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).
POWER OUTAGES
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.
DRUG PROCUREMENT AND DISTRIBUTION
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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