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 * Author e-mail: ©2018 Social Affairs Journal. This work is [email protected] licensed under a Creative Commons Attribution- NonCommercial 4.0 International License. -28- Health Governance at the Local Level in Nepal Narendra Raj Paudel 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 -29- Social Affairs. Vol.1 No.8, 28-40, Spring 2018 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