was not found to be widely used across the intervention area. This was due to a change
in an act, which does not allow the HFOMC alone to conduct a social audit. It involves a lengthy process and
can only be changed at the district level. The act requires formation of district audit committee under the
chair of the Local Development Officer. The district audit committee then selects a local NGO to perform
the social audit through competition. The selected NGO performs the social audit in the health facility,
coordinating with stakeholders. Only Pokharathok had once performed a formal internal audit, which they
found to be very useful.
The committees are interested in the accountability and transparency of the HFs, however they feel
incapable to perform audits as they lack basic accounting skills. Therefore, they have developed the
practice of presenting income and expenditure reports in their meetings to be aware of financial status.
Display of the citizen charter was observed in every health facility visited. The annual HFOMC work plan,
and listings of HFOMC members’ names and photos were also displayed in every HF.
“The practice of audits is very low across the HFs because knowledge about accounting is
essential to perform audits which is not usually found among HFOMC members. An audit was
possible only in Pokharathok because one member of committee was former bank staff and
he had good knowledge about accounting systems.”
- Research Officer, MIRA

4. OPPORTUNITIES FOR SCALING UP
AND SUSTAINABILITY
The project incorporated a sustainability plan from the planning stage and implemented it accordingly.
Representatives from DHO, DDC, and Women Development Organization were trained as district trainers so
that the HFMSP program could receive continuous support.
KIIs with the DHOr and PHOr revealed that DHO has acknowledged the roles of HFOMCs in strengthening
health facility management and health programs at the local level. DHO has perceived the need to sustain
the achievements and believes they have the ability to maintain the changes as the DHO oversees the
district trainers. The DHOs also believes the program will sustain because he feels that the HFOMCs
of Arghakhanchi have entered an era of social momentum. By seeing the HFOMCs’ achievements in
the intervention area, HFOMCs in non-intervention areas have also started strengthening health facility
management and health programs on their own. Furthermore, the DHO has been exploring resources for
sustaining the changes and to further scale up the program in all VDCs of the district.
“The follow up review developed impetus for doing audit as it provided us knowledge about
it’s importance and process of auditing…however the process it stated was tedious and we
could not follow it accordingly. Our one member is former bank staff, with his help we were
able to perform audit. We disseminated the findings among the committee, staff, FCHVs,
and representatives of “wada nagarik manch (ward citizens forum)”…. It was very helpful…
we were aware about our financial status; it helps prevents corruption. Most valuable is
that the community developed faith towards the HF and services provided.”
- Member Secretary, Pokharathok
KIIs and FGDs revealed that HFOMC members were aware of their roles and responsibilities. Many HFOMC
members commented on the value of being volunteers. They felt they had learned a lot through training and
believed that training was the key factor to their achievement and motivation.
In general, there are several potential resources for sustaining the HFOMCs’ achievement. The key
seems to lie with the foundation of capable HFOMCs that have internalized feelings of ownership and
belonging towards their HFs. Once HFOMCs are aware of their needs and have the ability to document
and plan for their needs, they can then approach resources to fund them, either within the
government structure or outside of it. Many are also doing income generating activities and lobbying
for more resources within their communities.
“I think the HFOMC program of Arghakhanchi will show good achievements in the future.
GoN should plan to make Arghakhanchi a model district for HFMSP. It is very inspiring that
HFOMCs of electoral constituency one (EC-1) have learned by seeing HFOMCs’ achievements
in EC-2; they have started taking ownership of their HFs. Further, we are planning to request
that new projects include HFMSP in their activities. We have coordinated with DDC to
ensure new NGOs having health programs coordinate with DHO, so that we can request that
they include this component. In the future we are planning to launch HFMSP in all HFs of
EC-2 and extend it to EC-1 in a phased manner. It is not difficult for us to do so as we already
have sufficient district trainers, all we need is material support.”
- District Health Officer

5. LESSONS LEARNED
The commitment of the District Health Office (DHO) team, especially the DHOr and Health Facility in-
charge, is crucial to make HFMSP successful. Their success largely depends on the extent to which the
district provides regular supervision support, delegates responsibility to them, and provides supports to
materialize HFOMCs’ innovative ideas and action plans.
The HFMSP training, particularly the sections on the decentralization process, importance of HFMSP,
Healthy Life “our health our responsibility”, and three year vision, help HFOMC members to create a sense
of ownership and belonging towards their HFs.
Self-assessment of HFOMC capacity helps HFOMC members to know and understand their existing
capacity and gaps, particularly in the areas of organizational capacity, HF management, and health
services. The subsequent action plan should be in accord with identified and prioritized problems and gaps
and feasibility of addressing them, rather than adhoc basis.
Even though this capacity building process is supposed to shift responsibility for health management to
the community level and create a bottom up approach, in actuality it is a long involved process and initially
requires more support from the DHO. This means that once HFOMCs have been trained, they still need
on-going supervision support from the DHO in order to use their knowledge and skills and sustain their
motivation.
Understanding of and support for the community capacity building process by the district health office is
key to the success of these interventions. For example, the commitment expressed by the DHOr to manage
essential medicines and equipment for the birthing centers and static clinics motivated the HFOMCs to
establish additional birthing centers and static clinics.
Capacity building should not be equated with training. It should be understood as a process. The
findings of KIIs and FGDs revealed that it is very important to regularly follow up on the HFOMC monthly
meetings. All stakeholders should internalize it as a continuous process and not a onetime event. It requires
continuous support, follow up, refresher, and promotional activities.
As inclusive an HFOMC committee as possible should be sought, including geographical representation,
in order to better identify health problems, generate resources, and maintain a spirit of active voluntarism
and group empowerment.
Regular coaching of Dalit and female HFOMC members on their roles and responsibilities is needed
to increase their participation in the HFOMC meetings and community awareness activities in their
communities.
Big and long term support like building construction of health facilities would be motivating factors for
HFOMC and HF staffs for further works and improvements.
Coordinating with the Forest Users’ committee to support the HF could be very fruitful in those areas
where they have forestry as a good income source (e.g. Siddhara).
Taking a step-by-step approach, moving from comparatively simple activities to more complex ones, is
an effective approach to slowly build HFOMC capacity over time. This approach helps create milestones to
mark and celebrate small, incremental achievements.

6. CHALLENGES and CONSTRAINTS
KIIs with DHO, PHO, research ofﬁcer, and health right district team revealed that HFOMCs are heavily
reliant on VDC resources for gearing up their activities. Though they have been initiating their small
income generating activities, thus far they are not adequate. Lack of a regular income source is the major
constraint for sustaining HFOMCs’ efforts.
Most of the interviewed members emphasized that the visits by district supervisors are very necessary
to update their technical knowledge and boost their work efﬁciency and morale. The challenge is how to
ensure that this important task is conducted in a sustainable way.

7. RECOMMENDATIONS
DHO should ensure the continuation of regular monitoring and supervision visits in order to encourage
and sustain the HFOMC initiatives.
Provide opportunities for HFOMC members to update and enhance their knowledge about their roles
and responsibilities, through regular refresher trainings, workshops, and exposure visits.
A focal person at DHO should be designated with the overall responsibility of managing HFMSP.
MOHP should allocate matching funds equivalent with VDC support, as well as HFOMCs themselves
generating regular and sustainable income, to sustain the changes.
Additional administrative and management training like audit and social audit skills is essential to make
the HFOMC capable in ﬁnancial management and transparency.
A mechanism should be sought for continuous encouragement of dalit and female participation.

REFERENCES
1. Nepal Family Health Program II. Health Facility Management Strengthening Program, Journal
Article. 2012 [cited 17]; Available from: www.nfhp.org.np.
2. Nepal Family Health Program. Review of activities undertaken by NFHP and its partners to strengthen
the partnership between Community and Health Facilities. 2007.
3. AKHS Kenya Community Health Department. Policy Brief No.4 Best Practices in Community-Based
Health Initiatives.
4. Nepal Family Health Program II. Health Facility Management Strengthening Program, Trainers Guide.
June 2012 [cited 17]; Available from: www.nfhp.org.np.
5. G. Gagan. Capacity building is not an event but a process: lesson from health sector decentralization of
Nepal. Nepal Medical College Journal 2009;11(3):2.
6. Government of Nepal Ministry of Health and Population Department of Health Services National Health
Training Center. Trainers guide, Health Facility Operation Management Committee Capacity Building
Training2067.

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