Written evidence submitted by Merlin

 

November 2009

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 (e.g. 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 3 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 3 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 5 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) 2008/2009, 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 (e.g. 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 (i.e. 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.