Written evidence submitted by Merlin
Merlin has had little direct contact with DFID
in Nepal due to the limited opportunities for the organisations
to meet in joint fora. DFID's involvement has largely focused
on central level meetings with Government and donors while Merlin
is involved in meetings outside Kathmandu and within the NGO community.
In addition as limited DFID funding is directed to International
NGOs, and Merlin does not currently receive funding, there are
few opportunities for dialogue. This submission is therefore based
on Merlin's own experience of working in Nepal; knowledge of DFID's
programmes as they are implemented in the country and examples
of their impact within the health system as witnessed by Merlin.
ABOUT MERLIN
Merlin is an international aid agency that specialises
in improving health in fragile states. All our work—from
saving lives in times of crisis to supporting the long-term delivery
of essential care—is geared towards building a health system
that can cope with the needs on the ground now and in the future.
MERLIN IN
NEPAL
Merlin has been working in Nepal since 2006
when it opened a programme in the remote rural districts of Pyuthan
and Rolpa in the Mid-Western Region of the country. Access to
health services was very limited due in part to the conflict,
though the health care delivery system was inadequate in these
areas even before the insurgency. At the time of Merlin's arrival
there was little in the way of health provision: human resources
were poor and drug availability was limited. Access for the population
was reduced due to both the conflict and the inaccessibility of
the terrain. In addition due to the long standing political crisis,
the mobility of both health workers, and the population seeking
health services, was reduced, and the ongoing support and supervision
from regional and central levels was substantially hindered.
Merlin adopted an approach to fill the gap in
government services through the use of mobile clinics, while also
supporting existing health facilities with human resource support
(eg through training) and the provision of equipment and drugs.
In addition awareness-raising within communities on the importance
and availability of maternal and child health services, helped
to promote the demand side of services.
With the cessation of the conflict, the situation
in the health sector moved to a recognised transitional phase.
There has been a marked improvement in the support by the Government
of Nepal/Ministry of Health and Population (MoHP) to the health
system over the last three years and this is reflected in the
positive trends in health system indicators such as availability
of staff and drugs and access by the population. At the present
time, it is estimated that in the region of 85% of health staff
are present in facilities. However support is still needed from
external agencies as access to basic health care services is still
limited by geographical issues in some areas of the country. Merlin
therefore continues to provide medical services, working closely
with the MoHP and adapting its approach to provide this support
in the changed environment. Merlin's re-orientated programme is
focussed on health system strengthening through work with local
civil society partners and direct support to the public health
system.
THE HEALTH
CARE SECTOR
IN NEPAL
The MoHP has developed a long term vision for
the health sector which is supported by a consortium of External
Development Partners (EDPs), including DFID. The MOHP has developed
a 20 year long-term health sector policy and plans covering 1997-2017.
The health sector strategies and short and medium term programme
implementation plans are also in place. The funding for the execution
of the health sector strategies and plans comes in a variety of
forms including direct support to the health budget as well as
grants for project/programme support.
In addition the Government is putting 7-8% of
the national budget into health sector and this is expected to
rise to up to 11% by 2015. The increased allocation to health
from the national budget has been instrumental in the improvements
in the health sector over the last three years. One example of
this is the policy of free health care services in remote rural
and peripheral areas supported by better availability of drugs
and supplies and trained human resources which has made a noticeable
difference in terms of access to health care.
In addition a number of international civil
society organisations including development and humanitarian actors
have played a key part. Currently however there is a limited number
of health INGOs remaining in the country and most of the funding
for International and local NGOs is through humanitarian funding
sources rather than development budgets; th the latter being directed
to the MoPH via budgetary support.
DFID AND ACCESS
TO BASIC
SERVICES
DFID is the largest bilateral donor in the country
and has been providing much needed support to the health sector
in terms of budget allocation and guidance on policy development.
Along with efforts from other actors and agencies, the focus given
to safe motherhood has helped Nepal realise impressive progress
in this sector. In 2006 the National Demographic and Health Survey
(NDHS) revealed that within five years the Maternal Mortality
Ratio (MMR) had dropped from 539 to 281 per 100,000 live births.
Despite scepticism over these figures the recent Maternal Mortality
and Morbidity Study (MMMS) 2008-09, implemented by the MOHP with
support from DFID and USAID, has also confirmed this trend. Nepal
is on track to meet MDGs goals 4 and 5 which is remarkable considering
political instabilities over the past years and frequent changes
of governments. The DFID funded "Support to the Safe motherhood
Programme" (SSMP) has largely contributed to improved performance
and DFID support in terms of strengthening policy (eg Health Sector
Programme implementation Plan, Skilled Birth attendants, Safe
Abortion, etc) has been crucial in ensuring that adequate national
policies are in place.
However some challenges to DFID's approach are
also evident. Though Merlin's involvement at central level has
remained limited over the past few years due to the nature of
its projects (ie more humanitarian and emergency related), the
organisation does have intensive experience of working at regional
and district levels particularly in remote and disadvantaged areas.
Whilst acknowledging the support of External Development partners,
particularly DFID at central level, Merlin's support to District
Health Offices and the Mid-Western Region Health Directorate in
the implementation of national polices has meant it has been witness
to the regular gaps in policy implementation at these levels.
There are a number of potential contributing factors as well as
consequences of these gaps:
1. One contributing factor is the lack of proper
monitoring from higher health authorities or limited third party
monitoring. At district level and in remote areas, the local health
system often has limited capacity to implement national strategies
and to monitor them. DFID provides its support at the central
level but implementation is at a distance and often in very remote
and inaccessible areas. This makes monitoring of the support difficult
without personnel on the ground to undertake this role. The quality
of services across the country is known to differ markedly between
areas and facilities and without appropriate monitoring systems
it is not possible to pick up on this variation and address as
needed. Other agencies take a more hands-on approach: for example
staff of the USAID funded bilateral Nepal Family Health Programme
(NFHPII) are regularly based in District Health Offices to support
and monitor supported projects allowing for closer proximity to
the implementation. One recommendation from Merlin's observations
is that improved monitoring of the implementation of central support
should take place at the appropriate level through national and
international organisations with the relevant expertise.
2. Evidence from Merlin's observations also suggests
that there are several challenges with the disbursement of funds
to lower levels of the health system. These include the slow bureaucracy
resulting in the budget being released very late and the need
to undertake activities in a rush to ensure completion within
funding frames. The channelling of funds directly through the
government may also lead to a lack of transparency on how the
money is disbursed on the ground. Merlin has observed examples
of this lack of transparency in the incentives provided to health
workers under the Safe Delivery Incentive Programme (SDIP), an
issue that was also raised in the 2008 SDIP evaluation.
3. Though the SSMP has been partnering with national
organisations such as the Safe Motherhood Network, the interaction
between several EDPs and civil society remains limited and there
is scope for improved experience sharing and collaboration with
International and Local NGO and Civil Society representatives
at local and regional levels of the health sector. Under the Department
of Health Services, there are a number of working groups which
mainly include EDP, bi lateral projects and MoHP representatives.
The decentralisation of such groups to regional level with improved
inclusion of civil society could help bridge some of the gaps
in the implementation of the well formulated national policies
and programme strategies.
4. While health needs may vary considerably from
one region or ecological zone to another, with hilly and mountainous
districts facing more development challenges, almost all EDPs
concentrate their support on long term programmes aimed at strengthening
the capacity of the MoHP in delivering quality health services.
However in many remote areas the local health delivery system
is unable to cope with the most immediate needs of the population
which require more immediate actions and investments. For instance
the recent 2009 diarrhoeal outbreak that hit the Mid-Western Region
revealed that less accessible areas are particularly vulnerable
to emergencies. The health system therefore requires a higher
level of support from International and Local NGOs and civil society
in these areas to support the response to emergencies and minimise
their impact, until such time as the local health system has sufficient
capacity to do so.
November 2009
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