Retention of Health Workers As a Critical Factor

Social Affairs. Vol.1 No.8, 28-40, Spring 2018

Social Affairs: A Journal for the Social Sciences ISSN 2478-107X (online) www.socialaffairsjournal.com

HEALTH GOVERNANCE AT THE LOCAL LEVEL IN NEPAL: RETENTION OF HEALTH WORKERS AS A CRITICAL FACTOR

Narendra Raj Paudel* Public Administration Campus, Tribhuvan University, Nepal

ABSTRACT

This article examines the health governance situation in Nepal in order to explore crucial factors responsible for effective health service delivery at the country’s local level, particularly its far-western region. To this end, qualitative information from two well performing and to bad performing Health Facilities (HFs) of Doti and Kailali districts out of the nine districts of Far Western Development Region was used. These sources included field observations and interviews, health profiles, public hearing records, and social audit reports pertaining to the aforementioned HFs. The study showed that HFs have to tackle issues of resource restrictions, availability of other facilities (such as human resources and training), internal reliability measures, and intra-HF coordination when delivering their services to the public. In this regard, increasing government reliance on contract-based employees rather than permanent ones has exacerbated the issue of decreasing employees in remote HFs, while resources seem to be increasingly allocated to well performing HFs, reinforcing the marginality of bad performing ones which are structurally disadvantaged as well. Resource scarcity has led to lack of incentives to increase the reliability, efficiency, and effectiveness of bad performing HFs, while having a similar impact on their coordination strategies too. The study argues, therefore, that while individual fields of action such as coordination and resource allocation should be given serious attention to, it is equally – if not more – important to make sure that the structural marginalities which perpetuate the ineffectiveness of bad performing HFs are addressed with public input, not only to make local health service delivery more effective, but also give true meaning to local self- government in Nepal.

Key words: Nepal, Health Governance, Health Facilities, Health Service Delivery

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INTRODUCTION last 50 years. These include adopting different models such as gram panchayats, Although there are a number of definitions panchayats, and the democratic model. In of governance, it is difficult to come across the country’s developmental history of local one that is universally acceptable. The roots governance, more than ten commissions of the concept of governance can be traced were also constituted to identify the strengths to classical Latin and ancient Greek words and weaknesses of these endeavors, with referring to steering boats. Conceptually, the a view to learn from past experience and meaning of governance has been clarified by introduce more informed models. To this the Oxford English Dictionary as ‘an action or end, institutional and legal frameworks manner of governing’. In an encompassing were developed and tested to make local definition by the Human Development governance more effective. However, results Center of Pakistan (1999), governance “is a have shown to be far below expectation. continuing process through which conflicting diverse interests may be accommodated and The Local Self Governance Act of 1999 is cooperative action may be taken. It includes the latest legal instrument that governs local formal institutions and regimes empowered government, its development practices, to enforce compliance as well as informal and delivery of public services in Nepal. At arrangements that people and institutions present, there are 75 District Development either have agreed to or perceive to be in their Committees (DDCs), more than 100 interest” (p. 29). Municipalities, and 3000 Village Development Committees (VDCs) as local bodies in Nepal. Despite efforts to improve the situation of These legal instruments and structures are governance in developing countries like Nepal, considered as a focal point to deliver services the status of governance in these countries to the people (LGSA 1999, p. 26). For health does not paint a bright picture (UNDP 1997). service delivery, there is at least one HF in This is partly due to the fact that efforts towards each VDC. improving governance do not sit well with local socio-cultural dynamics. Recently, the Health policies developed in Nepal have been Nepali government jointly initiated a project by guided by trends in global health policies/ with the German organization Gesellschaft strategies. Following the declaration of Health für Internationale Zusammenarbeit (GIZ) in for All Strategy in 1978, the Government of financial year 2013, called the Local Health Nepal (GoN) undertook policy measures Governance Service Programme (LHGSP) and programmes for promoting health at the which was implemented in the districts of national and district levels. The GoN is also Kailali and Doti in the Far Western Region of fully committed to implement the Programme Nepal. The main objective of the programme of Action of the International Conference was to strengthen local health governance. of Population and Development (ICPD) of This article explores the factors which play 1994, Beijing Plan for Action (BPFA), of a vital role in steering health service delivery 1995, and Millennium Development Goals in the rural areas of Nepal, focusing on the (MDGs) of 2000. The ICPD emphasizes on LHGSP project as its case study. integral linkages between population and development, and focuses on meeting the HEALTH GOVERNANCE SITUATION IN needs of individuals rather than on achieving NEPAL demographic targets. The Beijing conferences Several attempts have been made in Nepal emphasize on ‘women and health’ and ‘child to strengthen local governance since the health’ (Ministry of Local Development

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2004). The Millennium Declaration set out 2013), and the Thirteenth Interim Plan (2013- eight MDGs and eighteen targets to create 2016) all aim to realize this goal, in keeping an environment – at the national and global with the recommendations of the National levels – conducive to development and Planning Commission (NHP) made through elimination of poverty. The health sector the period of 1986-2010. is particularly involved in five of these The public health sector in Nepal consists of targets namely reduction of infant and child 87 hospitals, 6 Health Centers, 697 Health mortality rates, improving maternal health, Posts, 287 Ayurvedic Hospitals, 186 Primary achieving universal access to reproductive Health Centers, and 3129 sub-Health Posts. health services, combating HIV/ AIDS, and Among them, 75% are distributed in the rural combating malaria and other diseases (MOH areas of the country. However, they are in 2004). an overwhelmingly poor condition, with no The GoN is officially committed to devolve water, no electricity, and a serious lack of power in order to provide more effective health infrastructure (DOHS 2012). services for the people. However, in practice, 25,000 health workers – including health as in most developing countries, there is a experts – are engaged in providing health tendency to prefer delegating power to the services to the people (DOHS 2012). However, public service rather than to locally elected when distributed nationally, this number authorities (Paudel 2013, p. 175), because is woefully inadequate to maintain even a although there has been much rhetoric about minimum level of health care. Brain drain is participation and local autonomy, but central also a prominent reason contributing towards governments have jealously guarded their intensifying the inadequacy of health workers power (Turner and Hulme 1997). in Nepal (Paudel 2004; Paudel 2012). In this The focus of the GoN rather seems to be on background, the GoN launched the LHGSP gradually privatizing the health sector. There with the assistance of donor countries to are approximately 100 private hospitals and address these issues. The aim of this study nursing homes, along with thousands of is to assess the impact of the programme private health clinics and laboratories offering within a framework of identifying factors that access to pharmaceuticals (DOHS 2013). are critical in the effective implementation of a However, such facilities are mainly available sound health policy. in urban areas, and are offered by private METHODOLOGY hospitals which lie beyond the capacity of rural and poor people to afford (ESP 2001). For the purpose of this study, the districts of Doti and Kailali in the Far Western Despite these developments, the GoN has Development Region of Nepal were chosen. also introduced various means by which Out of the nine districts in the region, these health services may be obtained by the rural two were chosen because they have the majority. Starting with the National Health most disparity in terms of their respective Policy (NHP) adopted in 1991 to bring about population size, crude death rate, infant improvement in the country’s health conditions mortality rate, and maternal mortality rate. On as per national and international commitments the count of life expectancy, they were similar. (MOH 1991), the Eighth Plan (1992-1997), The two districts also accommodated both Ninth Plan (1997-2002), Second Long-Term good and bad performing HFs, which further Health Plan (SLTHP) of 1997-2017, the Tenth encouraged the choice. Plan (2002-2007), the Eleventh Interim Plan (2007-2010), the Twelfth Interim Plan (2010- Doti district has a population of 200,000,

-30- Health Governance at the Local Level in Nepal Narendra Raj Paudel and is located in the hills of the Far Western information pertained to issues of resource region. It has a crude death rate of 8.12 for mobilization, human resource hiring and every 1000 births. The infant mortality rate training, social audit conduction, coordination of the district is 42.18 for every 1000 births, with stakeholders, village health profile while the maternal mortality rate is at 107 preparation, ensuring the quality of health for every 100,000 deliveries. Kailali district services delivered, and maintaining stocks of accommodates a population of 100,000, and drugs. is located in the Far Western Terai region. FINDINGS Its crude death rate is at 7.64 for every 1000 births. Kailali has an infant mortality Resource Mobilization rate of 49.2 for every 1000 births, along with In total, Rs. 400,999 was mobilized in the a maternal mortality rate of 120 for every financial year 2014/15 in the Durgamandu 100,000 deliveries. Both districts have similar HF. The grant was for multiple initiatives life expectancy of 65 years (CBS 2014). including the Safe Mother Programme, the The performance of the HFs in these districts LHGSP, and the VDC. Funds were spent on was ascertained on the basis of their process, institutional delivery, infrastructure building, output, and outcome indicators as outlined in transportation of drugs, furniture, salaries, the Monitoring and Evaluation framework of and so on (see table 1). However, this HF the LHGSP (2013). This data was triangulated displayed a lack of spending capability which, by the observations of the field enumerators, according to its health in-charge, owed to the as well as interviews with experts in the scarcity of human resources, lack of guidance respective localities. Based on this input, one by the management committee, and issues good and bad performer HF was selected with effective identification of problems. In from each district. Thus, four HFs from both addition, he reported that there was a delay districts were selected for conducting the in the release of the grant on the part of the case study. The case study explores the government, resulting in a mirror delay in reasons behind the performance of the HFs, spending (Durgamandu HF health in-charge, thereby attempting to identify factors that may personal communication, Durgamandu HF, improve health sector service delivery in rural April 15, 2016). Nepal. In comparison, the volume of resource To this end, Dododhara HF from Kailali and mobilization in the Dododhara HF was found Durgamandu HF from Doti were selected as to be higher. In total, more than 1.2 million good performers because these HFs had was generated as income from sources achieved the set target of health indicators at such as LHGSP grants, VDC activities, and the time of fieldwork. In contrast, Durgauli HF the Safe Mother Programme. Of this, Rs. from Kailali and Barchhen HF from Doti had 1.1 million was spent on the Safe Mother relatively low health indicator achievements, Programme, procurement, infrastructure thus encouraging their choice as bad building, medicine, and salaries. performers. Following field location selection, Consultation of this HFs records and field work key informant interviews were undertaken revealed that the income and expenditure with the District Public Health Officer (DPHO), of the HF were always presented before GIZ local focal persons, respective Village the health management committee, and no Development Committee (VDC) secretaries, funds were spent without the approval of the and HF in-charges to collect additional in- committee. This strict following of financial depth qualitative information. The qualitative rules and regulations had resulted in greater

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Table 1: Income and Expenditure of the Durgamandu HF During the Financial Year 2014/15

Source of income Amount Line item Expenditure (Rs.) Safe Mother program 160,000/ Delivery 23,196/ LHGSP 100,000/ Transportation 11,000/ Free Health Program 25,000/ Cleaning 32,500/ Grants from VDC 100,000/ Infrastructure 60,000/ Child club 15,000/ ENT & BP set 6,400/ Matching funds from VDC 999/ Citizens’ charter 2,500/ Care Nepal 34,000/ Social audit 900/ DPHO 60,000 Sweeper salary 32,500/ - - TV showcase 15,000/ - - Furniture 20,000/ Total 494,999/ Total 203,996/ Source: Durgamandu Social Audit Report (2013)

Table 2: IIncome and Expenditure of the Dododhara HF in the Financial Year 2014/15

Source of income Amount Line item Expenditure (Rs.) Free health care 80,000/ Safe Mother Programme 599823/ LHGSP 55,000/ Procurement 47309/ Grants from VDC 31,000/ Infrastructure 77642/ Internal income ??? 12640/ Medical equipment 235080/ Safe mother program 10,05,745/ Medicine 50000/ - - Salaries 36000/ - - Training and orientation 14950/ - - Other (paint) 20583/ - - Incentives 24930/ Total 12,98,145/ Total 11,06,317/ Source: Dododhara Social Audit Report (2013) financial accountability in the Dododhara they are looking to tap into other sources to HF. Further, the level of activism in the HF complete the building construction, some of (stemming possibly from the satisfaction which has started to come from locally based with financial good practice) has encouraged sources (Dododhara HF health in-charge, greater mobilization of local financial resources personal communication, Dododhara HF, for the facility. To illustrate, the health in- April 17, 2016). charge of the Dododhara HF revealed that In the Durgauli HF (chosen as a bad performing workers of the HF had started constructing HF in this study), a total of Rs. 303,000 was an immunization center despite the absence mobilized in the financial year 2014/15. This of funding to complete the project. The seed was the income from the first and second grant had been a loan from the LHGSP instalments of the LHGSP and the free health fund. Continuing the initial enthusiastic spirit,

-32- Health Governance at the Local Level in Nepal Narendra Raj Paudel programme. The Durgauli HF had also been the government officer in charge of health, able to mobilize local resources by way of s/he is transferred immediately or within the timber, which was used for making doors and course of a few months (Secretary, personal other furniture. In terms of expenses, it had communication, Durgamandu HF, April 15, spent Rs. 83,351 on different line items such 2016). as medicine, procurement, health equipment, In the Dododhara HF too, at the time of field infrastructure building, and maintenance. observation, almost two dozens of drugs Despite its bad performance indicators, the out of 33 essentials were out of stock. In HF had followed the guidelines of the quality this case, a key informant reported that they improvement plan and VDC health periodical faced the problem of a high flow of patients, plan. Additionally, all expenditure was made which drained the HF of its medicine stock with the approval of the Health Management quickly. The respondent also mentioned Committee (Durgauli Village and Health that although the HF typically requests Profile 2013). reinforcements from the DPHO in time, the Only Rs. 136,000 as resources was mobilized DPHO also suffers from deficits and cannot by the Barchhen HF, which also was chosen always guarantee a timely supply to meet the as a bad performing HF. Out of this fund, Rs. demand. However, the crisis occurs only 2-3 36,000 was from the Free Health Programme, times during the year, not more, according and Rs. 100,000 from the LHGSP. Due to the to the respondent (Pharmaceuticals Officer, lack of a permanent health worker cadre, personal communication, Dododhara HF, income sources and expenditure records April 17, 2016). were not maintained by this HF due to the In the case of bad performing HFs, drug perception that it was not necessary to deficit is largely due to high patient inflow document temporary health workers. The and there not being a regular supply of drugs Secretary of the VDC informed that no local from the DPHO. A respondent explained that resource was mobilized, and its only source while the DPHO does not usually arrange of income from the locality came from Out a vehicle to transport only 2-3 drugs, the Patient Department charges (Secretary, HF also does not have a surplus of health Barchhen VDC, personal communication, workers to be assigned to bring the medicine Barchhen HF, April 20, 2016). from the DPHO. Another problem relates to Shortage of Medicine indicators of medicine stock-out: The bulk of these medicines is kept in the dispensary The Durgamandu HF has been suffering from once acquired. In such situations, even a shortage of medicine for some time now. though the registry indicates that the HF is Out of 33 medicines that the government has out of a certain drug, it is not (Secretaries, committed itself to make available at each personal communication, Barchhen HF, HF, 24 were not available at the time of the April 20, 2016; Durgauli HF, April 21, 2016). fieldwork. This was due to two factors: First, These coordination problems account for a the cost of transportation is not covered by significant proportion of the crises in HFs, and the District Public Health Office (DPHO), should be addressed before any accurate compromising the timely arrival of drugs in assessment of the capacities of such HFs can the HF. Second, the GIZ focal person opined be made. that this was also partly due to the lethargic recording and reporting system of the HF Health Manpower and Training in question, and that whenever the relevant In the well performing HF of Durgamandu, GIZ officer attempts to raise the issue with

-33- Social Affairs. Vol.1 No.8, 28-40, Spring 2018 all the sanctioned positions had been filled, were incidents of management committee including the post of Auxiliary Nurse Midwife members attempting to pressurize the HF into (ANM) which was filled on contract. As per the recruiting health workers of their choice, but Health Services Act of 1996, health workers to no avail. who meet the minimum required qualifications In the bad performing Durgauli HF, although as set forth by the Public Services Commission all the sanctioned positioned were filled, can be hired locally on contract basis if there this has been more due to the pressure of a deficit of permanent health workers. The contingencies than due to any particular number of permanent health workers in Nepal keenness of the HF to actually fill its vacancies. is not sufficient both nationally and locally This fact is evidenced by events in the recent (DOHS 2013), necessitating the recruitment past where one AHW and one ANM were hired of health workers on contract basis. An on the basis of the regional quota and district interview with the officer in charge of health of quota respectively from December 2014 to the Durgamandu HF revealed that all recruits, June 2015. But in June 2015, the contract include those on contract, are provided had expired and the post had become vacant. opportunities to receive training on Community In July 2015, there had been an increased Based Integrated Management of Childhood flow of patients due to an epidemic because Illness (CB-IMCI), Community Based of which the management committee had Nursing Care Plan (CB-NCP), and the use of decided to rehire them for an extra month at Intrauterine Contraceptive Devices (IUCDs) an additional cost of Rs. 5,000 per person. under the human resource development Rules, regulations, and guidelines prescribed programme of the HF. The Durgamandu HF by the LSGA had not been strictly followed in had been awarding outstanding Auxiliary the process of re-recruitment, and those who Nurse Midwives (ANMs) with the support were thus re-recruited had been transferred to of the District Health Office since the past the next HF immediately upon the expiration two/three years, in addition to winning the of their extended contracts. These employees best performing Female Community Health had also not got any opportunity for training Volunteers (FCHVs) together with the VDC. (GIZ focal person, personal communication, This HF also followed the Performance Based Doti District GIZ office, April 25, 2016). Incentive System (PBIS) to identify its best performing employees. As a result, this HF In the case of the bad performing Barchhen was evaluated by the District Health Office of HF, there were no permanent health workers Doti as one with a regular supply of trained available throughout the year. The ANM who health workers. was also serving on contract basis, worked as the acting officer in charge of health. The post In the Dododhara HF, the sanctioned positions of the officer in charge of health was filled in were in the main filled by permanent health May 2015. An interview with him suggested workers, while positions such as Auxiliary that he was unaware of the Local Health Health Assistant, ANM, lab assistant, and Governance Programme that was being office assistant were filled on contract. implemented in this HF. Field observations Similar to the Durgamandu HF, here too brought to light how administrative oversights supplementary training was offered to leading to severe human resource problems increase the competencies of the workers, have caused this state of oblivion on the part whether permanent or contract. While of the presiding officer. All the sanctioned fieldwork revealed that there were no great posts of the HF were vacant, save for those challenges or obstacles to carrying out the of the ANM and MCHW, which were filled with HF’s operations during the past year, there

-34- Health Governance at the Local Level in Nepal Narendra Raj Paudel employees hired on contract. In an interview regardless of the facilities available. with the VDC secretary, GIZ focal person, and Social Audit DPHO focal person, it was revealed that health workers did not stay in the HF in the long term In the good performing Durgamandu HF, a due to its remoteness and the unavailability social audit was conducted in the financial of basic logistical support. The Public Service years of 2014 and 2015 in accordance with Commission was also not too enthusiastic the procedure prescribed by MHP and GIZ, in filling these positions in a timely manner, following which a report was compiled in each according to the respondents. Thus, the year. People from every walk of life such as health programme could not be implemented political party activists, health workers, and the way it was envisaged. Further, fieldwork common citizens participated in the social revealed that no one working in this HF had audit organized by DHO and facilitated by the received training. Development and Communication Group of Doti. The audit sought people’s assessment The preceding account also raises important of and opinion on various dimensions of their questions about the implications of expanding HF such as regular supply of drinking water, the contract-based labour pool in government delivery room facilities, citizens’ charter, services. Having a permanent cadre for these laboratory facilities, availability of and access positions will obviously address the issues of to health service information and health lack of training and officers vacating their posts workers, etc. Field interviews revealed that due to lack of facilities. A permanent employee Safe Motherhood, child health, nutrition, of the government will have to serve in difficult and family planning programmes were areas as part of their training, and refusing the incorporated in the local plan as a result of the appointment without due justification will result social audit (Durgamandu Social Audit Report in the termination of employment. This being 2013). the case, why is contract employment treated as the go-to option without, in most instances, Similar to the Durgamandu HF, in 2014 and considering drawing from the permanent 2015 a social audit was conducted in the pool? If the permanent workforce is indeed good performing Dododhara HF as well. shrinking, what does this say, among other FAYA Nepal conducted the social audit under things, about the government’s incentive to the authorization of the DPHO, based on maintain such a workforce? As is well known, the guidelines prescribed by the MHP. As hiring on contract significantly reduces the the first step of the process, the HF took responsibility of the employer especially in measures to form a committee representing monetary terms (since no investment has all sectors of the local society. Next, members to be made in social security including EPF, from the Dalit (untouchable) community and ETF, paid leave, etc.). It could very well be, economically marginalized communities then, that the government opts for contract were invited to join. The final composition of employment as the first preference to lessen this body was 90 people, of which 52 were the monetary strain on itself. The impact of women and 38 were men. The social audit contract-based employment on the quality of concentrated on issues of annual expenditure health services in the chosen locations has and services delivered by the HF. The report already been illustrated. The government, prepared following the social audit flagged therefore, needs to invest in either improving such concerns as including a suggestion the facilities available in these areas to attract box in the HF, lack of training to the health trained contract labour, or in expanding its workers conducting delivery and implanted permanent force that will serve in any area family planning devices, lack of beds in the

-35- Social Affairs. Vol.1 No.8, 28-40, Spring 2018 birthing center, lack of ambulance services, a marginal gain, a toilet had been constructed the non-availability of drugs, and the need in response to the social audit (Barchhen for an x-ray machine. As a result of the social Social Audit Report 2013). At the time of the audit, a Citizens’ Charter was prepared and field research, the AHW was appointed as made public, and a waiting hall in the HF was health in-charge, but he was also not aware constructed (Dododhara Social Audit Report of the LHGSP programme. 2013). Quality Assurance The bad performing HF in Durgauli conducted In the interest of health quality assurance, its social audit in the financial year of 2015 a Quality Assurance Committee (QAC) has under the guidance of FAYA Nepal as per the been formed in the well performing HF of directives of the MHP. There were a series Durgamandu. It comprises the officer in charge of consultative meeting with health workers, of health, the nursing staff, and a member of members of the management committee, the health management committee. Health and public at large. In the first stage, 16 workers along with other stakeholders are people participated in the social audit. In the oriented about the quality assurance plan of second stage of the social audit, there were the HF through this body. As a complementary 111 people (49 males and 62 females) who structure, a Citizens’ Forum is also formed in participated. In addition, members from the each ward. However, the QAC has not been Dalit community as well as minorities were able to function properly due to the lack of also involved in the social audit separately. clear guidelines (Durgamandu Village and There was two-way interaction between the Health Profile 2013). people and the concerned authority by way of the former asking questions on health In the well performing Dododhara HF also service delivery and the latter answering them a similar body – with similar composition (Durgauli Social Audit Report 2013). and functions – has been formed on the directives prescribed by the MHP. However, In the bad performing Barchhen HF, a social the Committee has not been able to hold audit was conducted in FY 2014/ 2015. More a meeting until now, and its mandate (of than 60 people including those from political ensuring quality service delivery to the parties and local organizations, health public) is currently performed by the health workers, and common people participated in management committee. Due to the high the social audit. It was organized by the DHO quality of health services, a high flow of of Doti with the support of GIZ and facilitation patients from nearby VDCs comes into the of the Development and Communication Dododhara HF (Dododhara Village and Group of Doti. People voiced their need for Health Profile 2013). the construction of a building with adequate rooms and fencing, making health workers In the case of bad performing HFs of both available, an active management committee, districts, quality assurance directives are as well as effective coordination internally and received directly from the ministry, under externally. In addition, issues were flagged whose guidance a quality assurance task like the lack of required drugs, irregular force has been formed in each HF. However, conduction of the village clinic, and the even with the necessary institutional and unavailability of delivery services. However, resource provisions in place, neither of these the ANM who was in charge of the HF at the task forces function at present. time of the social audit had not been aware of the directives of the social audit. However, as

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Coordination Dododhara HF, April 17, 2016).

In the financial year 2015, the Health No calendar was prepared for HMC meetings Management Committee (HMC) of the as far as the Durgauli HF was concerned. Durgamandu HF was able to hold its monthly While HMC members were familiar with meetings regularly except for a few months. the LHGSP programme and the planning The committee was inclusive with the Dalit process of the HF was linked with those of community, women, and minority ethnics the VDC and DDC, there was no participatory groups adequately represented and involved mechanism for its stakeholders’ involvement. in local health management. Respondents of In the financial year 2014, HMC meetings with this field location held that the success of the all its members including women and ethnic HF was due to the team work spirit in team members were held seven times, and clear members. “Without motivation and positive decisions were made on the HF’s activities. attitude coordination is impossible,” (Officer Regular meetings of the HMC were held from in charge of health, personal communication, July to December, 2015 (Durgauli Social Durgamandu HF, April 15, 2016). However, Audit Report 2013). The officer in charge of the DPHO focal person argued that the health in the Dugauli HF opined that members performance of the HF would have been of the HMC were active and positive, and better if there had been good coordination demonstrated a keen interest in implementing between health workers and members of the new health-related programmes. In addition, HMC. he opined that they discussed the problems faced by the HF and put forward suggestions In the case of Dododhara HF, monthly to resolve them (Officer in charge of health, meetings of the HMC were held only six personal communication, Durgauli HF, April months in the year. The meetings witnessed 21, 2016). the participation of women, members of the Dalit community, and minority ethnic In the case of the Barchhen HF, the local communities. However, the key informant HMC’s meetings were not held regularly mentioned experiencing functional issues because of the post of the officer in charge because the members of the HMC were of health being vacant for a long time, a in the main old and lacked energy to take problem exacerbated by the VDC secretary’s constructive measures for the betterment of inability to fill in due to the remoteness of the the HF (Secretary, personal communication, location and the access problems it posed. Dododhara HF, April 17, 2016). Both the Consequently, no health programme was officer in charge of health and VDC secretary implemented in this HF until 2014. When claimed that the HF became a good an ANM was appointed in 2014, meetings performer due to proper coordination among of the HMC were held from April to July of the stakeholders. Regular HMC meetings that year (Minutes of Barchhen HF 2014). and staff meetings were key indicators of the Field observations suggested that neither smooth process of coordination behind the the members of the HMC nor health workers health facility. The officer in charge of health were particularly interested in coordinating reported that HMC meetings were held mostly their efforts to improve health service delivery every two months, but ad hoc meetings of the area. were summoned if needed. He also added DISCUSSION AND CONCLUSION that daily staff meetings were conducted for quality assurance (Officer in charge of health In order to examine factors that are crucial for and VDC Secretary, personal communication, effective health service delivery in rural Nepal,

-37- Social Affairs. Vol.1 No.8, 28-40, Spring 2018 this article has conducted a case study in four and funding, leading to increasingly less Health Facilities (HFs) in the Far Western incentives for the staff to improve internal Region of Nepal, based on their performance functions. The cycle is completed when the in delivering health services. These HFs government makes its funding decisions were Durgamandu and Dododhara (well based on such functions of HFs. performing HFs), and Durgauli and Bacchen Any attempt at improving local self- (bad performing HFs). Performance was government in the health sector of Nepal, assessed based on the health profiles, public therefore, should take into account these hearing records, and social audit reports of interplays in order to be effective. While the jurisdictions of the respective HFs. measures to strengthen individual fields The findings suggest a clear division between of action (such as coordination, resource well and bad performing HFs in terms of the allocation and mobilization, accessibility, etc.) resources available to them and their internal are indeed extremely important, they should be functions (such as the reliability measures undergirded by a larger attempt at identifying they take and the extent to which they and addressing structural marginalities coordinate affairs within the HF), which could that perpetuate the ineffectiveness of bad have mutually reinforcing effects on each performing HFs. These measures range from other. For instance, the well performing HF raising the awareness of the local population of Dododhara also had an excellent record of about the health facilities available to them, team work and coordination as well as timely to improving the infrastructure in and around social audits, driving their health indicators such HFs (like access roads and electricity), higher. They also had more resources at and to assigning a permanent cadre to such their disposal, which could partially owe facilities and arming them with the technical to their good performance attracting more capacity to enhance internal integrity and government funds, and partially to their central efficiency of the HF. location which attracted a lot of patients Consultations with the local community are an anyway. Increasing resources seemed to integral part of such a process because local have encouraged further enhancement of specificities can hinder or help the realization internal functions. Dododhara’s performance of an effective HF in the area. For instance, (in terms of the number of people who use people of Barchhen were reluctant to visit their the HF), however, was negatively affected by HF because it was geographically located some patients opting for private medical care above the Naga temple of the village, and and the high incidence of male migration out they were afraid of angering their goddess by of the region. seeking medical help from a facility that was At the other end of the spectrum one finds HFs located above her. This in turn impacted the like Durgauli which have not performed quite HF’s patient turnout figures, contributing in a so well. Again, similar explanations can be significant way to its ‘bad performer’ status. used to understand the situation whereby bad A culturally informed approach to improving performance and resource availability seem local health service delivery can therefore go to be interdependent. Durgauli is located in a a long way. Participatory decision-making to remote area, leading patients of the area to this end would not only increase the legitimacy seek help from the more accessible Tikapur of the process and thereby secure success for hospital. Consistently low patient turnout has the new strategy, but also give true meaning pushed this HF further into the background, local self-government in Nepal. drawing less and less government attention

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