DFID's bilateral programme in Nepal - International Development Contents

6  Health

76. Health has been a remarkable success story in Nepal. The country is on-track to achieve most of the health and nutrition related Millennium Development Goals (MDG) targets. In the last five years, skilled attendance at birth has doubled; the number of children with diarrhoea who are taken to a health facility has increased by 10% and teenage pregnancy has fallen by 10%. The UN's 2013 MDG Progress Report judges that Nepal has already achieved the target on maternal mortality (falling from 539 deaths per 100,000 live births in 1996 to 170 in 2010) and fertility has declined from 4.6 births in 2001 to 2.6 births in 2011: nearly 1 in 2 women use a modern method of family planning.[65] This remarkable progress in the Nepali health sector (which admittedly started from a very low baseline) has impressively also been achieved against a backdrop of a decade long war, ongoing political instability and low levels of spending.

77. Although much progress has been made, there is still room for improvement as significant challenges remain. This is not surprising given the small budget the GoN devotes to health. During our visit, DFID told us that Nepal's spending on healthcare equates to about 6-8% of the Government of Nepal's total annual budget. By comparison, the UK is forecasting that approximately 18% of its total budget for financial year 2014/15 will be spent on healthcare.[66] The Government of Nepal has just $13 per capita (including donor contributions) to spend each year on healthcare, compared to the UK's $2,800. This is extremely low, even by developing country standards: less than half of Rwanda or Indonesia and similar to Malawi or Burundi.[67] Given the low level of spending it is unsurprising that 40 women in Nepal die due to pregnancy each week, each day eighty children under the age of one die from preventable causes and although the HIV prevalence rate is stabilising at around 0.23%, it is still one of the highest in south Asia.[68]

DFID spending and influence

78. DFID's spending in the health sector (which will total £72.5m from 2010-15) is a combination of both sector budget support (£52m) and technical assistance (£20.5m). In addition to this, DFID also plans to spend an additional £18m between 2013 and 2017 to improve the use of family planning.[69] During our visit, DFID informed us that the UK's contribution to the health sector in Nepal equates to about 8% of the Government of Nepal's total spending on health. We were told that this significant contribution combined with the strong links DFID has with this Ministry gives DFID significant influence over the way Nepal spends its health budget. It is also, as the Minster of State mentioned, an example of how DFID is working well through the Government system.[70] During our visit the GoN Minister of Finance told us that DFID's development work in Nepal, particularly in relation to health sector support for women and girls, was going well. We asked the DFID Minster of State for an example of how DFID has successfully used this influence:

    We are able to use it for other programmes. Very often, violence against women and girls will present with someone going to hospital. We have been able through our influence in the health system to set up eight one-stop shops, effectively, in hospitals to deal with women and girls and domestic violence.[71]

Mark Smith, DFID's Deputy Head in Nepal added:

    On a health policy level, making sure that critical services are free at the primary health care level is an area where we worked in the past and managed to get real progress. That long-term engagement has helped us work on difficult areas. […] To come into the health sector from outside having never worked with the Government and talk about health procurement might be quite difficult; you have got to have built up a track record, be in the system and be able to know how the system works in order to be able to help influence.[72]

Sector budget support

79. In our Report on strengthening health systems in developing countries we strongly supported ways of improving Government health systems, and this included sector budget support. RESULTS UK informed us that:

    For a major donor with broad interest in the health sector, it is quite appropriate for DFID to continue to provide direct budget support to strengthen Nepal's health system.[73]

80. We are, however, aware that concerns have been expressed about the use of sector budget support in countries where Government corruption is judged to be a significant issue. Questioned about this Mark Smith told us:

    The way in which we support the health sector is through sector budget support linked to technical assistance. The technical assistance is financial as well as health policy assistance. That is in there to safeguard the funds. We work on not just what more can be done on maternal health but also how health procurement can be improved, which is a huge potential area for corruption. We are trying to take this twin-track approach of making sure the money is there on a scale to be able to make a difference to health care in Nepal and making sure there is technical assistance within the system to safeguard the money that is going in.[74]

81. Nepal has made remarkable progress in its health systems in recent years. We recommend that DFID maintain its policy of using sector budget support in Nepal, which should be linked to continuing improvements, and effective steps to safeguard UK money from corrupt misuse.

Health posts and birthing centres

82. During our visit we were informed that a key method of tackling challenges in the health sector has been and will continue to be the introduction of more and better equipped health posts and birthing centres in rural areas. Given Nepal's mountainous geography, a lack of decent transport infrastructure and the remote locations in which much of Nepal's population lives, these facilities are essential for providing a basic level of healthcare to those who are often most in need. As DFID noted, it takes the poorest more than three times longer to travel to a health facility than the richest, and longer for people who live in mountain regions.[75] In an attempt to combat this, DFID has supported the introduction of a programme which gives pregnant women a cash payment if they decide to give birth in one of these facilities. This payment is designed to overcome the costs of getting to the facility, and is higher in mountainous areas where services are less accessible. [76]

83. We visited a health post in Pumdhi Bhumdi, where we were told that the three biggest barriers to their continuing success were:

·  Road transport infrastructure which prevents access

·  High turnover of staff

·  Load shedding (interruption of electricity)

The high turnover of staff was attributed to the fact that many are unpaid volunteers (and this situation was thought likely to improve only if additional funding was secured to pay them).


84. We were particularly struck by the effects of failing power supplies. As CDC pointed out, "without a stable power supply, basic services like schools and hospitals cannot function properly"[77]. Asked about the use of solar panels on health posts, the Minister of State replied that it was part of DFID's programme, but generators would still be needed because there was equipment which had a high demand for electricity such as fridges.[78]

85. Power supplies to health posts are a serious problem. If health posts cannot chill their medicines or power their lights they become much less effective. We recommend that DFID reviews this part of its programme and assesses whether greater use can be made of solar power.


86. During our visit we heard that a major issue facing the health system in Nepal was the current system for tracking drugs. At present, a paper-based tracking system exists which is inefficient and inaccurate; medicines are frequently not located in the places they are most needed, and when in those places, they often expire. At a health post in Pumdhi Bhumdi we discovered that drugs currently stocked were a muddled combination of both in-date and out-of-date medicines.

87. We were informed of a promising and cost effective potential barcode system for the procurement and delivery of drugs. It was hoped that if this proposal came to fruition, it would solve many of Nepal's drug tracking issues, and for a sensible price. We pressed DFID on this subject and we were told that "it is with the Ministers at the moment for approval"[79]. The Minster of State continued to say that "[this] one is in my in-tray and therefore has to be signed by the 30th of [March 2015]"[80].

Staff attendance in the Ministry of Health

88. Another area of concern is the high level of absenteeism in the Ministry of Health. During our visit we heard that a survey recently showed that 73% of staff were not at their desks. Although we cannot be sure of the accuracy of this survey, it does seem a worrying statistic. The Minister of State told us that:

    [This] is a question not just for health; it is a question for the whole civil service. We have been working with the Administrative Staff College to try to engender a greater level of professionalism, and hopefully that will pay off in the long term. The difficulty is in a corrupt society: […], somebody's cousin gets appointed to the job rather than someone who can do it more effectively.[81]

89. We are concerned about reports of absenteeism at the Ministry of Health in Nepal. This should raise alarm bells about whether corrupt officials are paying 'ghost workers' or failing to take disciplinary action when staff are absent. We recommend that DFID use its influence in the Ministry of Health to require improvements in the attendance of civil servants at the Ministry. If this does not happen very quickly, the UK's budget support should be gradually withdrawn.

Stronger links between Nepalese and UK health institutions

90. In our Report on strengthening health systems we argued for fostering stronger links between UK health institutions and those in developing countries:

    Demand for NHS staff does not end with doctors and nurses. Though often criticised at home, the NHS is held in high international regard and many countries would greatly benefit from the assistance of those expert in managing and financing such a successful health system. In turn, NHS managers would benefit from tackling familiar problems in unfamiliar settings. This is a challenge to traditional development models and DFID must be sufficiently agile to adapt to changing and increasingly complex needs.[82]

91. We were told that in Nepal DFID supported:

    the Britain-Nepal Medical Trust to reach out for expertise from the UK to provide that support into the Nepalese health system. It is fairly small scale, but there is a component of our support that does that.[83]

Saul Walker, DFID's Head of Director's Office for the Asia, Caribbean and Overseas Territories Directorate added:

    It is certainly an area that the health services team in the Policy Division is looking at much more generally—how to maximise the opportunities for learning from the NHS and from UK healthcare in terms of delivering health benefits in other countries. We have schemes like the Health Partnership Scheme, which directly links hospitals in the UK with institutions in developing countries. I am not sure whether Nepal is part of that, but that is certainly a programme that has been underway and is under review.[84]

92. We recommend that DFID works to improve links between health sectors in the UK and Nepal and that Nepal be included in the Health Partnership Scheme (HPS). We further recommend that DFID improve links between its health advisors and the NHS, and assess the desirability of a short secondment to the NHS for its health advisor in Nepal.

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© Parliamentary copyright 2015
Prepared 27 March 2015