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Case Study of National

TuberculosisProgramme

Implementationin Nepal

October/November 2002

Neil Hamlet, Sushil Chandra Baral

World Bank Short Term Consultants

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Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002

Contents List of Abbreviations and Acronyms .............................................................................. 4

Executive Summary .......................................................................................................... 6Study context .................................................................................................................. 6 Review process ............................................................................................................... 6 Tuberculosis control in Nepal......................................................................................... 6 The NTP and lessons for the Nepal health sector ........................................................... 6 The NTP and health sector reform.................................................................................. 7 Partnerships and resourcing of the NTP ......................................................................... 7 Local application of the DOTS strategy – lessons for the region................................... 8

Introduction....................................................................................................................... 9Study terms of reference ................................................................................................. 9 Linkage to other areas of research .................................................................................. 9 Methodology ................................................................................................................... 9Constraints ...................................................................................................................... 9

Background information................................................................................................ 10Country profile.............................................................................................................. 10National health situation ............................................................................................... 11 The status of TB control in Nepal................................................................................. 13 Development of the health policy agenda in Nepal ...................................................... 15 Millennium Development Goals................................................................................... 18 Local Self Governance Act (1999) ............................................................................... 18 The Health Sector Reform Process in Nepal ................................................................ 18 The Nepal Health Sector Strategy - An Agenda for Change ........................................ 19 NTP and the current security situation ......................................................................... 20 The National Tuberculosis Control Programme ........................................................... 21

Lessons for the Nepal Health Sector ............................................................................. 25Leadership..................................................................................................................... 25Strong team approach ................................................................................................... 25 Staff motivation ............................................................................................................ 25 Communication............................................................................................................. 26 Peer review.................................................................................................................... 26Sharing of best practice................................................................................................. 26 Central policy – local innovation.................................................................................. 27 High quality technical support ...................................................................................... 27 Focused and consistent external donors........................................................................ 28 Partnership working ...................................................................................................... 28 Appropriate and phased decentralisation ...................................................................... 28 The formation of action – orientated, structured networks........................................... 29


Summary of key ‘success factors’ ................................................................................ 30 Negative factors ............................................................................................................ 30 New areas for attention ................................................................................................. 31

The Impact of Health Sector Reform............................................................................ 32Background ................................................................................................................... 32 Health Sector Reform in Nepal..................................................................................... 33 Summary ....................................................................................................................... 38 Introduction:.................................................................................................................. 40NTP Budgeting ............................................................................................................. 40 Securing political support and government funding..................................................... 41 Attracting external donor support ................................................................................. 41 Mechanisms for funding provision: .............................................................................. 42 Donor base profile: ....................................................................................................... 42 The ability of the NTP to use ‘released funds’ ............................................................. 44 The prospects for the next 5 years ................................................................................ 44 The positive and negative implications of the HSR process on sustained resourcing of the NTP..................................................................................................................... 45 Recommendations regarding NTP funding................................................................... 45

Lessons for the Region.................................................................................................... 46Success factors .............................................................................................................. 46Additional Key Operations ........................................................................................... 49

Thanks.............................................................................................................................. 52

Annexes ............................................................................................................................ 53Annex 1: Terms of Reference ....................................................................................... 54 Annex 2: Map of Nepal................................................................................................. 55 Annex 3a: Organisational chart of Department of Health Services.............................. 56 Annex 4: Tables, Graphs and Figures........................................................................... 59 Annex 4a: NTP 5 - year budget summary 1998-2003 .................................................. 60 Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-2003................. 62 Annex 4c: Contribution of JICA................................................................................... 63 Annex 4d: Contribution of LHL ................................................................................... 63 Annex 4e: Contribution of NORAD ............................................................................. 64 Annex 4f: Contribution of DfID ................................................................................... 64 Annex 4g: Contribution of WHO.................................................................................. 65 Annex 4h: Epidemiological assumptions of NTP 5-year plan 1998-2003 ................... 67 Annex 4i: TB Case notification in Nepal 1972-2002 ................................................... 68 Annex 6: List of background materials examined ........................................................ 70 Annex 7: List of external peer reviewers...................................................................... 72


List of Abbreviations and Acronyms ARI Annual Risk of Infection BNMT Britain Nepal Medical Trust CBO Community based organisation CCC Central Chest Clinic CTLHP Community TB and Lung Health Project DfID Department for International Development, UK DHO District Health Officer DoHS Department of Health Services DOTS Directly Observed Treatment Short-course DTLA District TB/Leprosy Assistant EDPs External Development Partners EHCS Essential Health Care Services FCHV Female community health volunteers GENETUP German Nepal Tuberculosis Project HEFU Health Economics & Financing Unit HeSo Centre for Health and Social Development, Norway HMG His Majesty’s Government of Nepal HSR Health Sector Reform INF International Nepal Fellowship INGO International Non-governmental organisation I-PRSP Interim Poverty Reduction Strategy Paper IUATLD International Union Against TB and Lung Disease JAT Japanese Advisory Team JICA Japanese International Co-operation Agency LHL Norwegian Heart and Lung Association LMD Logistics & Management Division MCHW Maternal and child health worker MDGs Millennium Development Goals MoH Ministry of Health MTEP Medium Term Expenditure Programme (or Framework) MTSP Medium Term Strategic Plan NATA Nepal Anti-TB Association NGO Non-governmental organisationNHS National Health Service, UK NIH Nuffield Institute of Health NLR Netherlands Leprosy Relief Association NORAD Norwegian Government Aid NTC National Tuberculosis Centre NTP National Tuberculosis Programme PHC Primary Health Care QC Quality control (microscopy) QCA Quality control assessors RCT Randomised controlled trial RIT Research Institute of Tuberculosis (Tokyo, Japan) RMS Regional Medical Stores RTC Regional TB Centre (Pokhara, Western Region) RTLA Regional TB/Leprosy Assistant SAARC South Asian Association for Regional Co-operation


SCC Short Course Chemotherapy SEARO WHO South East Asia Regional Office SLTHP Second Long Term Health Plan STC SAARC TB Centre SWAp Sector Wide Approach TAG Technical Advisory Group TB TuberculosisTBCP TB Control Project TLP Tuberculosis Leprosy Project (INF) ToT Training of trainers TQM total quality management UMN United Mission to Nepal VDC Village development committee VHW Village health worker WHO World Health Organisation YUHP Yala Urban Health Programme (UMN)


Executive Summary

Study context The National TB Programme (NTP) of Nepal is generally regarded as highly successful both nationally and internationally. The programme has never previously been studied to identify the key success factors both from the perspective of technical TB control implementation and generic health service functions. The impact of Health Sector Reform (HSR) on programmes such as TB control is a live topic of debate internationally and also in Nepal where an HSR process is currently in the late stages of planning. From these two perspectives Nepal provided an ideal case study opportunity to examine the NTP in the climate of imminent HSR. This work was commissioned by the World Bank.

Review process Two short-term consultants (one national, one international) with considerable working experience of TB control in Nepal were contracted to undertake the review over a two-week period in late autumn 2002. Information was gathered by interviews, site visits, correspondence and the examination of relevant documentation (in English). The world literature on HSR and TB control was explored to provide a framework for the work. The document was peer-reviewed prior to publication.

Tuberculosis control in Nepal TB causes an estimated 8,000-11,000 deaths per year in Nepal. In the year 2000/01 over 31,000 TB patients were registered and treated under the NTP, of which 13,000 were new smear positive. The NTP was revised in 1995 and DOTS implemented in 1996. By mid-2001 the DOTS strategy had been rolled out to 227 treatment centres with 684 sub centres, covering 84% of the total population across all 75 districts in the country. Treatment success rates of 85% or greater have been reported over the past 5 years.

The NTP and lessons for the Nepal health sector Examination of the Nepal TB Programme provides insights of value across the health sector in terms of generic issues such as programme management, organisational culture and implementation practices.

The areas highlighted as being key success factors were:

¶ Leadership and a strong team approach ¶ Staff motivation ¶ Communication ¶ Peer review practices including the sharing of best practice ¶ A clear central policy but encouraging local innovation ¶ High quality technical assistance at national and regional level ¶ Focused and consistent external donor partners ¶ Partnership working practices ¶ Appropriate and phased decentralisation ¶ The formation of action-orientated structured networks


The NTP and health sector reform The overarching objective of HSR is threefold: to maximise efficiency, equity and quality. The process involves the defining of priorities, the refining of policies, and the reforming of institutions through which these policies are implemented.

His Majesty’s Government of Nepal (HMG) have set three programme outputs which will be at the core of the Nepal HSR programme over the next 5 years. These are an Essential Health Care Service (EHCS) package, decentralisation, and a public-private mix of service provision.

The potential of the NTP to champion, or conversely, to hinder HSR change is addressed together with an analysis of the impact that HSR may have on the delivery of TB control. The eight Nepal HSR outputs and seven key areas identified by the TB/HSR literature are used as a template against which to evaluate the Nepal situation.

The strengths of the NTP in relation to maintaining quality TB control services during the HSR process are; the commitment to widespread advocacy, the close monitoring of anti-TB drug procurement and delivery, the retention of technical supportive structures for microscopy services and trimesterly cohort reporting mechanisms, the emphasis on service delivery through the PHC system and the awareness of ‘NTP’ donor partners of the HSR process.

The weaker aspects are a lack of pro-active participation of the NTP in the reform planning process, no evidence of advance planning to prepare for the implications of HSR on TB control programming and an absence of plans to pilot test the new institutional arrangements arising from the HSR process.

Partnerships and resourcing of the NTP One of the successful features of the Nepal NTP has been the ability to negotiate effective working partnerships and attract the required resources both financial and technical to implement an expanding programme of work. The preparation of detailed and budgeted 5-year development plans has been the foundation of this success. Sustained political and media advocacy has secured widespread awareness and support of the programme both nationally and internationally. An external review of the programme in 1994 became the catalyst for the revised NTP and led to a strong working partnership between the programme, external donors and a number of established in-country international development NGOs. Much of the non-government support provided to the NTP is in the form of technical assistance, training, supervision and service delivery mechanisms which are not currently quantified in NTP budgets. Currently therefore only an estimate can be made of the true resource envelope required for the NTP. Additionally not all financial flows are documented in the Ministry of Finance annual budget known as the ‘Red Book’. The NTP has demonstrated excellent capability to utilise government development budget ‘released funds’. This is a measure of the planning and implementation capacity of the programme. The sustainability of the current donor and implementing partner INGOs for the next 5-year phase requires exploration as two of the regional counterpart INGOs are currently undergoing restructuring. Additional challenges lie in the expected impact of HIV and the increasing attention being given to the syndromic approach to adult lung health.


Local application of the DOTS strategy – lessons for the regionA major component in the success of the adoption of the DOTS strategy in Nepal lies in the structured and phased manner in which the key operations for implementation were addressed. Using the 2002 WHO publication DOTS Framework for Effective TB Control as a template the lessons for other TB programmes in the region are defined. These are summarised as: ¶ Provision of adequate central unit office facilities for the NTP. ¶ A robust national review in 1994 leading quickly into the preparation of a

development plan. ¶ Choice of external consultant is important as is the continuity of leadership of the

NTP director in the period of any major revision of the NTP. ¶ A well developed national TB manual prepared in advance of any implementation. ¶ The introduction of the cohort based TB reporting documentation requires to be

handled as a project in itself. ¶ The availability of adequate financial resources to back a comprehensive, locally

adapted, rolling training programme. ¶ The widespread use of the WHO training modules to increase technical capacity

for senior staff and trainers.¶ The expansion of training into generic health care support roles and wider civic

society.¶ Recognition of the crucial importance of available microscopy services for a

functioning DOTS programme. ¶ The DOTS expansion programme consisted of a comprehensive package of new

site selection and preparation based on the 10-point checklist. ¶ Public (PHC and hospital), private and NGO facilities were used for service

delivery.¶ The management of drug supply has been closely monitored and controlled by the

central unit providing the fast expanding programme with the security of uninterrupted supplies.

¶ The supervision programme is an example of excellent partnership working between government staff, ring fenced donor support, and local capacity building by ’on the ground’ INGOs.

¶ The emphasis on proactive communication and networking at all levels was instrumental in the success of the programme.

¶ The partnership working between the NTP and the press provided wide local and national press and radio coverage, increasing awareness of, and confidence in, public attitudes towards TB and its treatment.

¶ The Nepal programme had a culture of working with different agencies in the control of TB which promoted the inclusion of new private and voluntary partners.

¶ The NTP has effectively resourced external assistance in the process of budget formulation and achieved good release of funds.

¶ The attention given to practical operational research has driven up technical capacity of both individuals and the programme as a whole.


Introduction

Study terms of reference Purpose: To produce a case study analysis of the NTP in Nepal with the following 3 specific objectives: 1. To provide lessons for public health, primary care and health sector development

in Nepal based on the successes and remaining challenges of the NTP and its integrated service delivery system.

2. To assess the level of funds available for the NTP from public and external sources, historical trend, assurance of financing for the next 3-5 years.

3. To summarise lessons for other countries on local adaptation and application of the recommended TB control strategy known as DOTS.

The complete terms of reference are in annex 1.

Linkage to other areas of research The Tuberculosis Strategy and Operations Unit in the Stop TB department of WHO is currently proposing to initiate a systematic review in 3 countries in collaboration with the Centre for Health and Social Development (HeSo), Norway. The countries selected are Nepal, Tanzania and Uganda. The purpose of this larger work is to explore the evidence as to how and to what extent vertical programmes contribute to or interfere with health system development. This World Bank Report will complement this evidence base by providing a case study approach to overlapping issues.

Methodology Information was collected over a 2-week period in Nepal. The dates coincided with those of an international review team who undertook an in-depth technical assessment of the TB programme. This allowed the authors to gain valuable access to related documentation, interviews with key international and national review team members and participate in the briefing and field report meetings. Documentation was obtained from a wide variety of sources including World Bank, Ministry of Health, External Donor Partners and local implementing INGOs. Semi-structured interviews were conducted across a wide range of stakeholders. Drafts of the report were peer reviewed by selected international experts and local key stakeholders (see annex 7).

ConstraintsThe consultants were scheduled to join one of the review field teams however this had to be cancelled at short notice due to lack of security clearance. Interview appointments were difficult to schedule at short notice particularly with senior government health officials. This problem was compounded by a national strike day.


Background information

Country profile Nepal is a landlocked country lying along the Himalayan chain. Rectangular in shape, the country is 885 kilometers in length (east to west) and 193 kilometers in width (north to south). It shares its northern border with the Tibetan autonomous region of the People’s Republic of China and its eastern, southern, and western borders with India. The total land area is 147,181 square kilometers and the population, according to the 2001 Census preliminary report, is approximately 23.2 million. The population has doubled in 30 years. The population growth rate increased from 2.1 in 1971 to 2.6 in 1981, then declined to 2.1 in 1991.1 The population density has doubled over the last three decades from 79 persons per square kilometer in 1971 to 158 persons per square kilometers in 2001. Nepal is predominantly rural; nevertheless, the urban proportion has increased steadily over the last 30 years, from 4 percent in 1971 to 14 percent in 20012.Topographically, Nepal is divided into three distinct ecological zones. These are the mountains, hills and terai (or plains). Of the total population, 49% live in the terai, 44% in the hills, and 7 % in the mountains. For administrative purposes, Nepal is divided into 5 development regions, 14 zones and 75 districts. Districts are further divided into village development committees (VDCs) and urban municipalities. At present, there are 3,914 VDCs and 58 municipalities in Nepal. Nepal is a multi-ethnic and multi-lingual society. The 1991 Census identified 60 caste or ethnic groups and sub groups of the population and 60 different languages or dialects prevalent in the country.Nepal’s economic development has been severely constrained by challenging geographic, topological and socio-cultural environments. Latterly the unstable political situation has further fuelled the difficulties facing the nation. Nepal is defined as a poor country where the estimated per capita gross domestic product (GDP) for the year 1999/2000 is US $244. About 80% of Nepalis rely on agriculture for their livelihood. Forty-eight percent of GDP comes from the service sector, 42% from the agricultural sector and the remaining 10% from manufacturing.3

Table 1: Basic Demographic Indicators Indicator 1971 Census 1981 Census 1991 Census 2001 Census

Population (millions) 11.6 15.0 18.5 23.1

Increased growth rate (%) 2.1 2.6 2.1 2.2

Density (pop/km2) 79 102 126 158

Percent urban (%) 4.0 6.4 9.2 14.2

Life expectancy (age)

Male

Female

42.0

40.0

50.9

48.1

55.0

53.5

Unknown

Unknown

Source- Central Bureau of Statistics 1995 and 2001

1 Central Bureau of Statistics, 1995 2 Central Bureau of Statistics, 2001 3 Ministry of Finance, 1996


National health situation The overall goal of health care in Nepal is to improve the health situation of the people providing them with preventive, supportive, curative and rehabilitative health care services and provide support for poverty alleviation. The population is diverse in Nepal. The mountainous terrain and geographic conditions isolate the primary rural population, many living below the poverty level. Such conditions provide a particular challenge to providing health care to all. As in many countries it is difficult to persuade health staff to work in the rural and remote areas and this is reflected in staffing of His Majesty’s Government (HMG) health facilities. In addition NGOs and private health care providers are concentrated in the better-off regions of the country.Estimates of Nepal’s relative burden of disease were undertaken in 1997. The ‘burden of disease’ study indicated that infectious diseases, nutritional disorders and problems related to reproduction dominate the overall pattern of morbidity in Nepal. The main causes of death and disability are infectious and parasitic disease, perinatal and reproductive health problems. The highest risk groups are children under five, (particularly females who accounts for 52.5% of all female deaths) and women of reproductive age. The burden of disease study estimates emphasised that the needs of children and mothers are not adequately met by the existing health delivery system. In the case of adult males (15-44 years), tuberculosis (TB), accidental falls, acute respiratory infections (ARI) and motor vehicle accidents were the leading causes contributing to the burden of disease for that age group. For females in the same age group the burden of disease was attributed to maternal disorders, tuberculosis, burns and major affective disorders. There is evidence of an increase in newly emerging and re-emerging diseases namely; malaria, kala-azar, Japanese B encephalitis, tuberculosis and HIV-AIDS. The issue of equality of access to health care compounds the impact of the burden of disease. In Nepal the major equity issues relate to gender, age, caste, ethnic group, income and area of residence (urban, rural, mountain, hill & terai). Transport costs are a significant deterrent to the poor in accessing health care in the remote areas. Despite such shortcomings Nepal has made significant improvement in some health care indicators during past years as a result of planned development. The child mortality rate has decreased from 107 per 1,000 live births in 1987 to 64 per 1,000 live births in 2000 and the maternal mortality has also decreased from 580 per 100,000 live births to 539 during the same period.4 Similarly the user percentage of family planning devices has increased from 3% in 1976 to 39% in 2001. There has also been considerable progress in the provision of childhood vaccinations, tuberculosis and leprosy control, malaria, kala-azar, and diarrhoea control programmes. However, the health care indicators show that overall the health care service has not progressed satisfactorily in Nepal in comparison to other countries. A summary of the progress made in the health sector is provided by the report of the Ninth Development Plan which spanned the period 1997 – 2002.

4 DHS Statistics of 1996


Table 2: Target and Progress of the Health Sector during Ninth Plan (1997-2002)

Target and progress of the health sector during ninth plan

Health Indicators Target Progress achieved

by 2002

Coverage by basic health services (%) 70 70

Maternity services provided by trained workers (%) 50 13

Family planning device users (%) 36.6 39

Total period fertility rate (live births per woman) 4.20 4.1

Crude birth rate (live births per 1000 total population per annum) 33.1 34

Infant mortality rate (deaths from 1st day of life to end of 1st

year of life per 1000 live births per annum) 61.5 64

Child mortality rate (per 1,000 live births per annum) 102.3 91

Maternal mortality (per 100,000 live births per annum) 400 539**

Crude death rate (deaths per 1000 total population per annum) 9.6 10

Life expectancy (years) 59 59

Total hospital beds (government and private) - -

¶ Government - 5023

¶ Non-government - -

Primary health centres - 160

Health posts - 710

Sub-health posts - 3167

Skilled human power - 24800

Number of women health workers - -

Number of hospital including district, zonal, regional, sub-regional, Ayurvedic and central hospitals - 85*

* Hospitals under the Ministry of Health only; ** According to Nepal Demographic and Health Survey of 1996 Source: HMG, MoH Tenth Health Plan 2002


The status of TB control in Nepal Tuberculosis is one of the foremost public health problems in Nepal, causing a significant burden of morbidity and mortality. About 45% of the total population is infected with TB, out of which 60% are adults (aged 15-64). Every year, 44,000 people develop active TB, of whom 20,000 have infectious tuberculosis. TB causes an estimated 8,000-11,000 deaths per year5. In the year 2000/01 over 31,000 TB patients were registered and treated under the NTP, among them about 13,000 are new smearpositive1.

Case notification Since the implementation of DOTS, case notifications of new smear positives have increased. This is a reflection of the increased coverage of the revised NTP implementing the DOTS strategy.

Case notification trends in NTP

02,0004,0006,0008,000

10,00012,00014,00016,000

1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01

year

Cas

es n

otifi

ed

No.Cases New P+ No.Cases New P-veNo. Cases EP No. Cases Retreat

DOTS implementation

Figure 1. Case notification trends in NTP (new smear positive cases only) Source: Annual Report of NTP 2000/01

Treatment outcome Treatment outcome under NTP seems sustainable and increasing after implementationof DOTS strategy. In 1996 DOTS was limited only in four centres. By July 2001 DOTS expanded to 227 treatment centres with 684 sub centres, covering 84% of total population in 75 districts. According to the NTP annual report global target of treatment success 85% has been achieved by NTP under DOTS strategy.

5 Annual Report of National Tuberculosis Control Programme, National Tuberculosis Centre, Nepal2000/2001


Treatment Outcomes in NTP

0%

20%

40%

60%

80%

100%

T.Out 4 32 22 54 72

Defaulted 10 109 201 250 570

Died 7 62 49 285 512

Failure 4 26 148 86 128

Treatment success 264 1542 3050 4849 8396

1996/97 1997/98 1998/99 1999/00 2000/01

Figure 2: Treatment Outcomes in NTP by annual cohort analysis Source: NTP annual report 2002

TB and HIV Four surveillance surveys of HIV infection among patients with TB have been undertaken in Nepal. The results of the surveys show an increasing trend of HIV infection among patients with TB from 0% in 1993/94 to 2.44% in 2001/2002. The survey indicates that 84% of HIV-TB co-infections occur in men between the age of 25 and 55 years.

MDR TB Since 1996 surveillance of anti-tuberculosis drug resistance has been conducted with the co-operation of the World Health Organization, NTC and GENETUP. Latest anti-tuberculosis drug resistance survey shows ‘any resistance’ at 16.5% (11.0% in new cases and 40.9% in previously treated cases). Multi-drug resistance was 4.9% (1.3% in new cases, 20.5% in previously treated cases). The resistance pattern in re-treatment patients was Isoniazid, (33.3%), Streptomycin (31.1%), Rifampicin (20.5%) and Ethambutol (9.9%). Compared to the survey of 1998-1999 multi- drug resistance in new cases has declined from 3.6% to 1.3% (p<0.01), any form of resistance from 13.2% to 11.0% and resistance to all four drugs from 1.8% to 0.8%. In previously treated cases drug resistance has increased. Multi drug resistance has increased from 12.5% to 20.5%, any drug resistance has increased from 28.6% to 40.9% (p<0.05). However resistance to all 4 drugs has decreased from 9.8 % to 9.4%. The reduction in resistance in new cases is likely to be the result of the successful DOTS programme during the last three years.


Anti-TB drug resistance surveysPattern 1996-1997 1998-1999 2001-2002

Primary Acquired Primary Acquired Primary AcquiredTotal tested 787

(100%) 0 673(100%)

112(100%)

755(100%)

171(100%)

Any resistance 77(9.8%) 0 89

(13.2%)32

(28.6%)83

(11.0%)70

(40.9%)Mono-

resistance45

(5.7%) 0 51(7.6%)

13(11.6%)

53(7.0%)

22(13.0%)

Multi-drugresistance

9(1.1%) 0 24

(3.7%)14

(12.5%)10

(1.32%)35

(20.5%)Resistance to

all 4 drugs 0 0 12(1.8)

11(9.8)

6(0.8%)

16(9.4%)

Table 3: Anti-TB drug resistance surveys in Nepal Source: NTC

Development of the health policy agenda in Nepal The policy framework for Nepal’s health sector has undergone significant developments in the last 10 years. Following restoration of multiparty democracy in 1990, a new National Health Policy was introduced in 1991. This paved the way for the newly created Department of Health Services under which a strong focus was the strengthening of primary health services delivered through a network of Primary Health Care centres (205 – one per electoral constituency), Health Posts (712) and Sub-health Posts for every Village Development Committee (3138). National planning is normally undertaken by means of ‘Five Year Development Plans’ whichare published by the National Planning Commission. The 8th (1992-1997) and 9th

(1997-2002) five year health plans focused on this extension of basic services to rural communities together with a policy of strengthening health service management, technical supervision, monitoring and evaluation. The 9th plan also identified the district as the focal point for decentralised planning and management of health care services.The production of the Second Long Term Health Plan (SLTHP 1997-2017) provided the broad framework from which the 20 components of the EssentialHealth Care Services (EHCS) package were identified as priority programmes. The control of infectious diseases including tuberculosis was one of these named priority elements. In order to build on the work of the SLTHP, reassess the capacity of the health system and develop a more coherent approach to planning and development in the health sector a document entitled a Strategic Analysis to Operationalise the Second Long Term Health Plan was produced by a consortium of Government Ministries, the National Planning Commission, the World Bank, External Development Partners (EDPs) and International Non-Governmental Organisations (INGOs) in early 2000. Four actions were proposed from this report: ¶ Strengthening health service delivery ¶ Decentralisation¶ Actions to improve the public-private-NGO mix ¶ Strengthening sectoral management


An additional key driver in the analysis of health care resources and policy development was the preparation and publication of the World Bank Report ‘Nepal,Operational Issues and Prioritisation of Resources in the Health Sector’, June 2000. This report generated 5 recommendations: ¶ Increase political commitment ¶ Focus on Group 1 diseases (which included tuberculosis) ¶ Develop institutional capacity – by creating a strategic framework and using

existing resources efficiently and effectively ¶ Develop better health care systems – by developing public-private partnerships ¶ Establish priorities – by identifying sequenced priority interventions

Together these two comprehensive reviews highlighted the strategic areas for the preparation of the Medium Term Strategic Plan (MTSP) which was published by His Majesty’s Government in February 2001. This document in the form of detailed logframes laid out the four areas for strategic interventions to be incorporated into the health sector component of the 10th Five Year Development Plan 2002-2007). The MTSP was also a tool to provide a basis for the development of a sector-wide approach and to guide collaboration and investment by development partners and agencies.

Table 4: Goal and Purposes of Medium Term Strategic Plan Goal:

Health status of the Nepalese population improved through a health care system that provides equitable access to quality health care

Purposes:1. An effective health system developed for the provision of affordable and accessible

EHCS2. Public-private-NGO partnership in health care provision promoted 3. Effective decentralisation in health system provision ensured with participatory

approaches at all levels 4. Improved quality of health care provided by public-private-NGO partnership

through total quality management (TQM) of human, financial and physical resources

Following on from this work was the preparation of the Medium Term Expenditure Programme (MTEP)6 to Operationalise 1st Three Years of 10th Five Year Plan’s Health Programmes, January 2002. This document also embraced the requirements of the Interim Poverty Reduction Strategy Paper (I-PRSP) for Nepal. Key programmes and activities were prioritised into 3 groups. Tuberculosis control was identified as one of the Priority 1 Programmes based on the parameters of: burden of disease, implementation capacity, equity consideration, programmes directed to the poor, marginalized, vulnerable and disadvantaged groups, programmes contributing to poverty alleviation and availability of resources. The document identified the inability to clearly determine financial requirements for the health sector and makes a number of recommendations including: ¶ The creation of ‘national health accounts’ covering public, private, NGO and

EDP health sector expenditures at all levels of the health system

6 This is also sometimes referred to as the Medium Term Expenditure Framework (MTEF)


¶ The establishment of a health economics body7 to provide technical support to the Ministry of Health (MoH) on health financing issues.

¶ Develop a common financial reporting framework for all EDPs. Interestingly the document notes that, ‘the process could build on steps already taken to develop sub-sector programmes such as TB, leprosy and reproductive health.’

The implications of the MTEP for donor assistance and donor behaviour is discussed along with the declaration of HMG to identify the 10th Five Year Development Planas the Nepal Poverty Reduction Strategy Paper. Finally the document encourages a move towards a Sector Wide Approach (SWAp) in order to optimise available resources from EDPs.

7 The Health Economics & Financing Unit (HEFU) of the Ministry of Health has now been established


Millennium Development Goals HMG/N was a signatory to the Millennium Declaration in September 2001. The first progress report on the status of attainment of the Millennium Development Goals (MDGs)8 in Nepal was published in February 2002. These 8 goals and 18 targets aim to create an environment conductive to development and the elimination of poverty. The health sector is particularly involved in 5 of these targets. In particular, target 8 sets out 2015 as the year by which the incidence of malaria and tuberculosis should be halted & reversed. The identification of TB in the National MDGs is highly significant for the prioritisation of the national TB control effort.

Local Self Governance Act (1999) This act established a framework for decentralisation to the district level. It would involve increased responsibilities for health care delivery being devolved to District Local Development Committees. The full implementation of this Act is scheduled to take place during the 10th Five Year Development Plan period 2002-2007.

The Health Sector Reform Process in Nepal In May 1997 a meeting was held in Kathmandu involving HMG and EDPs to consider a more coherent approach to planning and development within the health sector. Despite general agreement at that time little follow up action occurred. In 1999 following an assessment of stakeholders to support a government led joint strategic analysis of the health sector the HMG expressed a clear wish for EDPs to move towards a sector wide approach in planning and delivering health care.The initial outcome of this work was the preparation and publication of the StrategicAnalysis to Operationalise the Second Long Term Health Plan in May 2000. Together with the policy framework contained in the 1991 National Health Policyand the SLTHP this work progressed into the formulation of the MTSP and MTEP as route maps for the health component of the 10th Five Year Development Plan (2002-2007). The reform process is led by a Health Sector Reform Committee and chaired by the Health Minister. A separate core group comprising the Planning Division, key officials of the MoH, National Planning Commission, Ministry of Finance, EDPs and private and health related professional organisations was tasked to produce a coherent Nepal Health Sector Strategy.The outcome of this work was the recently approval by the MoH of the Nepal Health Sector Strategy – An Agenda for Change, June 2002. Currently a Programme Preparation Team has been formed to prepare a fully costed Nepal Health Sector Programme – Implementation Plan.The time frame for donor commitments to this programme implementation plan is Spring 2003 and operationalisation of the plan in the next Nepal fiscal year beginning July 2003.

8 The Millennium Development Goals (MDGs) are a set of goals and targets for monitoring human development. They are centred around 8 main goals and 18 targets: 1. Eradicate poverty & hunger; 2. Achieve universal primary education; 3. Promote gender equality and empower women; 4. Reduce child mortality; 5. Improve maternal health; 6. Combat HIV/AIDS, malaria and other diseases; 7. Ensure environmental sustainability; 8. Develop a global partnership for development


The Nepal Health Sector Strategy - An Agenda for Change The recently published Health Sector Strategy document is the current central guiding document arising from the sectoral reform discussions in Nepal over the past 3 years. HMG have set three programme outputs and five sector management outputs which will be the core of the reform programme over the next 5 years. These are:

Programme Outputs: 1. EHCS package: The priority elements of an Essential Health Care Service –

safe motherhood and family planning, child health, control of communicable disease, strengthened out patient care – will be costed, allocated the necessary resources and implemented. Clear systems will be in place to ensure that the poor and vulnerable have priority for access.

2. Decentralisation: Local bodies will be responsible and capable of managing health facilities in a participative, accountable and transparent way with effective support from the MoH and its sector partners.

3. Public-private mix: The role of the private sector and NGOs in the delivery of health services will be recognised and developed with participative representation at all levels. Clear systems will be in place to ensure consumers get access to cost effective high quality services that offer value for money.

Sector Management Outputs: 1. There will be coordinated and consistent Sector Management (planning,

programming, budgeting, financing and performance management) in place within the MoH to support decentralised service delivery with the involvement of the NGO and private sectors.

2. Sustainable development of health financing and resource allocation across the whole sector including alternative financing schemes will be in place

3. A structure and systems will be established and resources allocated within the MoH for the effective management of physical assets and procurement and distribution of drugs, supplies and equipment.

4. Clear and effective Human Resource Development policies, planning systems and programmes will be in place.

5. A comprehensive and integrated management information system for the whole health sector will be designed and implemented at all levels


NTP and the current security situation Over recent years there has been escalating violence between Maoist groups and the government. Originating in the remote hill districts this violence has extended throughout the country causing significant disruption to civil life and the delivery of government services. Unofficial sources would suggest that upward of 70% of the country is controlled by Maoist forces. Government control backed by security personnel is confined to Kathmandu, main municipalities, the easily accessible areas of the terai and the district headquarters in hill and mountain areas. The consequential political and security environment has major implications for the health sector and TB control. Key issues are: ¶ The government has this year revised budget allocations and diverted social sector

spending to the military and security forces. ¶ There is increasing anecdotal evidence of accelerated migration from Maoist

controlled hill areas to urban and peri-urban locations in the major valleys and the terai.

¶ Movement of food and medical supplies within districts has been hampered by activities of the Maoists or the security forces.

¶ Primary Health Care delivery outside of district centres in remote areas has been greatly hampered. Staff vacancies have increased and medical supplies depleted.

As the TB control programme is dependant on a functioning PHC system for diagnosis and treatment in hill areas it is expected that programme outcomes will be adversely affected. In terai and municipality areas the increased migration will place additional strain on stretched urban services. Increased poverty and poor nutrition combined with psychological stresses is likely to increase the breakdown from infection to TB disease in the population. The potential responses to the situation are discussed later.


The National Tuberculosis Control Programme BackgroundThe first organized attempts to control TB in Nepal began in 1934 with the construction of the Tokha sanatorium. A Central Chest Clinic (CCC) was established in 1951 to provide curative TB services including free treatment for the poor. In 1985 the TB Control Project (TBCP) was established and in the same year Short Course Chemotherapy (SCC) was introduced in some parts of country mainly by the non-governmental organizations working in TB control. In 1989, the National TB Programme (NTP) replaced the TBCP and the NationalTuberculosis Centre replaced the Central Chest Clinic. In 1993 SCC was adopted as the national drug regimen for tuberculosis treatment by the NTP. Following a joint HMG/WHO review of the NTP in 1994, a 5 year plan based on the WHO framework for effective TB control, with a policy of Directly Observed Treatment Short course (DOTS) was prepared, and approved by HMG in August 1995. The joint team concluded that only 30% of infectious cases at that time were being registered in the NTP, and only 40% of these cases completed treatment. The government identified TB as one of its top ten priorities in the 8th and 9th year health plans. DOTS was introduced into four demonstration centers in April 1996 and expanded throughout the country in the following 5 years. By July 2001, DOTS was being delivered through 227 treatment centres with 684 sub-centres and covered 84% of the population, across all 75 districts.

NTP Objectives ¶ 85% cure rate in new smear-positive pulmonary tuberculosis cases ¶ 70% case detection ratio in new smear-positive pulmonary tuberculosis cases ¶ Directly Observed Treatment, Short Course (DOTS) available in all 75 districts of

the country through the NTP ¶ By the end of the Tenth Fiscal Year Plan all the patients should be treated under

DOTS strategy

NTP Strategies ¶ Gradual expansion of DOTS throughout the country ¶ Establish a treatment centre with microscopy facilities for every 40,000-

100,000 population, with sub-centres as required. ¶ Promote early detection of infectious pulmonary cases on the basis of

sputum smear examination.

Major NTP Policies ¶ The basic unit of the NTP for diagnosis and treatment is the district

hospital and primary health care centre. ¶ All centres offering TB treatment must utilise the standardised regimens of

short course chemotherapy (SCC) adopted by the NTP, with Directly Observed Treatment, Short Course (DOTS).

¶ Free anti-tuberculosis treatment to all patients with active tuberculosis, through the basic health services, with a priority for sputum smear-positive cases, in every district of the country


¶ Evaluation by four monthly cohort analysis of treatment outcome ¶ Community involvement for DOTS implementation

NTP Activities ¶ Establish a national network of microscopy centres, and a system for

ensuring quality of sputum smear examination ¶ Organise treatment delivery and supervision of programme activities

through the general health services of the country, in an integrated way ¶ Ensure continuous drug supply and monitor the quality of drugs. ¶ Maintain a standard system of recording and reporting in line with the

integrated Health Management Information System of the department of health services

¶ Monitor the results of treatment and evaluate progress of the programme by means of 4-monthly cohort analysis

¶ Develop and maintain the skills of health workers by providing training. ¶ Promote involvement of the community in the NTP. ¶ Strengthen co-operation between NGOs and development partners

involved in the NTP ¶ Co-ordinate NTP activities with other PHC activities carried out in the

country, especially leprosy and AIDS/STD programmes ¶ Conduct relevant research to improve the effectiveness of the NTP.

NTP OrganisationAt the national level the National Tuberculosis Center is the central unit of the NTP. The Director of the NTC manages the National Tuberculosis Centre and National Tuberculosis Programme. NTC staff provide technical support to the field programme as well as running the NTC referral clinic and laboratory. The Regional Tuberculosis Centre (RTC) in Pokhara provides a focus for technical support in the Western Region.

At the regional level, all activities are carried out with the co-operation of the 5 Regional Health Services Directorates. Regional tuberculosis/leprosy assistants (RTLA) support the Regional Health Services Directorate in managing TB control activities in the region.

At the district level, the district health officer (DHO) is responsible to plan and implement NTP activities. A district tuberculosis/leprosy assistant (DTLA) supports the DHO in the management of TB control activities. Within the district, the basic unit for diagnosis and treatment of patients with tuberculosis is the district hospital and the primary health centre. Diagnostic and treatment services will not usually be provided lower than this level, though health posts may act as sub-centres for supervision of patients on DOTS.


Organisational Chart of the NTP

Co-ordination of the NTPwithin the health services

Technical policies for the NTPPlanning, Monitoring and EvaluationTraining, Supervision and Research

Management of the NTP at theRegional Level

Training and SupervisionMonitoring

Management of the NTP at theDistrict Level

Diagnosis, tratment andMonitoring

Case Holding andTreatment

Case Holding / Tracing

Ministry of Health

Director Generalof Health Services

National Tuberculosis Programme/National Tuberculosis Centre, Director Other National

Centres & Divisions of DOHRegional Directors

RTC/RTLA

District HealthOfficers

DTLA

Primary Health Centres

Sub Health Posts

NCASC PFADNPHL EDCDNHTC LMDNHEICC HRDDAIDS CentreCHD FHD

KEYMain Structure of NTP

Line ManagementTechnical Supervision

Responsibilities

Health post

DOTScommittee

NGOs

Communities

LogisticsNTC is responsible for national estimates and procurement of anti-tuberculosis drugs. The central store of anti-tuberculosis drugs is located in the NTC. Drugs are distributed from the NTC with support of the Logistics and Management Division (LMD). At the regional level supporting INGOs (Eastern, Central, Mid Western and Far Western Regions) and RTC (Western Region) manage drug supply from the central store up to the district with close cooperation of LMD and the Regional Medical Stores (RMS). Logistic below the district is managed by the respective DHO (with assistance from the supporting INGOs if required).

Agencies supporting the NTP Bilateral and multi-lateral agencies, INGOs, NGOs and research institutions together provide substantial support with financial assistance, technical assistance, materials in kind, diagnostic and treatment services, research and management capacity. Norwegian Aid (NORAD) has been supplying anti tuberculosis drugs to the NTP for the last two years. The Norwegian Heart and Lung Association (LHL) has supported the NTP through the provision of funds for supervision, training, research, supply of anti- tuberculosis drugs and the NTP annual review programme.The Department for International Development (DfID), UK, is currently providing anti-TB drugs and manpower support channelled through WHO for a five year period. The Japan International Co-operation Agency (JICA) supported the construction of the NTC and RTC buildings in Thimi and Pokhara, TB activities in the Westernregion, the supply of anti-tuberculosis drugs, logistic management systemdevelopment and technical support at the national level. JICA has also contributed to the development of the TB microscopy and quality control network. Currently JICA are supporting an urban TB control programme through their Community TB and Lung Health Project (CTLHP) in Kathmandu and Rupandehi.


The World Health Organisation (WHO) supports the NTP through the provision of staff and funding for training courses, attendance at international conferences and research into multi-drug resistance & HIV-TB. The International Union Against TB and Lung Disease (IUATLD) provides technical support and consultancy to the national programme. The SAARC Tuberculosis Centre (STC) is physically located within the NTC building and has organized several regional training courses in Nepal over the last five years.The Britain Nepal Medical Trust (BNMT) supports TB services in the Eastern region through training, supervision and drug logistics. The International Nepal Fellowship's Tuberculosis Leprosy Programme (INF TLP) supports government tuberculosis services in the Mid-West region through training, supervision, laboratory quality control, and logistic supply. In addition, TLP runs four referral clinics in Nepalgunj, Ghorahi, Surkhet and Jumla. The Netherlands Leprosy Relief Association operates in the Far West region supporting the NTP through drug supply, laboratory quality control, training and supervision.The United Mission to Nepal (UMN) provides TB services in all of its general hospitals including the Tansen hospital which is one of the largest TB diagnostic centres in the country. In addition, UMN has provided support to HIV-related counselling for TB patients. The German Nepal TB Project (GENETUP) is supporting TB control activities in Kathmandu, Bara, Parsa, Rautahat, Sarlahi and Mahottari. The Nuffield Institute for Health, UK, is involved in technical support for research into the adaptation of DOTS to suit the mountainous areas of Nepal and also into building links between the private sector and the NTP. The Nepal Anti-TB Association (NATA) plays an important role in controlling TB. It has health education activities at district level, and also provides treatment services in 7 districts.

Quality control system for sputum smear microscopy A quality control (QC) system for sputum smear microscopy was implemented in Nepal in 1996 coinciding with the start of DOTS implementation. Currently there are 5 Regional Quality Control Centres with trained quality control assessors (QCA) who carry out quality control on a quarterly basis.

ResearchTwo international collaborating centres support TB related research projects in Nepal. These are the Nuffield Institute of Health (UK) and the Research Institute of TB(RIT) in Tokyo, Japan. Current research includes: §

§

§ §

§

Family based DOTS and Community based DOTS. A Randomised Controlled Trial (RCT) to identify appropriate tuberculosis treatment delivery strategy in hard to access areas (10 hill districts) of Nepal, where institution based DOTS is not feasible to all TB patients. Pilot research to link private practitioners and NGOs with the NTP, to ensure that all patients receive a high standard of care and their results are reported.Drug resistant surveillance survey with participating sites across the country. The provision of voluntary HIV testing is being piloted in 5 major diagnostic TB centres.An Adult Lung Health Initiative international study to develop guidelines for the management of respiratory symptomatics attending primary health care facilities is underway in 2 districts.


Lessons for the Nepal Health Sector What lessons can be drawn both positive and negative from the experiences of the TB control programme in Nepal? In the eyes of many it has been a success story but what are the learning points for other programmes and the future development of the health sector? This section looks to provide insights of value to non-TB programmes while the later section ‘Lessons for the Region’ seeks to highlight issues for other TBprogrammes in the region. Technical aspects of TB control are therefore addressed in the later section while this section concentrates on generic issues of programme management, organisational culture and implementation. The section concludes by considering the implications of health sector reform (HSR) on the TB programme, and asks how the TB programme might assist or hinder the current reform process in Nepal.

LeadershipA consistent theme which arose in interviews was the impact of the NTC Director’s leadership of the programme as a key success factor. He has clearly earned the respect of his staff and they are motivated by his action-oriented leadership style. The NTP has been fortunate to have had a number of motivational senior staff associated with it who have all contributed to the leadership success of the programme. The lesson is that leadership is vital for success and should consist of: ¶ Consistency – the value of retaining a good director in the same programme for a

prolonged period of time ¶ Quality – good leaders should be identified and equipped with the necessary

technical and managerial training for their task.9

¶ Reach – to gain respect of staff and a clear understanding of the programme the leader must be prepared to make many field trips.

¶ Delegated responsibility – within the NTC tasks have been clearly defined and delegated. This reduced the inefficiencies often seen in health programmes when all decisions are referred up to the director.

¶ Example – Dr Bam and his senior officers work hard and long hours and demand the same of their staff. Demonstrating a positive work ethic can diffuse throughout the programme.

Strong team approach Under-girding the leadership was a strong, motivated and technically capable team consisting of the NTC staff, the regional and district level supervisors, the officers of the various implementing INGOs and significantly, the Nepal WHO TB Medical Officer. It should be emphasised that it was the particular synergy of the central level team at NTC, the WHO medical officer and the NTP Director that together provided the impetus and direction for the programme in the mid to late 90s.

Staff motivation At central and district level there was a general impression that staff enjoyed their work and were able to make a difference. Empowered staff are a powerful driver for success and innovative implementation. Evidence of commitment and enthusiasm for DOTS was also described at the local health post level. The key issues identified were:

9 In Dr Bam’s case he benefited from training in TB control and epidemiology at the Research Institute of Tuberculosis in Japan.


¶ Staff saw the DOTS approach produce results which re-enforced job satisfaction¶ Staff were trained, equipped and motivated¶ The JICA RIT training programme has provided excellent technical and

programme management training for successive cohorts of TB staff. ¶ The LHL funding has emphasised the requirements of quality technical training

and supervision at all levels. ¶ Peer-led monitoring and evaluation – this is discussed below. ¶ The national & international recognition of the Nepal TB programme through

the honouring of Dr Bam with various awards brought a significant moral boostto all staff working for the programme.

CommunicationCompared with other programmes the NTP displays a culture of wide and open communication. This communication is: ¶ Upward communication – in the form of advocacy, and awareness-raising to

senior government staff, politicians and the international TB donor community. ¶ Outward communication – in the form of widespread proactive media

reporting, health education activity to communities, and a wide range of tailored training programmes for health care workers and social action groups.

¶ Inward communication – across all cadres of health care staff working in TB control. This has created a shared vision and clarity of purpose using the DOTS strategy.

Peer review Closely linked to communication and staff motivation is the regularised practise of ‘peer based review’ for staff working in TB control. This quality improvement process can be seen throughout the programme: ¶ International – by means of the IUATLD technical consultancy field visits

funded by LHL and the annual national review process. By ensuring one external expert joins each regional field team the local managers are exposed to international technical expertise in programme evaluation.

¶ Regional (Asia)- The development of the annual South-East Asia Regional NTP Managers Meeting provided a platform for national NTP managers to be held accountable to their peers in the Region. Nepal as host country for the meetings benefited from the extra pressure of having its programme ‘on show’ and being able to include more NTP staff as observers or participants.

¶ National – by means of the trimesterly meeting of the Regional TB/Leprosy Assistants to review the last trimester’s data and plan for the future. In addition, most years there have been large national TB seminars held at NTC which have afforded District Health Officers the opportunity to meet and discuss their local TB control efforts.

¶ Regional, district, and treatment centre trimesterly reviews – at each level of responsibility the programme has instituted review meetings to generate and analyse the cohort report for the last trimester and be accountable for local programme performance. This greatly increases ownership of data, problems and ultimately local solutions. Indeed the emphasis of these meetings is identify and solve problems locally.

Sharing of best practice The quarterly cohort reporting schedule and associated technical peer review meetings are the vehicle through which district, regional and national planning is


discussed and shared. However staff interviewed also highlighted the value of other means of sharing best practice across the programme: ¶ Observational visits – permit staff to visit ‘model DOTS’ programmes in other

areas to share their own experiences and pick up new approaches that may be introduced in their own treatment centres.

¶ SAARC, IUATLD and WHO seminars and training events – The Nepal programme has been most fortunate to regularly host international training programmes and as a result national staff have benefited from the opportunity to attend and learn from TB technical staff working across SE Asia.

Central policy – local innovation The NTP is a good example of a technical programme which operates according to a clear national policy yet encourages local application of the model. The key features of this success factor are: ¶ Central features

o National adoption of an evidence-based strategy (DOTS Strategy)o Documentation of a policy framework and national implementation

manual (NTP manual) in Nepali as well as English language o Training materials in Nepali prepared for each cadre of staff o Strong emphasis on recording and reporting of programme outcomes

¶ Local innovation - a number of witnessed examples are listed to demonstrate the diversity of initiatives taken to apply the basic tenets of the DOTS strategy:

o A private nursing home in Lalitpur (Hargans Nursing Home) decided to provide a daily rice meal to several homeless patients with TB to encourage their regular attendance for directly-observed outpatient treatment of their TB.

o The UMN Yala Urban Health Programme (YUHP) has developed links that permit access to local carpet factories to seek out workers with TB. The programme has also trained ward/tole level volunteers who will carry sick patients to the clinic daily.

o The INGOs are encouraged to develop local strategies to meet local needs such as the INF ‘default tracers’ attached to the Nepalganj Clinic.

o BNMT has provided 'hostel facilities' at a district centre to those who are unable to attend the DOTS clinic on a daily basis in a hill district of eastern Nepal (Dhankuta).

High quality technical support A theme raised by interviewees as a reason for the particular success of the programme was the consistent high quality technical assistance available to the NTP over the previous decade. Of note were both the quality of the technical assistanceand the generally positive nature of relationships between the NTP and technical assisting agencies. This particular feature of the NTP is multifaceted and has been additive through the 1990s. Indeed certain reviewers went as far as to suggest that the INGOs contribution has been the backbone of the TB control programme in Nepal. The chronological development was as follows: ¶ Central assistance from JICA and JAT technical assistance to NTC and RTC ¶ District and regional assistance from technically focused INGOs such as

GENETUP, INF, UMN, BNMT and NLR.¶ The TB related NGO collaboration which later became formalised as the TB

Control Network (TBCN) ¶ The quality of the initial WHO review process in 1994


¶ The recruitment of Ian Smith as the first WHO TB Medical Officer who not only drafted the initial plan but also was integral to the implementation of the first 5 year development plan

¶ The impact of the annual external technical reviews¶ The development of the annual TBnet conferences hosted by NTC ¶ The increasing impact of the SAARC TB Centre¶ Nepal as host to the WHO/IUATLD Asia TB Programme Managers’ Training

Focused and consistent external donors The funding of the NTP resource envelope is discussed in greater depth later in the report but the key success features are: ¶ The continuity of the donor partners ¶ The in-country presence of many of the donor agencies ¶ The opportunity for donors to meet annually at the Technical Advisory Group

(TAG) meetings

Partnership working The past 5 years have witnessed major expansion of partnership working to deliver the DOTS strategy across health institutions and civil society. Now DOTS is administered through partnerships with: ¶ Academic institutions and private medical colleges ¶ Tertiary, regional and NGO operated hospitals ¶ INGO regional counterparts ¶ Private nursing homes ¶ NGOs such as NATA ¶ DOTS committees formed at the treatment facility level.10

¶ CBOs such as womens groups responsible for a DOTS treatment centre ¶ The media – although not actually acting as a delivery point for DOT are a major

partner in the awareness raising component of the NTP strategy.

Appropriate and phased decentralisation Decentralisation is a significant platform of the HSR process and therefore it is interesting to review the NTP from this perspective. Some commentators felt that the NTP has not been particularly active in the decentralisation process however we would disagree and point to the following positive developments in this area: ¶ The creation of the DTLA posts in every district was a major pillar in the

decentralisation of supervision and associated district level NTP functions within the District Health Office.

¶ There is evidence that the decentralisation of functions has been measured and responsive to the strength or weakness of the supporting technical or managerial structure. Thus logistics management was only partially decentralised to the regional INGOs as drug supply was seen as critical to the success of DOT. More recently however active plans have been made to pass responsibility to Regional Medical Stores and provide the required technical support to maintain an uninterrupted supply chain.

¶ With the recruitment of RTLAs and DTLAs into government service the implementing INGOs were able to provide counterpart staff to work alongside the

10 Members from these committees are now participating in VDC health co-ordination committees


DTLAs in the District Health Offices. This enabled the fast transfer of knowledge, skills and attitudes in TB control from the INGO staff to the government staff.

The formation of action – orientated, structured networks As a natural outworking of the above organisational culture of communication, peer support and partnership working, networks emerged which grew through the mid-1990s to become significant models for public health at a Regional and national level. Three examples of these are: ¶ TBCN – the TB Control Network. This arose from a desire by the in-country

implementing INGOs, the leader of the JICA JAT, and NATA to agree on case definitions, reporting mechanisms and shared health promotion activities. This expanded into a national group with documented group values, procedures and functions. The meetings were soon hosted at NTC and attracted a widespread commitment from agencies involved in the delivery of TB services across the country. When the development plan was launched in late 1994 this group had already worked through the ‘forming, storming, norming’ stages of group development and reached a high level of ‘performing’11. It provided the NTP with the ideal platform for the required change management process necessary to implement all the enhanced features embedded in the TB development plan. Interestingly the TBCN became a model for a similar group set up by the counterpart INGOs working in the Leprosy field in Nepal.

¶ TBNet – in many ways TB-net grew from the principles of the TBCN. TBNet originated from a meeting sponsored by the TEAR Fund UK evaluation unit to bring together NGOs that it supported throughout the south-asia region in 1992. The purpose was to identify model programmes and generate a guidance document. The experience of sharing ideas, supporting one another and making contacts across the region was so stimulating that the principle of a annual meeting, hosted in Kathmandu grew to become a much larger staged event and attracted global attention for its impact on TB action. The focus was on strengthening the capacity of the NGOs working in TB control and to be an independent, informal participative network using email, a website, published documents and an annual 2 day TBNet Conference as the means of shared communication. The steering committee was mostly composed of TB related professionals working in Nepal and so Nepal became the natural locus of TB information, training and activity. TBNet was probably one of the factors that brought the annual WHO/IUATLD TB programme managers training to Nepal. TBNet has now been absorbed into the STOP TB Partnership and many of the principles of the original group can now be seen in the workings of STOP TB at a global level.

¶ DOTS committees – while TBNet was a network that quickly expanded its impact outwards across the Region, the introduction of local DOTS committees is an example of the same principles applied at the grass roots of treatment delivery. These committees are formed, trained and sparked with enthusiasm to act as a local community based accountability mechanism for DOTS treatment centres. Membership seeks to cross the public, political, NGO and CBO spectrum of the locality. While not all are equally active there are some pathfinder examples of well functioning DOTS Committees.

11 See ‘On the Workings of Groups’ in Handy, Understanding Organisations, 4th Edn 1993, Penguin


Summary of key ‘success factors’ The matrix below seeks to summarise the success factors identified in the operation ofthe Nepal TB programme. The allocation of the tick marks is highly subjective and various combinations could be constructed. However the key message is that three skill areas are required – interpersonal, technical and administrative. We believed that the most critical skill is that of interpersonal communication and that technical and administrative capacity are required in equal measure for the successful implementation of a programme.

Skill areas required Success Factors Interpersonal Technical Administrative1. Leadership P2. Strong team approach P3. Staff motivation P4. Communication P P5. Peer review P6. Sharing of best practice

P P

7. Strong central policy with local innovation

P P

8. Quality technical support

P P

9. Focused and consistent external donors

P P

10. Partnership working P P11. Appropriate & phased

decentralisationP

12. Action-oriented structured networks

P P

Table 5: Success factors and skill areas

Negative factors Not all those interviewed were convinced of the ‘success’ of the Nepal TB programme. Issues of concern or alternative perspectives were raised. These are discussed below:

Success

Administrative skills Technical skills

Interpersonal skills

¶ “Successful but not a model” – it was suggested to the author that TB control as a public health programme is technically straightforward to implement – narrow case definition, evidence-based treatment protocols, delivered through primarycare setting. And when combined with the fortuitous state of charismatic and consistent leadership, high quality external technical assistance and a solid external donor support base much more should have been delivered by the programme than is apparent.


¶ “Immature and dependent” – despite the consistent external assistance in terms of finance, technical expertise and in – country implementing INGOs the central unit of the NTP based in NTC remains managerially vulnerable in terms of programme planning and administration.

¶ “Not sufficient acknowledgement of areas of weakness” – the apparent success of the pro-media approach to advocacy has overshot and now the programme has difficulty in acknowledging areas of weakness. One recent example of a technical area of concern would be the ongoing case finding gender imbalance.

¶ “Not enough emphasis on urban TB services” – in response to the current security climate there has begun a rural population migration towards the relative security of urban areas. The need therefore to strengthen TB services for already pressed urban facilities is urgent. While the JICA CTLHP has moved to support selected urban DOTS in the Kathmandu area the NTP as a whole continues to focus resources on service coverage for remote districts.

¶ “Strong elements of vertical programming remain” – despite full integration at treatment facility level the NTP continues to operate essentially vertical, and separate mechanisms for delivery of TB training, logistics supply, supervision, and programme statistical reporting. Some saw this as one of the NTPs greatest strengths while others saw this as a negative feature.

New areas for attention We asked those interviewed about the challenges that face the NTP in the future. While some issues relating to the interaction between the NTP and HSR are addressed later in this section other issues are a direct current challenge: ¶ The impact of the Adult Lung Health Initiative – this symptom-based approach

to lung health is conceptually attractive and already both the JICA project and the WHO in Nepal have embraced the approach. For a single disease-based programme to broaden its scope to encompass both the preventive public health approach and the need for a patient focussed clinical service is a major challenge.

¶ The impending tobacco-related disease epidemic – as the cohorts of heavy male and female smokers mature there will be a major increase in lung cancer and other forms of lung disease. A strategic approach is required to reduce smoking habits in Nepal and cope with the impending burden of lung pathology. While this is a decision required of the Ministry of Health perhaps the NTP is best positioned to lead an integrated public health response to tackle this problem.

¶ HIV/TB linkage – There has been little evidence of truly joint planning and implementation of activities between the National AIDS Centre and the National TB Centre. Anecdotally this is due to elements of ‘protectionism’ within both camps to keep the donor monies attached to either programme separate. As the AIDS epidemic swells across Asia and the requirement for treatment and care as well as prevention emerges as a significant component of HIV management the inter-working of the HIV and TB programmes becomes a greater necessity for Nepal.

¶ Integration maturation – as identified above the NTP is on a continuum between wholly vertical control and decentralised integration of a number of component TB control activities. The direction of travel is most definitely towards greater degrees of decentralisation and integration with other health departments. The distance of travel achieved towards appropriate integration varies according to the component elements of the programme. The NTP must identify solutions that will retain the ‘DOTS pillars’ and safeguard acceptable programme outputs while maximising the policy of interdepartmental working and the provision of


integrated logistics, training, supervision and reporting systems in the health sector.

The Impact of Health Sector Reform

BackgroundThe shape of Health Sector Reform (HSR) varies from country to country and hence definitions vary. One generic description is that HSR is concerned with ‘definingpriorities, refining policies, and reforming the institutions through which these policies are implemented.’12 A fuller definition is given by Cassels who describes HSR as ‘ a sustained process of fundamental change in policy and institutional arrangements guided by the government, designed to improve the functioning and performance of the health sector and ultimately the health status of the populations.’13 Weil14 summarises the over-arching objectives of reform as: ¶ Improved efficiency¶ Improved equity¶ Improved qualityShe goes on to identify 9 themes or strategies seen in HSR processes across the world: ¶ Decentralisation¶ Programme integration ¶ User fees in public facilities ¶ Focussed provision of essential services packages¶ Sector-wide approaches (SWAps) ¶ Civil service reform ¶ Corporatisation of public hospitals ¶ Engaging the private sector¶ Expanding insurance cover

The impact of HSR on national TB programmes has been a topic of debate and research since the late 1990s. Stimulated by a workshop organised by the International Union Against TB and Lung Disease (IUATLD) and the International Development Research Centre (IDRC) in Paris is December 199715 an edition of the International Journal of Tuberculosis and Lung Disease16 in July 2000 was devoted to a review and various national case studies. In the two opening editorials17 18 of that edition of the journal seven statements of advice were offered to readers: ¶ Advocacy at the highest level to secure or maintain political commitment. ¶ Proactive participation in the reform process by being present ‘at the table’

during the planning stages. Ensure that core elements of the DOTS strategy such as uninterrupted drug supplies are ring fenced during periods of rapid reform.

12 Cassels A. Health sector reform: key issues in less developed countries. WHO/SHS/NHP/95.4 Geneva: World Health Organisation, 1995 13 Cassels A. Health sector reform: key issues in less developed countries. J Int Devel 1995;7:329-374 14 Weil D.E.C. Advancing tuberculosis control within reforming health systems. Int J Tuberc Lung Dis 2000; 4(7): 597-605 15 IUATLD/IDRC Workshop. The significance of health sector reform for lung health services. Int J Tuberc Lung Dis1998;2:1044-1045 16 Int J Tuberc Lung Dis 4(7), July 2000 17 Miller B. Health sector reform: scourge or salvation for TB control in developing countries? Int J Tuberc Lung Dis 2000; 4(7): 593-594 18 Baris E. Tuberculosis in times of health sector reform. Int J Tuberc Lung Dis 2000; 4(7): 595-596


¶ Integration of service delivery but not necessarily of the supportive structures of NTPs (such as drug supply, laboratory network, information system) until ‘the dust has settled’.

¶ ‘Education’ of TB focussed donors to secure continuity of their funding within a sector wide approach.

¶ Respond to reforms taking place and learn the new skills required to integrate and decentralise such as new training programmes and streamlined supervisory methods.

¶ Document the nature of the reform process on the impact of TB control efforts and use TB programme outcomes as an indicator measure of the success or otherwise of the reform process.

¶ Operational research and pilot testing of the effectiveness of various institutional arrangements before nation-wide implementation.

Health Sector Reform in Nepal How could the NTP contribute to the plans for health sector programming in Nepal? Will the NTP prove to be a lead change agent or a stubborn outsider to the process? Conversely, how will the reform process impact on the effectiveness of the NTP? As has been mentioned already the HSR process comes in many shapes and sizes and is implemented at differing degrees of pace according to the unique national situation to which it is applied. In Nepal the structural policy framework for the HSR process has already been agreed and has been described in an earlier section. In summary there are 3 identified programme outputs and 5 sectoral management outputs. Using these 8 elements as a template this section seeks to identify the positive and negative impact that the NTP will exert upon the HSR process and vice versa. A table summarising the elements and the expected impacts follows the more detailed discussions below.

Programme Output Statements: 1. “EHCS package: The priority elements of an Essential Health Care Service – safe motherhood and family planning, child health, control of communicable disease, strengthened out patient care – will be costed, allocated the necessary resources and implemented. Clear systems will be in place to ensure that the poor and vulnerable have priority for access.” Impact of HSR on NTP: Highly positive. As TB control clearly lies within the ‘control of communicable disease’ priority element it should therefore be prioritised for funding and technical resourcing. This support should extend to the requirements for the anti-TB drug supply. Additionally the ‘strengthened outpatient care’ element is positive for TB control in that the delivery of the TB service is achieved through the PHC system and the outpatient departments of hospitals at all levels. The reference to ‘costing’ will drive forward the pressing need for the NTP to consolidate its budgeting process and more clearly delineate the true financial and other resource inputs necessary to operate the service. Finally the focus on providing ‘access to the poor and vulnerable’ will strengthen the hand of TB care as the disease preferentially impacts the socio-economically disadvantaged. Impact of NTP on HSR: Positive. The NTP is a good model from the perspective of an evidence-based technical programme for a disease which targets the disenfranchised and is implemented through generic outpatient services. As an established programme with a robust programme monitoring framework it could be used to pilot the envisaged HSR changes prior to sector –wide roll out of the HSR policies.


2. “Decentralisation: Local bodies will be responsible and capable of managing health facilities in a participative, accountable and transparent way with effective support from the MoH and its sector partners.” Impact of HSR on NTP: Dependant on quality and pace of the decentralisation process. The output statement refers to transferring local management to local bodies for local health facilities. If successfully achieved, local ownership of health facilities management will benefit programmes such as the NTP that reach the population through the network of health posts and sub-health posts. However previous experiences of ‘decentralisation’ within the health sector in Nepal has been of a ‘decentralisation by decree’ approach which was not supported by national or local change management arrangements. Robust transitional arrangements will be required to ensure there is no interruption to the delivery of services during this phased movement of responsibility from the centre to the district. Impact of NTP on HSR: Potentially positive. The longstanding experience of the district and regional level NGOs and INGOs within the NTP is one of close involvement with service delivery points such as district hospitals, health posts and sub-health posts. In many situations the support offered by the INGOs has been focussed to TB or Leprosy however the more efficient approach would be to harness the ‘onsite’ potential of the INGO or NGO to the decentralisation process and establish a health post support programme partnership between the Government District Health Office and the non-governmental sector – be that ‘private for profit’ or ‘voluntary sector’. In this way the expertise of the local partnerships build up by the NTP could be engaged to more wholistically strengthen and facilitate PHC delivery.

3. “Public-private mix: The role of the private sector and NGOs in the delivery of health services will be recognised and developed with participative representation at all levels. Clear systems will be in place to ensure consumers get access to cost effective high quality services that offer value for money.” Impact of HSR on NTP: Positive. This HSR driver for change can only be mutually positive. The international and Nepal approach to the application of the DOTS strategy is to build stakeholder coalitions and in particular to harness the potential of the mushrooming private sector. This approach is essential to the NTPs of the South Asia region where poor quality TB control within private practice can act as the conduit for the development and spread of MDRTB. ‘Recognition’ and ‘appreciation’are the key words pertinent to partnership working arrangements with the CBO/NGO/INGO community. ‘Regulation’ is also required to set clear frameworks for working arrangements and this is particularly important to the quality standards of TB control in the private for profit sector. An extension of this ‘regulation’ theme is for the government to control the quality, formulation and availability of anti-TB drugs to the private sector. Impact of NTP on HSR: Positive. The NTP has much experience of partnership working with the non-statutory sector at strategic, regional, district and community levels. As a government programme it has developed over time an effective participative involvement of (I)NGO partners in planning and executing control measures including quality control mechanisms such as for microscopy services. Developing effective interaction with the private-for-profit sector has been slow but progress has been made and valuable experience gained that will be of value to other programmes.

Sector Management Output Statements: 4. “There will be coordinated and consistent Sector Management (planning, programming, budgeting, financing and performance management) in place within


the MoH to support decentralised service delivery with the involvement of the NGO and private sectors.” Impact of HSR on NTP: Uncertain. Without an understanding of the nature and locus of this statement it is hard to predict impact. The strengthening of management capacity within the MoH can only be positive for all programmes. Similarly a change in focus to empower local level service delivery is good news for all programmes which deliver their functions through integrated PHC facilities. However the management function should not be divorced from the technical programme expertise. The transition phase in developing the structures for ‘co-ordinated and consistent sector management’ could lead to a period of uncertainty which would require careful change management and extra resources.Impact of NTP on HSR: Uncertain. The NTP model of trimesterly planning and statistical reporting meetings held at district, region and centre could be a valuable vehicle for a phased decentralisation process. Certain functions of the NTP such as anti-TB drug purchase should not be decentralised as this would lead to dis-economies of scale.

5. “Sustainable development of health financing and resource allocation across the whole sector including alternative financing schemes will be in place.” Impact of HSR on NTP: Uncertain. This statement holds concern for the NTP based on the experiences of other NTPs undergoing HSR. Too often HSR has led to budget cuts in an NTP despite the rhetoric of priority funding.19 There is general agreement that cost-sharing schemes in the public sector for diagnosis or treatment of TB do form a barrier to access for the poor. As such they are not favoured as a component of the DOTS strategy. Due to the considerable externalities in the form of ‘public good’ in the reduction of the transmission of TB in the community and concerns over cost barriers the gold standard for publicly-sponsored TB control is for free diagnosis and treatment for all. The desire to secure firm funding arrangements for the health sector as a whole and resource allocation according to sectoral priorities is a positive feature of the HSR as TB would appear high on the list of priority areas for funding.

Impact of NTP on HSR: Uncertain. It is expected that the current donors of the NTP would either support the HSR principles or seek to allocate their contribution to a ring-fenced area of the health sector budget linked to the NTP. There are positive lessons in the manner in which the NTP has brought donor partners together at the annual Technical Advisory Group meetings.

6. “A structure and systems will be established and resources allocated within the MoH for the effective management of physical assets and procurement and distribution of drugs, supplies and equipment.” Impact of HSR on NTP: Uncertain. In principle, removing the ‘supporting services’ such as drug procurement, and logistics distribution from previous vertically organised programmes and incorporating these separate systems into one co-ordinated expert service is an efficient organisational shift. The experience however in other countries undergoing HSR reform is that the loss of control of such a critical programme component as drug supply can be disastrous for programme effectiveness. Both editorials in the IUATLD journal edition which focussed on HSR highlighted concerns regarding the early ‘integration of supportive services such as drug supply,

19 Kritski, AL. Health sector reform in Brasil: impact on tuberculosis control. Int J Tuberc Lung Dis 2000; 4(7):622-626


laboratory network and programme monitoring information’.20 If such a process is to occur it should be rolled out in a phase-wise manner and closely monitored.

Impact of NTP on HSR: Negative. It is likely that until the MoH has established a robust system with quality assurance monitoring the NTP is both unlikely and unwise to absolve all responsibility for what is one of the key pillars of the DOTS strategy – ‘an uninterrupted system of drug supply of proven quality’. However the NTP has made tentative but definite progress along the road towards integrating the NTP logistics supply chain. Until very recently the onus of transportation and administration of drug supplies to the regions has been delegated to the regional implementing INGOs with additional assistance for delivery to districts in certain areas. The impact of this has been that during the state of emergency TB drugs were reaching the districts when other health supplies were not. The NTP must commit to the goal of integrating drug supply while protecting the programme from the damaging risk of stock-outs.

7. “Clear and effective Human Resource Development policies, planning systems and programmes will be in place.” Impact of HSR on NTP: Positive. The NTP depends on the availability of motivated, trained staff working from equipped facilities at region, district and health post levels. Many posts in remote districts are unfilled and this greatly hampers all health care delivered through PHC services. Better staffing is good for all. At the regional level the TB co-ordinators are currently funded by WHO, these posts should be transferred into government funded positions if the strategic importance of the DOTS strategy in Nepal is to be supported within the HSR process.

Impact of NTP on HSR: Positive. The NTP has fostered a motivating and empowering work culture within regional (RTLA and TB co-ordinators) and district (DTLA) level staff focussed on TB delivery. The methods employed could be applied more widely to positive effect in the health sector.

8. “A comprehensive and integrated management information system (MIS) for the whole health sector will be designed and implemented at all levels.” Impact of HSR on NTP: Negative. TB programmes use an information system with a multiple purpose: surveillance, management, and evaluation. Case by case monitoring of treatment outcome is THE key element and is more important than in many other diseases due to the risk of worsening the epidemiological situation with poor treatment outcomes. 21 While most management information systems depend on a form of district level cross-sectional activity reporting the TB control programme is built around trimesterly cohort reporting. Cohort outcome reporting must be retained while also providing appropriate information for a district level integrated MIS.22

Extensive negotiations have already taken place in Nepal around this issue and our understanding is that the NTP has been permitted to retain the DOTS reporting mechanism. A reversal of this decision in the interest of streamlining data collection would be severely detrimental to TB control.

Impact of NTP on HSR: Positive and negative. The NTP has developed a working system for promoting ownership of results by means of the 4 monthly statistical

20 Baris E. Tuberculosis in times of health sector reform. Int J Tuberc Lung Dis 2000; 4(7): 595-596 21 IUATLD/IDRC workshop: The significance of health sector reform for lung services. Int J Tuberc Lung Dis 1998;2:1044-1045 22 Chaulet P. After health sector reform, whither lung health? Int J Tuberc Lung Dis 1998;2:349-359


workshops for DTLAs. This permits problems to be identified early and corrective action taken. True ownership of programme outcomes by treatment centres is not commonly seen in Nepal so lessons could be learned from the NTP model. Others have suggested that TB services are an apt vehicle through which to measure the impact of the HSR process.23 This is because the long-term care required for the successful case management of TB patients is a particularly sensitive indicator of the ability of the health sector to deliver adequate service. And as the current TB information system is well developed it could provide a robust high level monitoring mechanism of the impact of HSR in Nepal. On a more negative note the NTP is unlikely to support any initiatives to dismantle the DOTS reporting mechanism in the interests of a totally unified process for collection of district level health sector data.

23 IUATLD/IDRC workshop: The significance of health sector reform for lung services. Int J Tuberc Lung Dis 1998;2:1044-1045


Programme Output Statements Impact of HSR on NTP Impact of NTP on HSR

1. EHCS package Highly positive Positive2. Decentralisation Dependant on quality &

pace of the decentralisation process

Potentially positive

3. Public-private mix Positive PositiveSector Management Output Statements Impact of HSR on NTP Impact of NTP on HSR

4. Co-ordinated and consistent sector management in place

Uncertain Uncertain

5. Sustainable development of health financing and resource allocation

Uncertain Uncertain

6. Effective management of physical assets, drugs supplies & equipment

Uncertain Negative

7. Human resource development Positive Positive

8. Integrated management information system

Negative Positive & negative

Figure 3: Summary table of expected impacts across NTP / Nepal HSR interface

Summary We conclude this section by summarising our assessment of the Nepali NTP against the 7 recommendations given to TB programme managers as mentioned earlier:

1. “Advocacy at the highest level.” This remains a key strength of the programme.

2a. “Proactive participation in the reform process by being present ‘at the table’ during the planning stages.” This has been a major weakness. The TB programme has been noticeable by its absence from the planning meetings around HSR.

2b. “Ensure that core elements of the DOTS strategy such as uninterrupted drug supplies are ring fenced during periods of rapid reform.” This remains to be seen. However as DfID are fully involved in the HSR process and also have a role in the funding of the TB drug supplies we have less concern over the risk of disruptions during the reform period.

3. “Integration of service delivery but not necessarily of the supportive structures of NTPs (such as drug supply, laboratory network, information system) until ‘the dust has settled’.” The NTP has achieved good integration of service delivery through the PHC system while retaining a stronger control over these programme components.


How the current approach responds to the new organisational environment will be the most testing aspect of the HSR process on the delivery of TB control.

4. “Education of TB focussed donors to secure continuity of their funding within a sector wide approach.” We are confident that the current donor partners of the NTP will adapt to the requirements of the HSR process. We expect they may request a degree of ring-fencing for any contributions to a sector wide funding arrangement.

5. “Respond to reforms taking place and learn the new skills required to integrate and decentralise such as new training programmes and streamlined supervisory methods.” We are not so confident that the NTP has prepared for the required changes that lie ahead. This requires considerable advance planning of which there is no evidence at present.

6. “Document the nature of the reform process on the impact of TB control efforts and use TB programme outcomes as an indicator measure of the success or otherwise of the reform process.” The commissioning of this work and the expected HeSo research study will provide a valuable baseline from which to monitor the impact of HSR in Nepal. We would recommend that one of the key indicators for auditing the HSR process is the cohort outcomes of TB control.

7. “Operational research and pilot testing of the effectiveness of various institutional arrangements before nation-wide implementation.” We saw no evidence of planning along these lines from the currently available plans. This is a cause of some concern.


Financing of NTP – the resource envelope

Introduction:The ability to secure sufficient funding from year to year is an essential prerequisite for the success of an NTP. Adequate funding is a measure of many factors such as the prevailing political support for the programme, the ability of the programme to present budgeted medium term plans and the attractiveness of the programme to potential external donor support. The financial management of the NTP is discussed below focusing on the following issues:

¶ The ability of the NTP to compile budgeted plans ¶ The ability of the NTP to secure political support and government funding ¶ The ability of the NTP to attract external donor support ¶ The mechanisms by which funds are released for TB control ¶ The profile of the donor base ¶ The ability of the NTP to use ‘released funds’ ¶ The prospects for the next 5 years ¶ The positive and negative implications of the HSR process on sustained

resourcing of the NTP

NTP BudgetingProgrammes often fail to secure adequate funding though an inability to present detailed and costed mid-term plans. This has not been the case in Nepal. Indeed it was the quality of the 1995-1999 NTP Development Plan24 with the inclusion of summaryand detailed unit budgets that provided the solid platform on which to build a partnership of governmental and donor commitment. In that plan it was estimated that the cost of the 5-year development programme would be approximately US 9.5 million with a steady increase in annual requirements. (Figure 4)

NTP Development Budget 1995-1999

0

0.5

1

1.5

2

2.5

3

1995 1996 1997 1998 1999

US $ (millions)

Figure 4: NTP Development Plan Budget 1995-1999 Source: Tuberculosis Control in Nepal 1995 - 1999

A second 5-year budget projection was formulated for the period 1998-2003 with similarly detailed breakdown of component costs. This document was able to identify an increase in government funding over the period 1995-1999 and for the first time to tabulate the various forms of assistance from NGOs and other development partners. It was estimated that the non-governmental support from such agencies amounted to

24 Tuberculosis Control in Nepal 1995-1999, A Development Plan for the National TuberculosisProgramme, HMG/N Ministry of Health and the WHO, Kathmandu, 1995


at least US$ 2.5 million per year.25 The expected 5-year budget for the period was estimated at US$ 13.2 million. In this calculation the government contribution was also quantified as 20% of the budget in 1998/99 rising to 30% by 2002/03. (Figure 5)

NTP Budget 1998 - 2003

0

1

2

3

4

5

1998/1999 1999/2000 2000/2001 2001/2002 2002/2003

US $ (millions)

Figure 5: NTP Budget 1998-2003 Source: Tuberculosis Control in Nepal 1998 – 2003 Long Term Plan

Securing political support and government funding While the NTP is to be commended on its ability to formulate budgeted plans such plans remain hypothetical until ownership of the financial implications are secured. Political commitment to the NTP is the key factor in attracting both governmentfunding and the involvement of external donor partners. The success of the NTP in Nepal over the last 10 years in is in no small part due to the careful attention given to political lobbying backed up with financial data. In 1993/4 the total governmentbudget for tuberculosis was 313,000 constituting 1% of the health sector budget. At that time the ratio of ‘regular’ to ‘development budget’ was 1:5.2 indicating a heavy dependency on donors.26 By the financial year 1998/99 this had risen to US$ 0.6 million and by 2001/02 was standing at US$ 1.4 million. This figure does not include the significant contribution in kind made by INGOs, currently estimated in the region of US $ 1 million.27 The use of health economics data as a driver for allocative and technical efficiency in Nepal remains at a primitive stage but even simple financialdata can be used effectively to support the requirements of the programme.

Attracting external donor support Pre-1995 the external donor commitment to the NTP came in the form of technical project support from JICA. In addition, the various implementing INGOs such as GENETUP BNMT, INF and UMN were providing TB services including the purchase of drug supplies. Post 1995 saw the increased involvement of WHO as a technical partner, and the offer of direct assistance by LHL who had taken the strategic decision to cease funding BNMT’s TB activities in the East and provide focussed financial support for core NTP activities such as training and supervision. The responsibility for funding, procurement and distribution of anti-TB drugs becamecentralised and removed the patchwork arrangement of each implementing INGO arranging its own drug supplies. Laterally external funding for the drug budget camefrom NORAD and more recently DfID has taken on a commitment to fund this key element of the programme. The partnership of external and in-country INGOs has

25 Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP/MoH/HMG,Kathmandu, 1999 26 Tuberculosis Control in Nepal 1995-1999, HMG/N & WHO, Kathmandu 1995 27 Dr Christian Gunneberg, Medical Officer, TB, WHO Nepal - Personal communication May 2003


been greatly strengthened in the past 8 years through the 6 monthly NTP technical reviews and the annual Technical Advisory Group (TAG) meetings when government, financial and in-kind donors can meet to exchange views and jointly assess progress.

Mechanisms for funding provision: Despite the increased presence and communication of donor partners it remains difficult to fully collate the funding streams that underpin the work of the NTP. This is due to the varied mechanisms that regulate each supporting donor budget. There is a clear requirement to more formally map out the contributions, both in funding and in-kind if the complete resource envelope is to be quantified. This would require increased transparency from Ministry of Health, NTC, and the donor partners. The mechanisms through which resources are currently channelled to the NTP are:

Government:¶ Regular Budget: This budget is allocated only for staff salaries,

administrative activities and other operational costs of the National Tuberculosis Centre. This is shown in the ‘red book’ of the Ministry of Finance and released on a trimesterly basis.

¶ Development Budget: This budget is primarily for the programme activities such as drugs and supplies, training, microscopy, supervision and monitoring. A proportion of the development budget is allocated to districts for district level activities. This budget is also shown in the ‘red book’.

Donor mechanisms:¶ Funds are provided direct to HMG: (eg LHL, WHO, JICA)

o Through Ministry of Health o Through Department of Health

¶ Funds are provided by one donor but channelled to NTP through WHO (eg DfID provides funds via WHO)

¶ Funds are provided by one donor but channelled to NTP through an in-country implementing INGO (eg DfID provides funding through the work of INF)

¶ In country implementing INGOs who provide a considerable volume of services in kind but no financial flows (eg INF, BNMT, GENITUP)

¶ National NGO’s who provide resources in kind but no finances (eg NATA)

Unfortunately not all these donor streams are recorded in the official government budget document known as the Red Book. There is therefore currently no one source that can identify all contributions either as cash or kind which are assigned to the support of TB control in Nepal through the National TB Programme.

Donor base profile: The Nepal TB Programme is fortunate to have a broad and committed donor base. This has grown over the past 10 years and in general the trend has been for new donors to express interest rather than established donors to withdraw. Over the past 5-10 years a natural progression towards a sub-sectoral ‘basket funding’ arrangement has evolved within the donor contributions such that now donors have distinct areas


of the ‘NTP cake’ that they clearly fund eg; JICA for microscopy, LHL for training and supervision, INF for mid west implementation. The table below outlines the areas of assistance of the NTP donor partnership.Development Partners over the period 1998 - 2003 Agency Support Main Activities RemarksNational Level

DfID T, F Anti-TB drugs Has provided funding for WHO MO and five regional TB co-ordinators

International Union Against TB and Lung Diseases T, R DOTS expansion Technical agency for LHL

JICA T, G

Lab materials, equipment, urban TB programme support (KTM)

Phase 2 project concluded mid 1999 followed by Community TB and Lung Health Project

Japanese Government G Drugs From Debt Relief Fund Norwegian Heart & Lung

Association (LHL) T, F Training and supervision New proposal to be negotiated from 1999

NORAD F Drugs Has provided buffer stocks of TB meds

Nuffield Institute for Health, UK T, R

DOTS in hard to access areas, involvement of Private Sector in TB control using DOTS

No budget to NTP

Research Institute of Tuberculosis, Japan R DOTS No budget to NTP

WHO T, F Training, surveillance, advocacy

Regional Level Britain Nepal Medical Trust

(BNMT) I East No budget to NTP

International Nepal Fellowship (INF) I Mid West No budget to NTP

Netherlands Leprosy Relief (NLR) I Far West No budget to NTP

District Level Friends of Shanta Bhawan I Kathmandu No budget to NTP

German Nepal TB Project (GENETUP) I

Kathmandu, Parsa, Bara, Rautahat and Mohattari

No budget to NTP

Medicin du Monde (MDM) I

Parbat, Myagdi, Baglung, Gulmi, Arghakhachi, Syangja, Palpa

No budget to NTP

Nepal Anti TB Association (NATA) I 28 districts No budget to NTP

United Mission to Nepal (UMN) I Lalitpur, Okhaldhunga, Gorkha, Palpa No budget to NTP

KeyTechnical support: TFinancial support: FGifts in kind: GImplementation: IResearch: R

Table 6: Development Partners 1998-2003 Source: Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP/MoH/HMG, Kathmandu, 1999 and current updates by NTC


The ability of the NTP to use ‘released funds’ One of the measures of the ‘capacity’ of a programme or department is its ability to use the funds allocated for activities within the proposed time scale. The NTP has demonstrated good planning and implementation management as measured by the percentage of ‘released funds’ to ‘released budget’.

HMG Development Budget for NTP

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40,000

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140,000

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Nep

ali R

oupe

es

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40%

60%

80%

100%

AllocationExpenditurePercentage used

Figure 6: Ability of NTP to utilise available HMG Development Budget allocation Source: Ministry of Finance, Annual Budget Statement (Red Book) FY 2054/55 to 2059/60

Another factor which can influence the ability of an NTP to effectively use donated funds is the manner in which the funds are disbursed. The LHL approach was to provide an annual commitment of a lump sum directly to the NTP based on a detailed annual plan. There were few limitations on how the money could be spent but an insistence on a strong annual independent audit. This approach was found to be extremely effective in enabling the NTP to spend money easily whilst ensuring accountability and a clear audit trail. Noticeably disbursement of LHL funds tended to be at a much higher rate than other donor funds as a result.

The prospects for the next 5 yearsInformal discussions with donor partners during the review process suggested that the donors are in general very favourable to the future needs of the NTP. However the diverse nature of the donors reflects differing viewpoints on the best way to channel funding to the control of TB in Nepal. Two of the key implementing in-country NGOs (INF and BNMT) are currently undergoing major internal restructuring which is likely to lead to a downsizing of NGO assisted TB focused activity in the Eastern and Mid-Western Development Regions. LHL remains strong in its resolve to assist the NTP in the key areas of training and supervision. The JICA project has adjusted its focus from pure TB technical assistance to that of ‘adult lung health’. It remains to be seen how the Department of Health responds to this new syndromic approach to lung health. DfID is the strongest advocate for a sector wide approach and is likely to support any endeavours to integrate and decentralise TB control within the health sector. As Nepal is seen as a key ‘model’ for other countries in the South Asia region and hosts both the SAARC TB centre and the annual WHO/IUATLD TB programmemanagers training course we would expect WHO and IUATLD to demonstrate high


levels of ongoing technical support into the near future. The NTP has not applied for funding of its national drug requirements from the Global Drug Facility (GDF) as currently DfID support this budget line. As the GDF is actively promoting countries to apply we would predict that Nepal will submit a proposal in the next 5 years.

The positive and negative implications of the HSR process on sustained resourcing of the NTP TB Control is well positioned as a public health intervention to receive priority funding under the requirements of any HSR process. The overarching objectives of reform are summarised as efficiency, equity and quality and on each of these parameters TB control has the potential to score highly28. TB services using the IUATLD/WHO programme model demonstrate both allocative and technical efficiency. Cost-benefit studies have demonstrated the strategic value of investment in national TB control. In terms of equity, TB control demonstrates a bias towards the poor which is highly valued as a feature of the restructuring of health services. Quality is demonstrated in the emphasis on cohort outcome reporting which provides clear measures of programme performance and the inbuilt community oversight element inherent in the DOTS methodology. Thus on empirical grounds, TB control should be prioritised within HSR processes. The elements of HSR which could be detrimental to the TB programme are: ¶ Loss of donor partners that have traditionally supported TB control if there

becomes no funding mechanism through which they can earmark their donations to TB control.

¶ Decentralisation of budget planning to district level could lead to TB services being de-prioritised at a local implementation level.

¶ Lack of adequate funding during any transitional phase of HSR implementation.

Recommendations regarding NTP funding 1. Public sector TB diagnostic and treatment services should remain free of charge at

the point of delivery. 2. A fully costed 5-year forward plan in English (for scrutiny by donor community)

is required to build on the firm foundation of the two earlier 5-year plans 1995-1999, 1998-2003. (Nepali version is available)

3. At present there would appear to be no centralised comprehensive record of funding (or in-kind contributions) from each donor and implementing agency. This should be rectified.

4. The good relationships between the NTP and donor partners & implementing NGOs should be retained through any HSR process by means of the established Technical Advisory Group meetings. The group might wish to meet more frequently during the HSR implementation phase.

5. The capacity of the current in-country implementing INGOs to support the NTP in the next 5 years should be explored and agreements secured.

6. Applications to the Global TB Drug Facility should be considered as this would allow donor funds to be reinvested into other aspects of the programme.

28 Weil, D E C. Advancing tuberculosis control within reforming health systems. Int J Tuberc Lung Dis 1998;2:349-359


Lessons for the Region

Success factors Success of the TB programme in Nepal as measured by internationally accepted outcome and programme indicators is clearly evident. But what were the ingredients of that successful recipe? And can it be replicated in other programmes in Nepal or indeed in other nations? This section seeks to identify the ‘why’ and the ‘how’ of the Nepal NTP success. A major component in the success of the adoption of the DOTS strategy in Nepal lies in the structured and phased manner in which the key operations for implementation were addressed. The WHO Stop TB Programme issued an expanded DOTS Framework for Effective TB Control in 200229 and identified a set of key operations required. These key operations are used as a template in this report for analysing the Nepal programme:

1. Presence or establishment of a National Tuberculosis Programme (NTP) with a clearly identified central unit In Nepal the presence of a large and well equipped purpose built outpatient, office and training facility known as the National TB Centre located some 30 minutes drive from the Department of Health Services (DoHS) has given the TB programme a clear physical and operational identity. The same building also houses the SAARC TB Centre which provides a synergy of additional TB technical resources. This was an advantage for the NTP in terms of office resources and a degree of autonomy from the activities within the DoHS. The resultant managerial distancing from other DoHS programmes and national centres also had a negative side in hampering the networking between the NTP and other programme.

Learning Point: The early provision of adequate central unit office facilities for the NTP is often not considered. Such facilities should be located within or near the DoHS.

2. Preparation of a programme development plan for the NTP based on findings of a systematic review of the prevailing situation, with details on budget, sources of funding and responsibilities The creation of just such a document prepared within months of a detailed country review by the WHO and IUATLD was undoubtedly a powerful driver for the DOTS implementation strategy and a focal instrument to attract HMG and donor funding. The draft 5-year plan prepared in late 1994 was widely discussed leading to ownership by the TB related INGOs in the country. The choice and continuity of the WHO short tem consultant who prepared the plan and then was contracted to provide technical assistance for its implementation was another significant success factor.

Learning Point: A robust national review leading quickly into the preparation of a development plan can provide the focus to harness political, donor and INGO support. The choice of consultant is important as is the requirement for continuity of leadership of the NTP director and any external technical support consultant in the early stages of any major revision of the NTP.

29 An Expanded DOTS Framework for Effective Tuberculosis Control, WHO/CDS/TB/2002.297, WHO 2002, Geneva


3. Preparation of a national programme manual containing: NTP aim, objectives, policy, strategy, programme structure, job descriptions, case definitions, case finding, diagnosis and treatment guidelines, instructions for reporting formats, logistics, and supervision The preparation of the Nepal TB Manual was a key process as well as an outcome. It was drafted originally in English with full participation of senior managers in the NTP plus the active involvement of the Tuberculosis Control Network (TBCN) which divided into short term working groups to tackle component parts. Once ratified it was translated into Nepali and widely distributed. Adequate budgeting of both time and money for the drafting, translating, adequate print runs and final distribution gave this document the status, quality and exposure needed to drive the extensive change process.

Learning Point: A weak manual leads to a weak programme. A well developed national TB manual prepared in advance of any implementation is a solid foundation for introducing the other programme elements such as training and supervision.

4. Establishment of the DOTS recording and reporting system The IUATLD/WHO reporting system, centred around the capacity to generate quarterly cohort outcomes for a district population of approximately 100,000 population, was accepted as national policy. Local adaptations were made such as reporting cohorts on a 4 monthly basis to align reporting with national government practice. The transfer of patients to the revised registers, recall of previous reporting systems and correct completion of the new forms required initial intensive training and strict supervision.

Learning Point: As with the TB manual the introduction of the reporting documentation requires to be handled as a project in itself. Materials, training and subsequent supervision are all required.

5. Plan and initiate a training programme covering all aspects of the policy package and prepare a plan for training regional and district primary health care staff and laboratory technicians involved in the TB programmeFrom the start of the DOTS programme a donor partner (LHL) took responsibility to fund the required training programme. At the national level the WHO modular training package was used extensively for the training of trainers (TOT). Training materials were devised for all cadres of health care workers ranging from the District Health Officers to Female Community Health Volunteers (FCHVs). As the programme expanded training was targeted at health support staff such as storekeepers and statistical assistants. Provision was also made for training or orientation of community groups, local NGOs and most significantly the ‘DOTS Committees’ who then ensured local accountability for DOTS treatment centres.

Learning Point: Three issues stand out. First the availability of adequate financial resources to back a comprehensive, locally adapted, rolling training programme. Secondly the widespread use of the WHO training modules to increase technical capacity for senior staff and trainers. Thirdly the expansion of training into generic health care support roles and wider civic society.


6. Establish a microscopy services network with binocular microscopes and adequate ancillary equipment and with laboratory technicians trained in sputum smear microscopy Another donor partner (JICA) took responsibility to address this need. The provision of binocular microscopes, widespread training and the setting up of regional quality control laboratories has significantly improved the quality and access of sputum microscopy. However frequent transfer of microscopy technicians has often hampered the development of this service in less accessible areas. Nepal would appear to be one of the few countries in the region with a functioning smear microscopy quality control mechanism. This should be recognised as a major achievement. The emphasis on quality of diagnosis has played a significant part in convincing private doctors to refer patients for microscopy rather than relying on radiology.

Learning Point: Recognition of the crucial importance of available microscopy services for a functioning DOTS programme requires that priority is given to the allocation and retention of trained staff to DOTS treatment centres. The presence of a quality control programme has ensured diagnostic standards are maintained.

7. Establish treatment services within the primary health infrastructure where directly observed short course chemotherapy is administered Nepal’s initial experience with DOTS was an overhasty implementation in 6 districts. The errors of this were picked up at the annual external review and the NTP revised its planning process to generate a more robust approach. Central to this was the establishment of 4 ‘National DOTS Demonstration Centres’, the development of a 10-point checklist30 for the inclusion of a potential health care facility to be adopted as a DOTS treatment centre. The backbone of the service is delivered through PHCs or Health Posts but also extends to Medical Colleges, district, regional and tertiary hospitals. Local and international NGOs also provide DOTS treatment facilities. Standardised treatment regimens (categories I, II & III) are used. The spectrum of ‘direct observation’ varies from the gold standard of 6 day a week attendance at the health facility and administration of the medicines under the eyes of the health care worker to ‘community’ or ‘family-based’ DOTS research areas. In community based DOTS an appointed community member such as a Female Community Health Volunteer (FCHV), Village Health Worker (VHW) or Maternal and Child Health Worker (MCHW) and in family based DOTS a reliable family member identified by the patient will observe the daily administration of the medicines. Operational research is ongoing but interim results would suggest that there is little difference in final cure rates in both strategies.

Learning Points: The DOTS expansion programme consisted of a comprehensive package of new site selection and preparation based on the 10-point checklist. Public (PHC and hospital), private and NGO facilities were used for service delivery.

8. Secure a regular supply of drugs and diagnostic materials based on previous case notification data This ‘DOTS pillar’ includes the budgeting, procurement, quality assurance, shipping, warehousing, in country distribution system, local stock keeping, buffer stocks and quarterly reporting mechanism. In Nepal the budget for drug supplies has at times

30 The ’10 Steps to DOTS’ was later developed into a short manual that was printed and distributed to other NTPs by SEARO.


been precarious. Currently one donor (DfID) is fully supporting this area for a 5-year period. The NTP has felt this area to be of such importance that it has sought interim but robust delivery systems using the major implementing INGOs in the 3 more remote regions and used central and regional TB dedicated resources for distribution in the other 2 regions. This is in essence an unsustainable and vertical mechanism but has ensured the uninterrupted supply of drugs from centre to district from where the local health service takes responsibility to deliver drugs to treatment centres.

Learning Points: The management of drug supply has been closely monitored and controlled by the central unit and implementing regional INGOs. This has provided the fast expanding programme with the security of uninterrupted supplies. However the consolidation phase of the DOTS coverage programme must include mechanisms to integrate the NTP logistic chain into the responsibilities of the generic DoHS Logistics and Management Division.

9. Design a plan of supervision of the key operations at the regional and district level to be implemented from the start of the programme In Nepal one of the early signs of government commitment to the strengthening of its NTP was the creation and salary provision of regional and district level supervisor posts with joint responsibility for TB and Leprosy. Known as Regional TB/Leprosy Assistants (RTLAs) and District TB/Leprosy Assistants (DTLAs) these appointments provided a structure through which the NTP could deliver a quality of supervision and data reporting above the capacity of the basic district health services. In addition implementing INGOs were able to provide counterpart district and regional TB dedicated staff to capacity build this new cadre of staff. Finally, one of the donor partners chose to support the entire supervision programme and provided the necessary funding (including motorbikes for terai districts) for comprehensive field supervision at all levels. In response to an NTP review team recommendation, WHO with the help of DfID has recently recruited five regional tuberculosis co-ordinators to help NTP at the regional level. This new cadre of regional technical managers should help to strengthen NTP implementation capacity and permit more efficient planning at the regional level.

Learning Points: The supervision programme is an example of excellent partnership working between government staff, ring fenced donor support, and local capacity building and practical support by’ on the ground’ INGOs.

Additional Key Operations 10. Information, Education, Communication (IEC), Advocacy and Social MobilisationAn emphasis on ‘communication’, whether it be in the form of advocacy to politicians, education to patients and their families or grass roots mobilisation of communities is a marker activity of a thriving and positive NTP. Throughout the mid and late 1990’s a Health Education subgroup of the TB Control Network (comprising INGOs, local NGOs and the NTP) drove forward the development of tools and strategies for effective communication for use across the country. Much emphasis was placed on tapping into the power of the local and national media to communicate information to the public and indeed politicians. It became standard practice to release press statements and invite press reporters to attend events such as the opening of a new treatment centre or a planned street drama based on TB. World TB Day was


developed into a major event attracting considerable media and political attention. Perhaps the most innovative and strategic action was the training of cohorts of media reporters from across Nepal and South Asia through a joint partnership between the Panos Institute for South Asia31 and the NTP/STC/WHO. Communication and networking were key themes that underpinned the extraordinary success of the TbNet organisation which arose in Kathmandu from a desire to bring together TB activists, managers and health professionals.

Learning Points: While demonstrated in a multitude of ways the emphasis on proactive communication and networking at all levels was instrumental in the success of the programme as a whole. In particular the partnership working between the NTP and the press provided wide local and national press and radio coverage, increasing awareness of, and confidence in, public attitudes towards TB and its treatment.

11. Involving private and voluntary health care providers The history of TB control in Nepal is closely linked to the work of NATA, (Nepal Anti-TB Association) the national NGO dedicated to TB and a significant number of INGOs who provided a patchwork of TB treatment services ranging from a single urban clinic to a multi-district programme. As these agencies met together under the umbrella of the TBCN, other agencies for which TB was a component activity were invited to join. As the momentum grew and DOTS was expanded approaches were made to link with urban private practitioners, community health programmes, private medical institutions and even some development work with traditional healers in the mountain districts. Particular efforts have been made to involve the expanding urban private medical sector with some excellent results. In 1998 a project entitled the Kathmandu Valley Coalition Against TB (KV-CAT) was launched to develop DOT provision in the urban setting. A Public-Private-Partnership (PPP) was initiated in Lalitpur Municipality in the same year. The Lalitpur Urban TB Programme is now seen as a model in forging operational partnerships with the private sector in TB control. Pathfinder examples are Hargan’s Nursing Home in Lalitpur and the UMN YALA Urban Health Programme (YUHP), both of which are part of the Lalitpur Urban TB Programme. With the experience gained from Lalitpur Urban TB Programme the NTP has now expanded the urban DOTS programme across Kathmandu Metropolitan City where more than five different stakeholders are supporting urban DOTS. Another area of involvement with the private sector has been the development of DOTS demonstration centres in each of the 6 private teaching hospitals in Nepal and the inclusion of DOTS within the medical school teaching curriculi.

Learning Points: The Nepal programme had a culture of working with different agencies in the control of TB which promoted the inclusion of new private and voluntary partners. Work with the private sector has been slow and challenging but is now bearing fruit. The building of trust and co-operation with private practitioners must be earned and this takes time.

31 Panos Institute South Asia is based in Kathmandu and works to build the capacity of media to improve coverage of vital development issues, encourage cross-border perspectives and better regional interchange of information. GPO Box 13651, Kathmandu, Nepal


12. Economic analysis and financial planning The 1993 World Bank Report graphically demonstrated the cost effectiveness of TB control as a public health measure. Using the tools of health economic analysis NTPs have the potential to demonstrate the utility of TB control to national planners and politicians. In Nepal there has been little work in this field although recently a health economics unit has been set up in the Ministry of Health.32 The NTP has prepared two five-year budgets (1995-1999 and 1998-2003) both of which have been instrumental in the approach to external donor partners. The linkages between central financial planning mechanisms in the Health Ministry and that undertaken within the National TB Centre appears weak, however within the NTP itself resource requirements are identified and appropriately incorporated into budget planning. The NTP would appear to engage external technical assistance from WHO and donor partners in the preparation of annual budgets however it has been more effective and flexible in the mobilisation of available funds within its control.

Learning Points: The application of health economics is weak in the Nepal health system and this is reflected in the NTP. The NTP has effectively resourced external assistance in the process of budget formulation and achieved good release of funds.

13. Operational Research The promotion of operational research has been an integral aspect of the NTP largely due to the technical assistance of the ongoing JICA Community TB and Lung Health Project which has strong links with the Research Institute of Tuberculosis (RIT) in Tokyo. Latterly the Nuffield Institute for Health (NIH), UK has set up a research programme based within the NTP. For many years WHO has been running TB drug resistance surveys and TB-HIV surveillance. Nepal also collaborates in international studies with the IUATLD on drug regimes and drug resistance patterns. These linkages between renowned academic institutions and staff within the NTC have woven operational research into the fabric of the programme. Additionally, the counterpart INGOs, particularly BNMT and GENETUP have a strong pedigree for publishing TB related research.

Learning Points: The attention given to practical operational research has driven up technical capacity of both individuals and the programme as a whole. The current research partnerships are an additional stimulus to quality improvement. Investing in operational research has been of true benefit to the NTP.

32 Health Economics & Financing Unit, Ministry of Health was established in July 2002


ThanksWe should like to express our thanks to the following institutions and individuals:

Lanarkshire NHS Board, NHS, UK for release of Dr Hamlet to undertake this work Nuffield Institute for Health, UK for release of Mr Baral to undertake this work Dr Diana Weil, World Bank, Washington Dr Christian Gunnerberg, Medical Officer, WHO, Nepal Dr DS Bam, Director NTP, Nepal Dr Tirtha Rana, World Bank, Nepal


Annexes

Annex 1: Terms of Reference

Annex 2: Map of Nepal

Annex 3: Organisational Charts

Annex 3a: Organisational chart of Ministry of Health

Annex 3b: Organisational chart of Department of Health Services

Annex 3c: Organisational chart of National TB Centre

Annex 4: Tables, Graphs and Figures

Annex 5: List of key people interviewed

Annex 6: List of background materials examined

Annex 7: List of external peer reviewers


Annex 1: Terms of Reference

Purpose: To produce a case study analysis of the National Tuberculosis Program in Nepal.

Specific objectives:

(a) To provide lessons for public health, primary care and health sector development in Nepal based on the successes and remaining challenges of the TB control program and its integrated service delivery system. The analysis will examine how the program is structured, how required public health functions are pursued, and a whether a focus on results, impact and accountability is fostered. It will also address the means of collaboration among the Government, non-Governmental organizations, communities, donors and technical assistance agencies. Furthermore, the analysis would examine how future plans for health sector programming In Nepal might strengthen and further enable adaptation and expansion of the TB program and how the program might contribute to the development of the sector program goals and strategies. Nepal’s National TB Program has been noted as one of the most successful public health initiatives in the country and merits exploration. This analysis should be informed by ongoing actions in MOH with regard to the development of "Health Sector Strategy - An agenda for change" and the preparation process and progress of "Nepal Health Sector Program - Implementation Plan" in collaboration with the external development partners.

(b) To assess the level of funds available for the National TB Program from public and external sources - historical trend, assurance of financing for next 3-5 years. Although Tuberculosis control is one of the Priority one (P1) projects of the Government out of 17 P 1 projects as defined in the Medium Term Expenditure Framework (FY 03-05), the support services may not be adequately met through the projected level of allocation and it is likely to pose a risk for future program implementation. The author can then present views on the potential resource envelope and additional options for the period of the PRSP (FY 03-07).

(c) To summarize lessons for other countries on local adaptation and application of the recommended TB control strategy, known as DOTS. Nepal has been consistently seen as a good performer in TB control since the DOTS approach was adopted and expanded in the 1990s. The Director of TB program now directs as well a regional technical advisory service for TB control in South Asia. While there are challenges that remain in Nepal particularly in case detection and gender differences, the successes in a very low resource environment have been impressive and results have been widely published. However, further analysis is merited on the socio-economic, human resource, institutional and financial characteristics that may contribute to this success as well as inhibit even greater speed in reaching global TB control targets and the communicable disease control Millennium Development Goal (MDG).


Annex 2: Map of Nepal


Annex 3a: Organisational chart of Department of Health Services

Ministry of Health

CENTRALLEVEL

DIVISIONS

PFAD

FHD

CHD

EDCD

LMD

HIM

D

LCD

CENTRES

NH

TC

NH

EICC

NTC

NCA

SC

NPH

L

Regional Health Services Directorate

Central Hospitals

Department of Health Services

REGIONALLEVELZONALLEVEL(14)

DISTRICTLEVEL (75)

ELECTORALCONSTITUENCY (205)

VDC LEVEL (3,995)

District Public Health Office (14)

District Hospital (59)

Sub Health Post (3,132)

Health Post (710)

Primary Health Care Centre / Health Centre (172)

District Health Office (61)

Zonal Hospital - 11

Reg

iona

lTB

Cent

re (

1)

Reg

iona

l Med

ical

Sto

re(5

)

Reg

iona

l Lab

orat

ory

(1)

Reg

iona

l Tra

inin

g Ce

ntre

(5)

Reg

iona

l Hos

pita

l (1)

FCHV47,261

TBA15,554

PHC Outreach 15,349

EPI Outreach15,201

COMMUNITY LEVEL


Acronyms

PFAD: Planning and Foreign Aid DivisionNHEICC: National Health Education, Information and Communication Centre FHD: Family Health Division CHD: Child Health Division NTC: National Tuberculosis Centre EDCD: Epidemiology and Disease Control Division NCASC: National Centre for AIDS and STD Control LMD: Logistic Management Division NPHL: National Public Health Laboratory HIMDD: Health Institution and Manpower Development DivisionFCHV: Female Community health Volunteer LCD: Leprosy Control Division PHC: Primary Health Centre NHTC: National Health Training Centre EPI: Expanded Programme of Immunisation

Source: DoHS, Annual Report 2057/58 (2000/2001)


Annex 3b: Organisational chart of National TB Centre

Organisational Chart of the NTP

Co-ordination of the NTPwithin the health services

Technical policies for the NTPPlanning, Monitoring and EvaluationTraining, Supervision and Research

Management of the NTP at theRegional Level

Training and SupervisionMonitoring

Management of the NTP at theDistrict Level

Diagnosis, tratment andMonitoring

Case Holding andTreatment

Case Holding / Tracing

Ministry of Health

Director Generalof Health Services

National Tuberculosis Programme/National Tuberculosis Centre, Director Other National

Centres & Divisions of DOHRegional Directors

RTC/RTLA

District HealthOfficers

DTLA

Primary Health Centres

Sub Health Posts

NCASC PFADNPHL EDCDNHTC LMDNHEICC HRDDAIDS CentreCHD FHD

KEYMain Structure of NTP

Line ManagementTechnical Supervision

Responsibilities

Health post

DOTScommittee

NGOs

Communities


Annex 4: Tables, Graphs and Figures Annex 4a: NTP 5 year budget summary 1998-2003

Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-2003

Annex 4c: Contribution of JICA

Annex 4d: Contribution of LHL

Annex 4e: Contribution of NORAD

Annex 4f: Contribution of DfID

Annex 4g: Contribution of WHO

Annex 4h: Epidemiological assumptions of NTP plan 1998-2003

Annex 4i: TB Case notification in Nepal 1972-2002

Ann

ex 4

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90

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411,

387

754,

640

1

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4

93,6

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36,6

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2

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3

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1

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2

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NTP

con

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tion

excl

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33%

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Cas

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1

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834

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3

27,5

46

506

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Trea

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2,4

21,1

58

71

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1

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2

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853

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1

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1

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3,77

4

73,

438,

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7,0

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-

829,

688

8

29,6

88

-

Tech

nica

l Ass

ista

nce

-

-

-Te

chni

cal A

ssis

tanc

e

8

06,8

16

-

806

,816

881

,723

-

881

,723

4,0

27,0

06

-

4,0

27,0

06To

tal

4

,132

,654

71,5

82,8

69

2,9

26,5

61

4,5

97,8

86

1,3

82,9

44

3,2

14,9

40

18,

668,

157

7

5,41

9,46

7

13,

625,

465

NTP

con

tribu

tion

excl

udin

g Te

ch A

sst

36%

37%

35%

Ove

rall

Con

trib

utio

n 29

%71

%30

%70

%27

%72

%

Assu

mpt

ions

:

HM

G c

ontri

butio

n to

mos

t bud

gets

initi

ally

40%

, inc

reas

ing

annu

ally

by:

2.5

0%

HM

G d

rug

cont

ribut

ion

incr

ease

s by

20%

per

yea

r H

MG

staf

f cos

ts o

ther

than

thos

e in

NTC

and

RTC

not

show

n. P

roje

ct st

aff (

regi

onal

supe

rvis

ors a

nd c

entra

l uni

t sta

ff) o

nly

show

n.

Supe

rvis

ion

cost

for p

roje

ct st

aff o

nly-

oth

er su

perv

isio

n co

st in

HM

G b

udge

t. C

ost p

er p

atie

nt tr

eate

d:

$ 11

8 C

ost p

er p

atie

nt c

ured

: $

139

Cos

t per

life

save

d:

$ 30

3

Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-2003

Central level development budget allocation for NTP reflected in ‘Red Book’ HMG Donor Total US$

Year NRs. (,000) US$ (,000) NRs. (,000) US$ (,000) (,000)1997- 1998 31,700 412 - - 4121998- 1999 26,302 342 25,560 331.95 6741999- 2000 10,000 130 100,000 1,299 1,4292000- 2001 12,760 166 110,702 1,438 1,6032001- 2002 29,300 381 79,300 1,030 1,4102002- 2003 19,602 255 83,499 1,084 1,339

HMG Total Development and Regular Budget for NTP reflected in ‘Red Book’

YearDevelopment

Budget(US$ 000)

RegularBudget(US$)

Total (US$)

1998- 1999 674 46,494 720,4941999- 2000 1,429 43,506 1,472,5062000- 2001 1,603 74,312 1,677,3122001- 2002 1,410 60,610 1,470,6102002- 2003 1,339 84,390 1,423,390

NTP Budget (Development and Regular)

720,494

1,472,5061,677,312

1,470,610 1,423,390

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

1998-99 1999-00 2000-01 2001-02 2002-03

Nepali Fiscal Year

Bud

get U

S$

Annex 4c: Contribution of JICA

Contribution of JICA to NTP Nepal (US$) Year Contribution Amount in US$

1994Equipment - vehicle, computer, microscope (17), photocopier and others 170,109Drugs 376,997Local cost 123,338

1995Equipment - vehicle, microscope (3) and others 154,035Drugs 416,635Local cost 194,322

1996Equipment - microscope (34) and others 376,068Local cost 147,482

1997Equipment - microscope (50) and others 225,645Local cost 192,283

1998Equipment - microscope (50) computer(3) and others 217,015Local cost 214,000

1999Equipment – Motorbike (5), computer (1) and others 36,490Local cost 161,700

Total 3,006,119 Source: Report on JICA TB Control Phase II (5th July 1994- 4th July 2000)

Annex 4d: Contribution of LHL

LHL support to NTP Nepal (US$) Heading 1998 1999 2000 2001 2002 Total

Material production 22,056 23,579 32,136 32,136 25,183 135,090Resources 5,467 9,595 8,921 8,921 7,877 40,781Staff development 12,432 13,798 13,712 13,712 14,092 67,746Staff and capital cost 29,955 32,441 32,512 32,512 50,861 178,281Regional level activities 56,856 27,232 35,572 35,572 22,796 178,028District level activities 30,662 95,668 111,294 111,271 139,350 488,245Central level activities 21,901 20,048 20,503 20,548 26,978 109,978Other 82,018 6,912 12,598 12,598 22,417 136,543TOTAL 261,347 229,273 267,248 267,270 309,554 1,334,692 Released amount 259,103 205,755 260,267 260,267Expenditure 259,019 205,849 254,878 259,497 *Expenditure% on total released 100% 100% 97.9% 99.7%* expenditure not available


Annex 4e: Contribution of NORAD

NORAD funded the National Tuberculosis Programme through WHO between 2000 and 2001 to pay for drugs.

In addition there was a need for microscopes, accessories and other equipment to expand the microscopy network to all 75 districts.

Activity Estimated cost 2000 Estimated cost 2001 ThroughPurchase of anti tuberculosis medicines (rifampicin, ethambutol, and streptomycin) 279,680 279,680 IUATLDIUATLD administrative cost (8%) 24,320 24,320 IUATLDProcurement of diagnostic supplies and other equipment 66,120 WHOFoil wrapping and boxing of anti-tuberculosis medicines 66,120 WHOWHO project support cost 9,880 9,880TOTAL 380,000 380,000

Annex 4f: Contribution of DfID

DFID finance to NTP 2001 2002 2003 2004 2005 Total(£,000) (£,000) (£,000) (£,000) (£,000) (£,000)

Drugs 574 629 686 742 801 3432WHO PSC (6%) 34 38 41 45 48 206Sub total + PSC 608 667 727 787 849 3638INF/TLP programme costs 396 199 208 221 236 1260WHO technical Assistance 104 104 104 0 0 312Sub total 500 303 312 221 236 1572WHO (PSC 13%) 65 40 41 29 31 206Subtotal +PCS 565 343 353 250 267 1778Grand total 1173 1010 1080 1037 1116 5416

Ann

ex 4

g: C

ontr

ibut

ion

of W

HO

WH

O s

uppo

rt to

NTP

, Nep

al

Prod

ucts

Reg

ular

bud

get (

US$

) 19

96

19

9719

9819

99

20

0020

0120

0220

03Te

chni

cal a

nd a

dmin

istra

tive

supp

ort

-

-

1,50

0

1,

500

2,00

0

2,

000

2

7,00

0

27,

000

Surv

eilla

nce

of d

rug

resi

stan

ce

-

-

8,00

0

-

13,

000

Surv

eilla

nce

of H

IV in

pat

ient

s w

ith T

B

-

7,

700

8,00

0

2,

500

9,00

0

9,

000

Nat

iona

l aw

aren

ess

and

com

mitm

ent f

or

TB c

ontro

l

47,

575

75

0

5,

000

2,00

0

13,

000

2,00

0

6,

000

3,00

0C

apac

ity o

f NTP

man

ager

s fo

r pla

nnin

g,

impl

emen

ting,

mon

itorin

g an

d ev

alua

ting

an e

ffect

ive

TB c

ontro

l pro

gram

me

base

d on

DO

TS s

trate

gy e

nhan

ced

-

-

2

0,50

0

6,

000

8,50

0

13,

500

5,00

05,

000

Tech

nica

l tra

inin

g fo

r asp

ects

of T

B di

agno

sis

and

treat

men

t

63,

000

5,00

0

22,

400

2

2,40

0

26,

000

1

0,00

0

10,

000

1

0,00

0Lo

gist

ic s

uppo

rt to

the

prog

ram

me

-

-

11,

000

2,00

0C

oord

inat

ed T

B co

ntro

l pro

gram

me

for

the

Kath

man

du V

alle

y

22,

550

1,75

0A

five

year

stra

tegi

c pl

an fo

r TB

cont

rol i

n N

epal

for t

he p

erio

d of

200

0-20

04

8,00

0To

tal

13

3,12

5

15,

200

6

5,40

0

42,

400

7

1,50

0

36,

500

5

9,00

0

47,

000

Annex 4h: Epidemiological assumptions of NTP 5-year plan 1998-2003

Epidemiological Assumptions

Population 1991: 18,491,097Population growth rate: 2.60%ARI in 1991: -2.10%Annual change in ARI: -2.00%

Year 1998/1999 1999/2000 2000/2001 2001/2002 2002/2003Population

22,130,652 22,706,049 23,296,406 23,902,112 24,523,567ARI 1.82% 1.79% 1.75% 1.72% 1.68%

Assumptions Median EstimatesWell Treated Proportion 30% 40% 55% 60% 65% Poorly Treated Proportion 50% 40% 30% 25% 20% Untreated proportion 20% 20% 15% 15% 15% Mortality in P+ Well Treated 5% 5% 5% 5% 5% Mortality in P+ Poorly Treated

20% 20% 20% 20% 20%

Mortality in P+ Untreated 70% 70% 70% 70% 70% Mortality in P-/EP Well Treated

5% 5% 5% 5% 5%

Mortality in P-/EP Poorly Treated

15% 15% 15% 15% 15%

Mortality in P-/EP Untreated 20% 20% 20% 20% 20% Prevalence to Incidence ratio 2 1.9 1.8 1.7 1.5ARI to incidence/100,000 ratio

49 49 49 49 49

Ratio of P-/EP to P+ cases 1.22 1.22 1.22 1.22 1.22

Note: The impact of HIV is assumed to be low during this period Source: Tuberculosis Control in Nepal 2055-2060 (1998-2003), Long Term Plan


Annex 4i: TB Case notification in Nepal 1972-2002

Case Notifications 1972-2002

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

12000

13000

14000

15000

1972

/73

1973

/74

1974

/75

1975

/76

1976

/77

1977

/78

1978

/79

1979

/80

1980

/81

1981

/82

1982

/83

1983

/84

1984

/85

1985

/86

1986

/87

1987

/88

1988

/89

1989

/90

1990

/91

1991

/92

1992

/93

1993

/94

1994

/95

1995

/96

1996

/97

1997

/98

1998

/99

1999

/00

2000

/01

2001

/02

New P+

New P-ve

EP


Annex 5: List of key people interviewed

Name Designation OrganisationAllaby, Martin (Dr) Public Health Specialist YUHP, UMN Nepal Bam, Dirgh Singh (Dr) Director National Tuberculosis Centre Baral, JP (Dr) Director Leprosy Control Devision

Bista, Krishna Prasad Co-ordinator Health Sector Reform, Programme preparation team

Chherti, MK (Dr) Director RHD Central Region Devkota, Uma Nath (Dr) Programme Officer GTZ Health Sector Support Programme Dhakal, Ramji Deputy Programme Manager GTZ Health Sector Support Programme Gautam, Jagadish Administrator INF/TLP Nepalgunj Gurung, Devi DTLA DHO Lalitpur Gurung, Lekh Bahadur Field Officer INF/TLP Nepalgunj Gyawali, Badri Nath Statistical Officer NTCJaishi, Bishnu Prasad RTLA Central Regional Health Directorate Jha, Kashi Kanta (Dr) Senior Chest Physician NTCKasland, Olav Deputy Manager/Consultant Norwegian Lung and Heart Association Kato, J (Dr) Expert JICA/CTLHP, Nepal Malla, Pushpa (Dr) Senior Chest Physician NTCMark, Rana Vijaya Managing Director Hargan's Nursing Home Nepal, Damodar Regional Supervisor Central Region/NTC Neupane, Bhisma Chief Accountant NTCO'Dwyer, Michael (Dr) Senior Adviser DFID, Nepal Osuga, K (Dr) NTP reviewer (external) Research Institute of Tuberculosis, Japan Overberg, K (Dr) NTP reviewer (external) Norwegian Lung and Heart Association Pande, Shanta Bahadur (Dr) Senior Researcher Nuffield Institute for Health/NTP, Nepal

Preston, Christine Director YUHP, UMN Nepal Rahaman, Md. Mojibur (Dr) Epidemiologist SAARC TB Centre Rana, Tirtha (Dr) Health Sector Specialist World Bank, Nepal country office Sharma, D N Trainer Britain Nepal Medical Trust Weakliam, David (Dr) Director of Health Service UMN, Nepal Yoshiyama, T (Dr) Chief Advisor JICA/CTLHP, Nepal


Annex 6: List of background materials examined

1. A Comprehensive Report on JICA TB Control Project, Phase II (5th July 1994 – 4th

July 2000), JICA TB Control Nepal

2. Ala Alwan & Peter Hornby ‘The implications of health sector reform for human

resources development’ Bulletin of the World Health Organisation 2002,80(1)

3. Annual Report Department of Health Services 2057/58 (2000/2001)

4. Annual Report Tuberculosis Control Programme Nepal 2057/58 (2000-2001)

5. Annual Report, Department of Health Services 2052/53 (1995/96)






11. Anti- tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal

IUATLD 4(8):730-736 , 2000 March

12. Esperanza C. Martínez, Hari Koirala ‘Primary Health Care Services in Nepal’ Field

Report October 2002

13. Health Sector Strategy Development – An Agenda For Change, HMG MoH, August

2002

14. Institutional Assessment of the Nepal Health Sector, Term of Reference

15. Medium Term Expenditure Programme (MTEP) to Operationalize 1st Three Years of

10th Five Year Plan’s Health Programmes, Ministry of Health, Nepal January 2002

16. Medium Term Strategic Health Plan, Department of Health Services, MoH, February

2001

17. Nepal Demographic and Health Survey 2001

18. Nepal Family Health Survey 1996

19. Nepal Operational Issues and Prioritisation of Resources in the Health Sector, June

2000, Health Nutrition and Population Unit, South Asia Region – Document of the

World Bank, Report No. 19613

20. Population Census 2001- National Report, HMG, Central Bureau of Statistics, June

2002


21. Project Memorandum – Support to the NTP Nepal 2001-2006: WHO-DFID Nepal

22. Strategic Analysis to operationalize Second Long Term Health Plan, Nepal (Vol. 1)

23. TB control Network (TBCN) Draft Procedures and Functions Document

24. Tenth Five Year Health Plan (Draft), HMG MoH, 2002

25. The minutes of discussions between the Japanese management Consultant Team and

the authorities concerned of HMG, Nepal on the JICA/CTLHP

26. Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP MOH,

HMG, Nepal

27. Tuberculosis Control Programmes and the Impact on Health System and Service

Development, A systematic review of three countries, Country case study protocol-

Centre for Health and Social Development


Annex 7: List of external peer reviewers

Reviewer Position1. Dr Ian Smith WHO, Geneva 2. Dr Tirtha Rana World Bank, Nepal 3. Dr Diana Weil World Bank, Washington 4. Dr Christian Gunnerberg WHO, Nepal 5. Dr SB Pande NTC6. Dr Pushpa Malla NTC7. Dr K.J. Jha NTC8. Mr Tony Bondurant DfID, Nepal

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