Critical Review of NHSS-IP_Sagar Parajuli.pptx

Critical Review of Nepal Health Sector Strategy
(NHSS) & Implementation Plan (NHSS-IP)
Sagar Parajuli
Roll No:07 MPH Second Semester 2023
School of Health & Allied Sciences
Pokhara University

2/7/2023
2
Presentation Outlines
• Background
• History of Strategic Planning in Nepal
• Nepal Health Sector Strategy (2015-2020)
• NHSS-Implementation Plan (2016-2021)
• NHSS-IP Format & Sample
• Development Process
• Review on NHSS Progress
• Critical Review
Presentation followed by discussion

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Background; Nepal Health Sector Strategy
• Nepal Health Sector Strategy (NHSS) considered as primary instrument for
guiding health sector for defined period of time i.e. 5 years
• Adopts vision and mission set by National Health Policies and carries ethos
of constitutional provision for ensuring fundamental right of citizen to basic
health services
• Based on Sector Wide Approach (SWAp) and emphasizes partnership as
well as multi-sectoral approach to address social determinants for achieving
Universal Health Coverage (UHC), developed by government and partners
• Views health as core for socio-economic development and aligns with
government vision to upgrade from Least developed country to Middle
Income developing Country by 2022
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Need of Nepal Health Sector Strategy
• Despite significant reduction in Under five mortality by 73% and infant
mortality by 67% in the period 1990-2014 during MDGs, reduction in
neonatal mortality and malnutrition remain less comparably,
• Health challenges like inequity, accessibility barriers (institutional, financial,
geographical, socio-cultural) were identified,
• Need of urban health services realized with growing urbanization,
• Shifting demographic and epidemiological transition in burden of disease
and increasing threats of natural disasters due to climate change
• Need of restructuring and rebuilding health system as provisioned by the
Constitution of Nepal followed by Earthquake in 2015
• Need of sectoral plans, interventions and for multi-sectoral approaches
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Basis of Nepal Health Sector Strategy
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Health Outcomes
Equity gap in Health
Care Services
Population Dynamics
& Health
Quality of Care
Shifting burden of Diseases
& Health Problems
Post-disaster
situation
Health care Financing
& Financing Protection
Sector Management
& Coordination
Health System
Strengthening
Ayurveda Health Services &
Alternative Medical System

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History of Strategic Planning in Nepal
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2004
• Council of Ministers endorsed Health Sector Strategy: An agenda for reform in response
to Poverty reduction strategy and MDGs, Vulnerable Community Development Plan 2004
2004
• Development of Nepal Health Sector Program (NHSP 2004-2009) guided by National
Health Policy 1991, Second Long term Health Plan 1997-2017 & Health Sector Strategy
2010
• Extension of NHSP I to Nepal Health Sector Program II 2010-2015, with greater
emphasis on partnership, accessibility, equity, inclusion, local governance and decentralized
service delivery, GESI Strategy 2009
2015
• Development of Nepal Health Sector Strategy (2015-2020) and NHSS-Implementation
Plan 2016-2021 based on expanded policy and monitoring framework of National Planning
Commission (NPC), focuses on multi-sectoral collaboration

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Nepal Health Sector Strategy (2015-2020)
Defined Health Sector as beyond exclusive domain of MoHP; multitudes of
state line agencies and non-state actors working for socio-economic development
Vision: All Nepali citizens have productive and quality lives with highest level
of physical, mental, social and emotional Health.
Mission: Ensure citizen’s fundamental rights to stay healthy by utilizing
available resources optimally and through strategic cooperation between service
providers, service users and other stakeholders. (National Health Policy 2014)
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Goal: Improved health status of all people
through accountable and equitable health
service delivery system
Strategic Approaches or Principles
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1. Equitable access to health services: addressing demand and supply side barriers in
accessibility, GESI in all policy, address urban poor and context (socio-economic,
demographic characteristics)
2. Quality Health services: Improving quality at point of delivery, developing
minimum service standards for both public and private sector, focuses on major
quality dimensions (effective, safe, client-centered, timely, equitable, culturally
appropriate, efficient and reliable), envisions development of Quality Assurance
autonomous body
3. Health Sector Reform: restructuring health sector, rebuilding health system,
decentralized planning & budgeting, prioritizes the implementation of the
‘Collaborative Framework for Strengthening Local Health Governance in Nepal’
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Health Sector Reform: provision of flexible health grant, making linkages at
three tiers for planning and budgeting, emphasis on disaster preparedness, state
and non-state partnership, regulation across public and private health system,
research and use of evidence, application of modern technologies
4. Multi-sectoral approach: Emphasis on social determinants of health,
prioritizes Health in all policies, promoting healthy lifestyle and environment
through collaboration, Children as starting point, healthy school environment,
HFs as learning environment for healthy lifestyle, improved road safety, nutrition
as cross-cutting issue, establishing multisectoral response to climate change
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Includes 9 outcome statements with 29 indicators and 26 output statement with 56
output level indicators
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Outcome 1 Rebuilt and strengthened health systems: Infrastructure, HRH management, Procurement
and supply chain management; 7 outputs, 41 key interventions
Outcome 2 Improved quality of care at point-of-delivery; 3 outputs, 17 key interventions
Outcome 3 Equitable utilization of health care services; 2 outputs, 15 key interventions
Outcome 4 Strengthened decentralized planning and budgeting; 1 output, 7 key interventions
Outcome 5 Improved sector management and governance; 5 outputs, 16 key interventions
Outcome 6 Improved sustainability of health sector financing; 2 outputs, 9 key interventions
Outcome 7 Improved healthy lifestyles and environment; 1 output, 11 key interventions
Outcome 8 Strengthened management of public health emergencies; 2 outputs, 12 key interventions
Outcome 9 Improved availability and use of evidence in decision making processes at all levels;
3 outputs, 18 key interventions

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Nepal Health Sector Strategy 2015-2020
Moving towards Universal Health Coverage (UHC)
1. Basic health services: provision of basic health services for every citizen
2. Social health protection: National health security program (health insurance)
for services beyond BHS for ensuring equitable access
3. Health service delivery tier: delivery arrangement and partnership with non-
state sectors, expansion of ayurveda and other allied health services, provision of
community health unit, decentralization and delegation of authority
4. Financial management: internal revenue generation and external support
5. Implementing NHSS and measuring sector performance
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Measuring sector performance under NHSS
• Establishment of Health Sector Partnership Forum to review progress on
NHSS, through quarterly meeting under chairmanship of secretary-MoHP
• Instruments for measuring sector performance
1. Result Framework of NHSS
2. Mid-term review (MTR) of NHSS; carried out by a team of independent
external experts to assess the progress made in achieving the outcomes
and results of NHSS
3. Regular Performance Review
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Result Framework
• The NHSS Results Framework
monitors sector performance on
an annual basis.
• The Framework sets out a range
of key indicators at Goal,
Outcome and Output level.
• NHSS Results Framework (RF),
with indicator matrix includes
baseline, milestone, target, data
source, disaggregation,
periodicity and responsible
agency for each indicator.
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Result
Framework
includes
– Code
– Indicator
– Baseline
– Target
– Data Source
– Monitoring
frequency
– Responsible
Agency
– Remark

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Focuses of Nepal Health Sector Strategy 2015-2020
1. Equitable service utilization, health system strengthening and demand
generation to underserved population including urban poor, promote
supportive cultural practices, improving quality of care at point of delivery
2. Strengthening research and use of evidence
3. Leverage use of modern technologies for health information system
4. Implementation of Collaborative Framework for strengthening Local
Health Governance in Nepal
5. State and Non-state partnership, regulation of public and private health
system, shift from inter-sectoral to multi-sectoral approaches
6. Defines Basic Health Package and service delivery arrangements
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Guiding Policies for NHSS
• The Constitution of Nepal 2015; basis for restructuring health system
• National Health Policy 2014
• Local Self Governance Act
• Development Cooperation Policy 2014; agenda for aid effectiveness in
health sector
• Multi-sectoral Nutrition Plan (MSNP)
• International Health Commitment to Primary Health Care and Universal
Health Coverage
• Paris Declaration on Aid Effectiveness
• Sustainable Development Goals 2030
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Introduction to NHSS-IP (2016-2021)
• Nepal Health Sector Strategy- Implementation Plan (NHSS-IP) is an output-
based plan with comprehensive set of activities necessary to achieve
output, outcome and ultimately the goal of NHSS.
• NHSS-Implementation plan and subsequent Annual Work Plan Budget
(AWPB) translates NHSS into actions, guided by results based framework.
• Includes sub-sectoral plans for departments, divisions, centers, NHRC
• NHSS-IP (2016-2021) developed for NHSS 2016/17-2021/22
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NHSS-IP 2016-2021
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1. Background of NHSS
2. Scope of NHSS-IP
3. Ministry of Health
4. Department of Ayurveda
5. Department of Drug
Administration
6. Department of Health Services
6.1 Child Health Division
6.2 Family Health Division
6.3 Epidemiology and Disease
Control Division
6.4 Leprosy Control Division
6.5 Primary Health Care
Revitalization Division
6.6 Logistic Management Division
6.7 Management Division
6.8 National TB Center
6.9 National Center for AIDS and
STD Control
6.10 NHEICC
6.11 NHTC
6.12 NPHL
6.13 National Health Research
Council
6.14 Social Health Security
Development Committee
Annex: Proposed structural
reforms
NHSS-IP
2016-2021 Outline

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NHSS-IP 2016-2021
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Layout for each Chapter
1. Background
2. Program components
3. Outputs & Interventions
4. Result Framework

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Development Process
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Committee & Team Structure: Steering Committee- chaired by Secretary, MoHP,
Technical Team- coordinated by chief PPMD-MoHP, Core task Team
Process
1. Preparation and sharing of template to all departments/divisions/ centers
2. Drafting of Implementation Plan by technical working group (TWG) at
divisions/centers comprising of relevant development partners
3. Compilation and Finalization by core task team
4. Round of meetings, email communication and face to face meetings for draft
finalization; consultative workshops
5. Approval of draft

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Review of NHSS- NJAR Report 2021/22
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Progress on NHSS Goal level Indicators
1. MMR- 174 per 100,000 live births
2. U5MR- 33 per 1000 live births
3. NMR- 21 per 1000 live births
4. Total Fertility Rate- 2.1
5. Stunting %- 25 %
6. % of women 15-49 years with BMI less
than 18.5- 17.3%
7. Life lost due to RTA- 9.9 per 100000
population

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Progress on NHSS Goal level Indicators
8. Suicide rate - 23.4 per 100,000 population
9. DALY lost
10. Incidence of impoverishment due to OOP
expenditure in Health
Regular program review through NJAR,
till 2018 National Annual Review & Joint
Annual Review were separate

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Financing during NHSS Period

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Review based on Outcome- NHSS Progress
Outcome 1 Rebuild and Strengthen Health Systems: Infrastructure, Human Resources for Health,
Procurement, and Supply Chain Management
• Health infrastructure developed as per plan and standards; Nepal Health
Infrastructure Development Standards (NHIDS) and Integrated Health
Infrastructure Development Program (IHIDP), Health Infrastructure Information
System (HIIS) land acquisition and relocation policy
• Damaged health facilities rebuilt
• Improved management of health infrastructure
• HRH- National Strategy on HRH 2077/78 - 2086/87, National Nursing and
Midwifery Strategic Action Plan 2020-30
Outcome 2 Improved Quality of Care at Point-of-delivery
Revision of National strategies and plans for improving the quality of care, and
guidelines for implementing specific interventions like IMNCI, Reproductive Health,
NHFS 2021, MSS

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Outcome 3 Equitable Distribution and Utilization of Health Services
PNC Home visit provision, COVID19 vaccination, TCV, 8 new CEONC sites, SMNH
Roadmap 2030, GBV Multisectoral coordination committee formed, GESI-targeted
interventions, Social Service Units (SSUs) established in referral and district-level
hospitals, Tuberculosis Free Nepal Declaration Initiative events at 25 local levels
Outcome 4 Strengthened Decentralized Planning and Budgeting
Use of Sub-National Treasury Regulatory Application System (SuTRA) to prepare
budget formulation, implementation, accounting and reporting

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Outcome 5 Improved Sector Management and Governance
Drafting of Nepal Health Sector Strategic Plan (2022-2030), Geriatric Health Service
Strategy, Geriatric Health Service Operational Guideline and Geriatric Health Service
Protocol, Digitisation of OCMC, SSU, and geriatric service recording and reporting
tools in DHIS2 platform, Regular meetings of the Multisectoral Medico-Legal Service
Implementation Committee, GESI strategy- Madhesh Province, National Ambulance
Guideline 2021, MPDSR Guideline
Outcome 6 Improved Sustainability of Healthcare Financing
Government health expenditure as a percentage of the Gross Domestic Product (GDP)
for FY 2020/21 is 2.4%. There is a 0.7 percentage increase compared to the NHSS
baseline year (1.7% for FY 2016/17), comprehensive National Health Financing
Strategy, Expansion of Health Insurance Program

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Outcome 7 Improved Healthy Lifestyles and Environment
Developed the Health Promotions Strategy 2022-2030 (to be endorsed) and the
Advocacy package for Sabridha Nepal, Swastha Nepali, Developed a Communication
Strategy on Tobacco Control (to be endorsed), SAFER initiative, Addition of NRT to
the essential drug list, Communication for Behavioral Impact (COMBI training)
Outcome 8 Strengthened Management of Public Health Emergencies
International Health Regulation (IHR) 2005 Orientation, COVID19 Screening, testing
and vaccination, Surveillance Outbreak Response Management and Analysis System
(SORMAS) under CORESMA (COVID-19 Outbreak Response Combining E-health,
Serolomics, Modelling, Artificial Intelligence and Implementation Research) work
package in Gandaki and Sudurpaschim Provinces

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Outcome 9 Improved Availability and Use of Evidence in Decision Making Processes at All Levels
IHMIS roadmap (2022-2030) was endorsed as per the ministerial decision in 2022,
HMIS tools revised after 9 years, Information Management Unit (IMU) under the
Integrated Health Information Management Section (IHIMS) for the effective
management of COVID-related information related to surveillance, HMIS e-learning
modules, Recording and reporting tools of the One Stop Crisis Management Centre
(OCMC), the Social Service Unit (SSU) and Geriatric health care in DHIS2, Health
Facility Registry updated, Routine Data Quality Assessment (RDQA) tool and the e-
learning package updated, Basic Health Service dashboard has been hosted at the
FMoHP website

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Major Achievements NHSS
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Policy, regulatory and strategic documents developed during NHSS Period
1. Immunization Act 2016
2. National Strategy on Reaching the Unreached, 2015-2030
3. National eHealth Strategy 2017
4. Health Insurance Act 2017
5. Disability Management (Prevention, Treatment and Rehabilitation) Policy 2017
6. The Right to Safe Motherhood and Reproductive Health Act 2018
7. Disaster Risk Reduction National Strategic Plan of Action, 2018
8. Social and Behavior Change Communication Strategy 2018
9. Public Health Service Act 2018

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Major Achievements NHSS
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Policy, regulatory and strategic documents developed during NHSS Period
10. National Health Policy 2019
11. National SMNH Roadmap 2015-2030
12. Public Health Service Regulation 2020
13. National Adolescent Health and Developmemt Strategy 2020
14. National HRH Strategy 2020/21
15. National Health Financing Strategy (Draft)
16. UHC; Strategic Framework (Draft)
17. National Health Care Quality Assurance Framework 2022
18. IHMIS Roadmap 2022

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Critical Review of NHSS & NHSS-IP
Importance & Significance:
• Crucial for health sector improvement, management and for performance
review as well as supports evidence-based policy development and program
planning
• Alignment with other sectoral plan and strategy like agriculture, urban
development is essential at planning process
Development Procedure:
• Jointly prepared by Government and development partners
• Participation from private sectors need to be ensured while developing
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Policy Framework & Instruments:
• Guided by the Constitution of Nepal, National Health Policy and other
applicable policies
• Delegation of authority and provision for developing Health Sector Strategy
at provincial and local level can support in improving overall health sector
performance
• Regulatory body as envisioned by National Health Policy can support in
sector performance review
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Strengths
• Adoption and progressive translation of the vision and mission of the
National Health Policy 2014 to guide health sector for next five years
• Identified four key strategic direction or approaches for achieving Universal
Health Coverage
• Define and supports implementation of Basic Health Service package
• Focuses on monitoring of health sector performance under NHSS through
result framework, Mid-term review and regular review
• Provides guidance for development of AWPB
• Emphasizes social health security programs, health insurance
• Provides sectoral reforms and suggestions
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Strengths
• Prioritizes research and practice of evidence-based planning, including
NHRC in NHSS-IP
• Structural Reforms
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Weakness
• More focused on public health system
• Less emphasis on private health sectors
• More ambitious target set at national level
• Mid Term Review at provincial and local level can monitor progress of
NHSS
• Result-based Framework; more focused on national level rather than
provincial and local
• Clear roles and responsibilities could be defined for three tiers for improving
sector performance
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Opportunities
• Promotion of multi-sectoral collaboration
• Public private partnership for service delivery
• Improving foreign aid effectiveness
• Sector performance improvement and management at federal, provincial and
local level
• Scaling of social security programs like health insurance
• Global partnership and collaboration
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Challenges
• Global Economic Crisis
• Emerging and re-emerging diseases and health problems- concentrated funds
for single problem like COVID19 resulting into disruption of other services
and programs
• Natural Calamities and Disasters
• Healthcare financing and protection
• Limited foreign aid- with upgrade to Middle Income Developed Country
(Bilateral and Multilateral organization)
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Way Forward
• Delegation of authority in development of Health Sector Strategy at
Provincial and local level for improving overall sector performance and for
achieving Universal Health Coverage
• Effective implementation of Basic Health Services and Social Security
programs including health insurance
• Localization of Health Sector strategy at provincial and local level
• Meaningful participation and engagement of Private sectors in preparation
and implementation of sector strategy
• Mid-term Review practice
• Defined roles and responsibilities for three tiers of government in
implementation
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References
• Nepal Health Sector Strategy 2015-2020. MoHP Nepal
• Nepal Health Sector Strategy- Implementation Plan 2016-2021. MoHP Nepal
• Progress of Health and Population Sector-NJAR Technical Report 2021/22.
Ministry of Health & Population, Nepal
Visit http://www.nhssrf.mohp.gov.np/ for each indicator review based on Result Framework-NHSS
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Critical Review of NHSS-IP_Sagar Parajuli.pptx

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