Strengthened Local Capacity Improves Nepal’s Health Delivery

A new day has dawned for healthcare in Jumla, Nepal. The community has expanded the number of health facilities. It boasts mobile health camps, an ambulance, and home health check-ups for over 70 people a month. “Now we are providing free services to pregnant women, people with disabilities, and elderly people,” says the proud deputy municipal chairperson.

Jumla isn’t alone. In Rukum West, representatives and health management committees have completed health-related training. “By doing that, they become sensitive to things they didn’t understand about health before,” says the local health section chief. “That is why their attachment to health is increasing.”

And in Jajarkot, “the priority of the health sector has definitely improved,” says the deputy mayor. “If we don’t have any medicine and if people are continuously ill with some disease or condition, then what is the value of other physical development?”

Two factors have helped make healthcare a top priority for communities in Nepal. One is Nepal’s transition to federalism in 2017, which gave municipal officials responsibility for health. “This is a gift of federalism,” says the deputy municipal chairperson of Jajarkot. 

The other is the work of USAID's Abt-led Strengthening Systems for Better Health (SSBH) Activity. To learn more about administering health systems and what would be effective and impactful, elected municipal officials and municipal health staff in Karnali and Lumbini Provinces participated in three rounds of consultative assessments led by SSBH between 2018 and 2022. They enabled local officials to set priorities and channel funding where the needs were greatest and take practical steps to address them. The result was real world impact: improved healthcare delivery.

Over the life of the project, SSBH conducted four Health Systems and Capacity Assessments to:

• Understand the capacity and readiness of municipalities to plan, implement, and monitor health service delivery
• Identify strengths, weaknesses, gaps, and opportunities
• Inform development of customized technical assistance plans 
• Monitor, measure, and report on changes in health systems and municipal capacity
• Review progress with municipal health section chiefs and staff, elected officials, and chief administrative officers
• Update the technical assistance plans for each municipality

Assessment Team Information Gathering

A team of trained SSBH staff performed the first assessment between December 2018 and July and the second assessment between April and July 2021. The assessment team interviewed elected officials, including mayors, deputy mayors, chairpersons, and other senior staff at municipal level to collect the necessary information about eight areas:

• Legal and policy frameworks 
• Institutional arrangements 
• Planning, budgeting, and budget execution 
• Human resources mobilization and management 
• Information management and review system 
• Essential medicines logistics and supply 
• Monitoring, evaluation, and supervision 
• Governance and other systems.

SSBH Activities Contributed to Health System Improvements

The biggest improvement came in the availability of functional software to manage accounting and budgeting systems and the presence of a municipal health committee to govern health systems. Other areas that made advances were: 

• Improved skills of responsible officials to manage logistics and supply 
• Adoption of standard quality improvement processes and tools
• Presence of a legal framework to manage an information system at the municipal level

SSBH helped produce these changes by outlining oversight roles and responsibilities for municipal health committees, on-site coaching for health workers on electronic logistics management information systems (eLMIS), and helping health facilities implement quality improvement processes.

Rukum West Municipality Assessment Led to Healthcare Delivery Improvements

The Musikot municipality, Rukum West, showed how a customed technical assistance approach, with an assessment, improvement plan, support, and evaluation components, can help produce major improvements. Institutional deliveries of newborns rose from 37 percent to 78 percent. Initially, staff weren’t confident about using DHIS2 or eLMIS, but by the second assessment, health facilities were using both systems and reported 92 percent on time data collection.  And stockouts of essential medicines declined. “Four to five years ago, I did not have the required technical skills,” admits the health section chief of Jajarkot. “Now I know a lot about recording and reporting processes. I use DHIS2 to enter data in eLMIS. I have also learned about planning and budgeting…I see a lot of growth in me.”