hri report 2_hfmsp

This publication is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of the Partnership for Maternal and Neonatal Health Project, HealthRight International in partnership with Mother and Infant Research Activities (MIRA), and do not necessarily refl ect the views of USAID or the United States Government.

STRENGTHENING HEALTH FACILITY OPERATION AND MANAGEMENT COMMITTEES TO IMPROVE MATERNAL

AND NEWBORN HEALTH STATUS IN

PERIPHERAL HEALTH FACILITIES OF ARGHAKHANCHI, NEPAL

Partnership for Maternal and Neonatal Health an Innovation of the Child Survival and Health Grants Program

STRENGTHENING HEALTH FACILITY OPERATION AND MANAGEMENT COMMITTEES TO IMPROVE MATERNAL AND NEWBORN HEALTH STATUS IN PERIPHERAL HEALTH FACILITIES OF ARGHAKHANCHI, NEPALStudy Team membersChandra Rai 1

Hari Rana 2

Mohan Paudel 3

Dr. Dharma Shrna Manandhar 4

Jyoti Shrestha 5

Dhruba Adhikari 6

August 2013

1 Project Director/Country Representative, HealthRight International2 Training and Operation Coordinator, HealthRight International3 Monitoring and Evaluation Coordinator, HealthRight International4 President, Mother and Infant Research Activities (MIRA) 5 Research Coordinator, Mother and Infant Research Activities (MIRA)6 Research Offi cer, Mother and Infant Research Activities (MIRA)

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iMC to im

HealthRight and Mother and Infant Research Activities (MIRA) would like to express gratitude towards District Health Offi cer Dr. Yam Bahadur Basnet, and District Health Offi ce Arghakhanchi team for their kind co-operation, encouragement, and collaborative efforts to implement the Health Facility Management Strengthening Program (HFMSP) with HealthRight and Mother and Infant Research Activities (MIRA). Special thanks go to the health staff and Health Facility Operation and Management Committee (HFOMC) members from Thada Primary Health Care Centre, Narapani Health Post (HP), Pokharathok HP, Subarnakhal HP, and Siddhara HP. HealthRight also would like to thank all of the respondents who spent their valuable time during the interview and documentation process.

Special thanks goes to the National Health Training Centre, Nepal, Family Health Program II, and Nepali Technical Assistance Group, for providing the training materials, trainers, and technical support to the program.

This project was immplemented with funding support from the United States Agency for International Development (USAID) through the Child Survival Health Grants Program. HealthRight would like to express gratitude to USAID in Nepal and Washington.

Finally, especial thanks go to Ms. Sangita Bista and Jen Leigh, independent consultants for data collection, report writing, and editing of this process document report.

Acknowledgements

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 ii

CB-NCP Community Based Maternal Newborn Care Package

DDC District Development Committee

DHO District Health Offi ce

EC Electoral Constituency

FCHV Female Community Health Volunteer

FGD Focus Group Discussion

GoN Government of Nepal

HF Health Facility

HFMSP Health Facility Management Strengthening Program

HFOMC Health Facility Operations and Management Committee

HP Health Post

HW Health Worker

KII Key Informant Interview

MIRA Mother and Infant Research Activities

MNC Maternal and Newborn Care

MNH Maternal and Newborn Health

MoHP Ministry of Health and Population

NGO Non Government Organization

NHTC National Health Training Centre

OR Operations Research

PHCC Primary Health Care Center

PHC-ORC Primary Health Care - Out Reach Clinic

QI Quality Improvement

SHP Sub Health Post

VDC Village Development Committee

Acronyms

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iiiMC to im

Table of ContentsACKNOWLEDGEMENTS.........................................................................................................................................i

ACRONYMS.......................................................................................................................................................... ..ii

TABLE OF CONTENTS...........................................................................................................................................iii

EXECUTIVE SUMMARY........................................................................................................................................ iv

1. INTRODUCTION............................................................................................................................................1

1.1 Background.............................................................................................................................................1

1.2 National Policy Context ..........................................................................................................................1

1.3 Health Facility Management Strengthening Program Approach........................................................2

1.4 Scope Of Study........................................................................................................................................3

1.5 Objectives Of The Study..........................................................................................................................3

2. METHODOLOGY............................................................................................................................................4

2.1 Study Design...........................................................................................................................................4

2.2 Study Site................................................................................................................................................4

2.3 Data Collection.......................................................................................................................................4

2.4 Data Analysis..........................................................................................................................................4

3. ACHIEVEMENTS AND FINDINGS................................................................................................................5

3.1 Capacity Development Of Health Facility Operation And Management Committees.......................5

3.2 HFOMC Capacity Assessment Findings.................................................................................................6

3.3 Communication, Coordination, and Support.......................................................................................7

3.4 Planning, Implementation, and Monitoring..........................................................................................9

3.5 Resource Mobilization...........................................................................................................................13

3.6 Essential Medicine and Equipment....................................................................................................14

3.7 Human Resources Management........................................................................................................15

3.8 Physical Infrastructure.........................................................................................................................16

3.9 Good Governance.................................................................................................................................17

4. OPPORTUNITIES FOR SCALING UP AND SUSTAINABILITY....................................................................18

5. LESSONS LEARNED..................................................................................................................................19

6. CHALLENGES AND CONSTRAINTS..........................................................................................................20

7. RECOMMENDATIONS...............................................................................................................................21

REFERENCES......................................................................................................................................................22

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 iv

Executive Summary

This report describes the process of the Health Facility Management Strengthening Program (HFMSP) implemented by Mother and Infant Research Activities (MIRA) in partnership with HealthRight International and the District Health Offi ce of Arghakhanchi. HFMSP was a capacity building process with the Health Facility Operation and Management Committees (HFOMCs) of fi ve peripheral health facilities, to help them identify, prioritize, and solve health problems by utilizing local resources to improve maternal and newborn health, and increase community facility linkages.

HFMSP was implemented as one intervention of Operations Research (OR) conducted in electoral constituency two of Arghakhanchi District. The OR was designed by HealthRight International under the USAID funded Partnership for Maternal and Neonatal Health Program, and implemented from 2010 to 2013. Eighteen district trainers and 57 HFOMC members were trained using a package from the National Health Training Centre, Ministry of Health and Population that included three days of basic training, two follow up reviews, and monthly monitoring visits by district trainers.

The objective of this report is to explore and document the HFMSP process and activities, achievements, challenges and constraints, and lessons learned for institutional retention and future sharing with relevant stakeholders. Changes in the capacity of the HFOMCs were investigated, in terms of institutional capacity and committee empowerment, health facility management, and status of health service provision and utilization. Both quantitative and qualitative methods were utilized, including a review of safe motherhood HMIS data and meeting minutes, key informant interviews, focus group discussions, and observation of the participating health facilities.

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 vMC to im

Key fi ndings: The HFOMCs’ capacity to manage the health facilities and health programs was increased. Average

assessment scores increased by about 50% between basic training and the second follow up, with none of the HFOMCs scoring below 78% at second follow up.

The HFOMCs are encouraging regular participation of all members in a newly established series of regular meetings to discuss community health issues, action plans, and fi ndings of supervision visits. The meetings are helping to build stronger relationships among members. They have also established a system for communicating in case an emergency meeting must be called.

There is increased coordination between the HFOMCs and DHO and other stakeholders involved in supporting the health facility.

Each of the HFOMCs has developed periodic and annual plans for the last three fi scal years and have implemented them accordingly.

The committees have been working to identify communities without access to health services through social mapping and supervision of outreach clinics. To respond to the needs of these communities, the HFOMCs have resumed outreach clinics, established static clinics, changed the sites of outreach clinics, conducted awareness campaigns, supported community screenings, and held health camps.

HFOMCs have developed and implemented a schedule for monitoring and supervising the health facilities, PHC-ORCs, and Epi clinics using the provided supervision checklist.

The HFOMCs have increased resource generation for health facility management by coordinating with the VDC, DHO, forest users groups, community groups, and leaders. They have also initiated their own income generating activities like introduction of a users’ fee scheme, renting HF resources, selling unused HF resources, and planting banana and coffee plants. They also manage a bank account for the HF income.

HFOMC management of medicine and equipment has improved, including coordination with DHO to ensure regular supply of medicine and equipment, especially for birthing centers and newly established static clinics, and preparation for potential outbreaks.

Human resources management has improved. The majority of newly generated resources have been used to expand staffi ng. Increased focus has been placed on motivating staff, including development of a performance appraisal and recognition system including certifi cates and fi nancial incentives.

HFOMCs have made notable advances in the development, expansion, and maintenance of the physical infrastructure at their HFs, based on needs identifi ed through supervision.

In every HF visited, the citizen charter, along with the HFOMC annual work plan and names of HFOMC board members with photos, was displayed.

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 1MC to im

1. INTRODUCTION

1.1 BackgroundHealthRight International implemented the Partnership for Maternal and Neonatal Health (PMNH) Project in Arghakhanchi and Kapilvastu districts of Nepal from September 30, 2009 to September 29, 2013. The main goal of the project is to contribute to reducing maternal and newborn morbidity and mortality in the project districts by increasing and sustaining utilization and quality of community and facility based Maternal and Newborn Care services. HealthRight International is also implementing Operations Research in Arghakhanchi district in collaborative partnership with Mother and Infant Research Activities (MIRA), a non-governmental organization (NGO) in Nepal. The PMNH Project implemented the Community Based Newborn Care Package (CB-NCP), use of misoprostol at community level for prevention of postpartum hemorrhage, and Chlorhexidine for prevention of cord infection district-wide in both project districts. MIRA conducted OR comparing the outcomes of those interventions along with the outcomes from the addition of a health facility management strengthening program, a maternal and newborn care (MNC) quality improvement (QI) process, and maternal and neonatal near miss and death review process with basic equipment support, which were implemented in electoral constituency two (EC 2).

Table 1: Arghakhanchi district demographics

Categories PopulationTotal Population 246,569Children under fi ve 30,773Women of reproductive age (15- 45) 65,867Expected Pregnancies per year 6,738Source: Estimated Target Population for 2010/2011, Annual Report, DHS 2009/2010

Arghakhanchi district contains 42 Village Development Committees (VDCs), with one district hospital, two Primary Health Care Centers (PHCCs), eight Health Posts (HPs) and 31 Sub Health Post (SHPs). The district has a total population of 246,569, of which 65,867 are women of reproductive age.

The OR intervention area in EC 2 includes one PHCC, four HPs and 18 SHPs. The Health Facility Management Strengthening Program (HFMSP) was implemented with the objective of increasing community and facility linkages by strengthening partnerships between health facilities and communities in managing public sector health services through active involvement of Health Facility Operation and Management Committees (HFOMCs). The HFMSP was implemented in fi ve health facilities of the OR area: Thada PHCC, Siddhara HP, Subarnakhal HP, Pokharathok HP, and Narapani HP. By implementing the HFMSP, the project envisions improved knowledge, skills, and accountability of HFOMC members, and improved community involvement in health facility management and governance resulting in timely identifi cation and addressing of community maternal and newborn care needs by cross sectorial resource mobilization, which commonly results in increased utilization of MNC services.

1.2 National Policy ContextThe Government of Nepal’s (GoN) vision for health and development focuses on self-reliance, community participation, and involvement of the private sector and non-governmental organizations (NGOs). In 1999, GoN passed the Local Self-Governance Act, which led the Ministry of Health and Population (MoHP) to decentralize health services management to local bodies (1). The main thrust of the initiative is to make the community legally responsible for and technically capable of managing local health facilities and health programs (2). Decentralization enables the community to participate

Strengthening HFOMC to improve MNH status in Arghakhanchi, PMNH, HealthRight International, 2013 2

in managing health services and bring services closer to people’s homes (3). MoHP began the decentralization process in 2002. By 2006, 1,433 HFs in 28 districts had been handed over to local bodies (4).

Under the decentralization policy, HFOMCs are formally constituted as the responsible bodies for overseeing overall management of the health facilities (5). Each HFOMC consists of nine to thirteen representatives from the village development committee or municipality. In order to foster social inclusion and ensure everyone has a voice in health facility management, membership includes the health facility in-charge, the village development committee chairperson and elected members, school teachers, Female Community Health Volunteers (FCHVs), and dalit (disadvantaged caste) and women members. The committee members are selected through public meetings and general consensus. Some are selected by virtue of their posts, and the rest are nominated by other members of the committee at a public meeting (6). Presently, however, there is a lack of locally elected bodies, making it diffi cult and in some cases unfeasible to form the committees according to national guidelines.

HFOMCs are supposed to manage the human resources, physical infrastructure, medicines and equipment, funds, and health programs at the local level. The National Health Training Center (NHTC), MoHP developed a standard package (including participant’s handbook, trainer’s guideline, and operating guidelines) to build the capacity of the health facilities and HFOMCs through a series of orientations and trainings. It is expected that once the HFOMCs assume full ownership of local health facility management, the committees will meet at least once a month at their health facilities and discuss the health issues brought by different community groups, identify local health problems, prioritize them, develop and implement action plans, and mobilize local resources to solve the identifi ed problems. Furthermore, they are to prepare periodic and annual health plans, monitor and supervise health facilities, and review the progress of health facilities periodically. The main source of funding for HFOMCs is a fi xed budget, coming either directly through the District Public/Health Offi ces or through the District Development Fund. HFOMCs also get funds from their village development committees, non-governmental organizations, and the local community (6).

1.3 Health Facility Management Strengthening Program ApproachThe HFMSP approach builds on the national decentralization policy, and aims to improve the health of communities (focusing on marginalized and underserved people) by empowering the local community to manage their own HFs and health programs. Salient features of this approach include:

Involving disadvantaged groups (e.g. dalits, janajatis, women) in health facility management decision making

Delivering a complete package of interventions to develop knowledge and skills in managing health facilities, rather than one-time events like trainings

Using simple, community friendly tools, guidelines and training methods

Focusing on building skills in organizational development, HF management, and health services provision using a phased model

The HFMSP process worked over two years to build HF management capacity, through situational assessments, a three-day interactive session, periodic review meetings, and monitoring visits.


Figure 1: The HFMSP Process

HFMSP Process

Self-assessment using standard tools

Monitoring visits in every monthly meeting of HFOMC

3 days basic

training6 months 6 months

2 days review

meeting

1 day review

meeting

HealthRight International coordinated with Nepal Family Health Program-II (NFHP), Nepali Technical Advisory group (NTAG,) and NHTC prior to initiating HFOMC training in Arghakhanchi and arranged for their technical assistance to conduct the training. Several rounds of meetings between NFHP-II, MIRA and HealthRight International were held to discuss the training process, and selection of trainers. NHTC developed the HFMSP training manuals in coordination with NFHP. Two facilitators from NTAG facilitated the trainings. MIRA implemented the HFMSP at the selected fi ve health facilities in close coordination with DHO, Arghakhanchi.

1.4 Scope of the StudyThe study this report is based on sought to document how MIRA, in coordination with the Arghakhanchi DHO, built the capacity of HFOMCs to improve Maternal and Newborn Health (MNH). It describes the steps taken to build the capacity of HFOMCs to understand, document, prioritize, and develop solutions for their problems. This report also presents some of the key activities and innovations that HFOMCs of fi ve peripheral health facilities have implemented to improve maternal and newborn health in their communities and sustain their achievements. This document also notes some of the important lessons learned in strengthening HFOMCs, as well as some constraints and challenges faced.

It is important for readers of this document to realize that this is not an evaluation of the Health Facility Management Strengthening Program (HFMSP). Rather, it is meant to document the process of HFOMC capacity building employed by the project and the HFOMCs’ efforts in improving quality and utilization of maternal and newborn health using local solutions.

1.5 Objectives of the StudyThe Objectives of the study documented in this report are:

Document activities undertaken to build the capacity of HFOMCs to identify, prioritize, and develop solutions for their problems.

Document activities done by HFOMCs to improve maternal and newborn health through community involvement and using local solutions.

Explore quality of MNH services and trends in service utilization.

Identify lessons learned and best practices of this process.


2. METHODOLOGY2.1 Study DesignThe study utilized both quantitative and qualitative methods. The research process comprised secondary data review as well as primary data collection, conducted by an independent consultant over ten days in the fi eld.

2.2 Study SiteFour of the fi ve health facilities where HFMSP was implemented were visited by the consultant for this study. These were Siddahara HP, Pokharathok HP, Subarnakhal HP, and Thada PHCC. These were chosen for HFMSP with the aim of selecting relatively well performing committees, and to encompass variety in facility type.

2.3 Data CollectionThe study employed both qualitative and quantitative methods of data collection. Consent to be included in documentation was obtained prior to conducting interviews and discussions.

a) Document research: Review of offi cial documents for government decentralization policy and self-governance act 1999, and training manuals used for HFOMC capacity building.

b) Record review: Two types of records were reviewed. The three year data trend for safe motherhood activities from 2010/2011 to 2012/2013 was reviewed. A detailed review of meeting minutes was also done by developing a format to collect data about frequency of meetings, participation of dalit and female members, and their activities to strengthen health program and health service delivery.

c) Key Informant Interviews (KIIs): Eight key informant interviews were conducted with a district health offi cer, public health offi cer, research offi cer, chairperson, member secretary and members representing dalits, janajatis, and women, to explore questions that were not answered by reviewing meeting minutes, especially regarding the factors that enhanced management capacity, diffi culties and challenges faced, and future plans and perspectives for sustaining their efforts.

d) Focus Group Discussions (FGDs): Two focus group discussions were conducted in Thada PHCC and Subarnakhal HP with members of HFOMCs comprising fi ve participants in Subarnakhal and eight participants in Thada. The HFOMC members discussed their thoughts on the HFMSP process, its usefulness, and progress so far.

e) Observation: HFs were visited to observe cleanliness of HF, display of citizen charter, annual work plan and name board of HFOMC members, etc.

2.4 Data analysisData generated from the record review and observations were entered into PC using MS Excel 2007. Frequency tables and descriptive statistics were generated and used in the presentation of fi ndings.

The interviews and discussions were audio recorded by Sony voice recorder, transferred to PC and transcribed. The fi eld notes from the observations and informal communications were also transferred to a Word document to be used in analyses. The transcription was conducted in native language, Nepali being the only language used to communicate with informants. Preliminary analyses of transcripts were conducted throughout the data collection period to allow interview questions to be refi ned. A thematic analysis of qualitative data was done. Themes were derived based on the roles and responsibilities of HFOMCs as outlined by HFMSP.


3. ACHIEVEMENTS AND FINDINGS

Picture 1: HFOMC training exercise

3.1 Capacity Development of Health Facility Operation and Management CommitteesTo conduct HFOMC training, 18 district trainers from different sectors (DDC, Women Development Offi ce, DHO, MIRA and HealthRight International) were trained with trainers in February 2011 at DHO, Arghakhanchi, with trainers from Nepali Technical Assistance Group (NTAG). The objective of training district trainers was to prepare local people to train the HFOMCs and ensure sustainability of the program. Three days of theoretical training and classroom demo sessions in the DHO training hall were followed by a three day training for HFOMC members. The district trainers were divided into fi ve groups and assigned one HF for each group. Following the training of trainers, the participants, facilitators, and resource persons traveled to their respective health facilities to conduct the three-day training to HFOMC members. A total of 57 members from fi ve committees received training, including 14 committee members from dalit and disadvantaged groups, 12 women, and 5 FCHVs. On the seventh day, all district trainers returned to the DHO training hall and shared their fi eld training experiences. The master trainers provided feedback to all trainers.

Content of the three day HFOMC training: Decentralization process

Importance of Health Facility Management Strengthening Program

Healthy Life “our health, our responsibility”

Services available through health facility

Health facility management


Structure of HFOMC

Role and responsibility of HFOMC

Process to conduct HFOMC meetings

Self assessment of work of HFOMC

Social inclusion in health and process of social inclusion

Three year vision of health facility and HFOMC

Work plan of HF and HFOMC

After training, the HFOMCs were supported regularly with monitoring visits by the district trainers. In addition, district staff from MIRA and HealthRight International and DHO supervisors played a key role in the monthly monitoring visits to the health facilities. During the monitoring visits, district trainers observed, coached, and facilitated HFOMC meetings. Information regarding gaps in knowledge and skills of HFOMC members were collected, action plans were implemented, and supportive supervision and follow-up was provided.

After eight months (November 2011), a two day review was conducted, and another one day review was held six months (June 2012) after that, in the same modality as the initial training. Review workshops helped to address the gaps identifi ed during monitoring visits. Further enhancement of knowledge and skills in the areas of resource mobilization, program monitoring and supervision, good governance, need assessments and plans developed during the review workshops.

3.2 HFOMC Capacity Assessment fi ndingsThe Health Facility Management Strengthening Program focuses on capacity development of HFOMCs. To evidence change in HFOMC capacity, the approach included self-assessment of their capacity during the initial three day training, and at the two follow up reviews. The self-assessments include three dimensions: institutional capacity and committee empowerment; health facility management; and health service status. Each dimension has a maximum score of 17 comprising a maximum aggregate score of 51. HFOMCs achieving from 13 to 17 are considered to be performing well, 8 to 12 as fair, and less than or equal to 7 as performing poorly. Changes in self-assessment scores demonstrate changes in HFOMC capacity.

The review of self-assessment scores showed signifi cant improvement in their capacity to manage institutional development, health facility, and health service status presents the trend of changes in HFOMC capacity during the intervention (Fig 2). On average, the aggregate score increased from 35 percent at baseline to 84 percent at 2nd follow up, with none of the health facilities scoring less than 78 percent.

In addition to the self-assessment fi ndings, questions were included in the KIIs and FGDs to identify perceived changes in HFOMC capacity. Most of the HFOMC members noted that the main change they found in themselves was a feeling of ownership and belonging towards their HF.

3 days basic training

First follow upsecond Follow up

Thada

Perc

enta

ge

siddhara

Narapani

Suwarnakhal

Pokharathok

Avera

ge of

5 HFs

100908070605040302010

0

Figure 2. HFOMC Self Assessment Score

84

63

3337

25

2435

3541

8086

78

9084


“Earlier we did not care about the health facility and its services. This training developed in us a feeling that this is our health facility and it is our responsibility to manage it. At present, we are committed to providing quality services. We ensure the availability of 36 items of medicine in the HF. We have planted banana and coffee as income generating activities for the health facility.”

-- FGD participant, Subarnakhal

“At present we feel responsible towards the HF. If some complaints are heard in the community about service provision, we listen to them carefully and counsel them accordingly. We share those complaints in the meeting to solve them.”

-- FGD participant, Thada

3.3 Communication, Coordination, and SupportAccording to the national guidelines, the HFOMC should conduct meetings on a monthly basis. It should also develop action plans as needed, with the active participation of all members and consensus during the decision making process.

Through the process of HFMSP implementation, the HFOMCs have indeed developed a system of having regular meeting with active participation of all members, and all HFOMCs have fi xed dates and times for their meetings. All HFOMCs completed the activities prepared in the plan of action developed during the initial training. The HFOMC felt that developing new action plan as tedious work. Development of written new action plans was found not into practice. However the new issues were discussed in the regular meeting and recorded in the minutes. At present only annual plan is prepared.

The HFOMCs have established the practice of systematically keeping minutes of every meeting. Their decisions are communicated through the network of FCHVs, mother’s groups, HFOMCs, social forums, and sometimes through media (e.g.to announces availability of 24hour delivery service).

Provisions have been established for communicating with HFOMC members through the secretary in case an emergency meeting must be called. The HFOMC of Pokharathok arranged a CDMA set and Siddhara has set up a post paid sim and they have allocated funds for their management.

All of the HFOMCs held at least 60% of their scheduled meetings (range 60% -100%). Findings from meeting minutes triangulated with KIIs and FGDs with HOMC members revealed that most HFs did not hold meetings during the month of the national festival “Dashain and Tihar.” Thada was the only HF where meetings could not be held three times due to lack of a required 51% of members present, over three fi scal year (FY) periods. Similarly, there is a provision of monthly monitoring visits by district trainers during the HFOMC meetings. Table 2 presents detail of HFOMC meetings and monitoring visits by district trainers.


Table 2 : Number (%) of HFOMC meetings held and facilitated by district trainers

Health facility2010/2011 N=5 (months)

2011/2012N=12 (months)

2012/2013N=9 (months)

Meeting HeldSiddhara 5 (100) 11 (92) 7 (78)Narapani 3 (60) 9 (75) 8 (89)

Subarnakhal 4 (80) 10 (83) 7 (78)

Pokharathok 5 (100) 9 (75) 7 (78)

Monitoring visits made by district trainers, among meeting held

Thada 4 (80) 6 (50) 6 (67)

Siddhara 2 (40) 4 (33) 5 (56)

Narapani 3 (60) 5 (42) 4 (44)

Subarnakhal 3 (60) 3 (25) 4 (44)

Pokharathok 3 (60) 4 (33) 3 (33)

“The main thrust is that, at present, we are well trained. Training developed in us a feeling of ownership of our health facility. We understood the importance of regular meetings, i.e, only through regular meetings can we understand the status of the health facility and identify gaps so that we can take appropriate action.”

- FGD participant, Subarnakhal

There was improvement in the quality of meetings in terms of active participation of all members, decision making by consensus, and division of roles and responsibilities. The training helped the HFOMC members to better understand their roles and responsibilities, including the importance of regular meetings.

The HFMSP approach envisions active participation of female and Dalit members in the monthly meetings. Female participation is above 50% for all HFs in FY2012/2013, except for Subarnakhal (table 3).

Table 3: Number (%) of Female and Dalit participation in meeting

Health facility2010/2011N=5 (months)

2011/2012N=12 (months)

2012/2013N=9 (months)

Female participation, among meetings heldSiddhara 5 (100) 9 (75) 5 (56)Narapani 2 (40) 9 (75) 7 (78)

Subarnakhal 1 (20) 7 (58) 1 (11)

Pokharathok 5 (100) 9 (75) 7 (78)

Dalit participation, among meetings held

Thada 2 (40) 3 (25) 2 (22)

Siddhara 4 (80) 8 (67) 6 (67)

Narapani 1 (20) 4 (33) 6 (67)

Subarnakhal 4 (80) 8 (67) 4 (44)

Pokharathok 3 (60) 8 (67) 5 (56)


Though female and dalit representation has improved, there is still room for development of their capacity, especially for those members who could not participate in the initial three day training. Pokharathok and Narapani included dalit members in the committee only after the training, while Subarnakhal and Siddhara included them on the very fi rst day of training. Those members participated in the initial training were more empowered. They were aware about their role of representation in the committee.

“We are here in the community to identify and bring health problems of our community to the committee, discuss it and make people aware about health problems and services available at the health facility and decisions made at committee.”

- Dalit Member, Siddhara

Most female and dalit members felt their capabilities have improved after being HFOMC members, including increased ability to speak in a group, decreased feelings of hesitation and shyness, and increased knowledge on health issues.

“This is the fi rst time for me to be in a committee. Earlier I used to feel hesitation to speak in a group. Being a member of HFOMC, I got the opportunity to learn new things and developed the capacity to speak in a group, but still I feel hesitation to speak among the Health Facility In-charge and other group of elite people in the committee. I haven’t tabled any agenda items so far, but I along with dalit member did supervision of static clinic as delegated by committee and presented the identifi ed gaps. We are happy that gaps identifi ed got priority in the meeting and was solved.”

- Janajati Member, Pokharathok

3.4 Planning, Implementation, and MonitoringCapacity building training of HFOMCs in all HFs has transformed them from dormant entities to active stakeholders, increasing their sense of belonging and motivation through their active participation in planning, implementation, and monitoring of health facilities and health programs. After only two years, there are some impressive signs of success in the fi ve interventions HFs.

All HFs in the intervention area have developed annual and three years plans for the last three fi scal years and created three year visions during the training, with the active participation of all members. Agendas during planning are brought forward by HFOMC members, regarding either health issues of the community they represent or the fi ndings of supervision visits. Agenda items are also brought by the member secretary on topics identifi ed during Ilaka (sub district) level or district level staff meetings, or identifi ed while reviewing health indicators. Health indicators with poor coverage are discussed and solutions are sought. Discussion with HFOMC members revealed that those agendas that were urgent and can be locally managed are fulfi lled immediately; however, those less urgent, requiring large amount of funds like ambulance service or construction of a new building are not completed within the planned period.

Picture 2: HFOMC members identifying marginalized groups in the community through social mapping


Table 4: No. of PHC-ORCs resumed

Health Facilities PHC-ORCs resumed

Thada 3 (revitalized)Siddhara 2

Narapani 2

Subarnakhal 1

All HFOMCs have identifi ed the pocket areas in their community with poor access to HFs, through community mapping and supervision of Primary Health Care – Outreach Clinics (PHC-ORCs). With an aim to increase access to health services for these hard to reach communities, HFOMCs have been doing various activities. For example, HFOMCs resumed and revitalized PHC/ORCs in their respective areas (table 4). It is noteworthy that Siddhara and Pokharathok converted one PHC-ORC each to static clinics, so that these communities can have regular access to health services. Other HFs (Thada and Subarnakhal) have brought forward agendas for establishment of static clinics. These static clinics are providing services at the level of Sub Health Posts (SHPs). In addition to the static clinics, DHO, at the request of the HFOMCs, has been conducting health camps, uterine prolapsed screening camps, awareness campaigns, and family planning camps at least once a year.

Similarly, HFOMCs have prioritized the maternal and newborn health program based on the review of indicators. As such, they have identifi ed the barriers to accessing services and have been involved in creating an enabling environment for the improvement of maternal and newborn health. Their activities to improve MNH in the community are noteworthy. At present 100 percent of the intervention HFs are providing 24 hour delivery services. Siddhara, Subarnakhal, and Narapani started delivery service after the intervention period, while Thada resumed it. With an aim to increase HF delivery, Subarnakhal and Siddhara have been initiated to provide an incentive of Rs.100 (about 1 USD) to FCHVs for bringing pregnant women to deliver at the HF. In later part Subarnakhal has increased incentive to Rs. 200 to FCHV for brining pregnant woman to deliver at the HF. The provision of incentives to FCHVs has been effective in increasing HF delivery at Subarnakhal.

“Provision of incentive to FCHVs has helped in increasing institutional delivery. There were about 3 to 5 deliveries per month which is very good in this small area. We also increased the FCHV incentive from Rs. 100 to 200 to enhance its further effectiveness.”


Similarly, to promote institutional delivery and improve newborn health by preventing infection and hypothermia, Thada has begun providing baby set (Nepali name daura, topi and suruwal set) to newborn babies who deliver at the health facility. Pokharathok is also providing cloth wrappers for newborn babies born at the health facility. Thada has been using a cost sharing mechanism for the bhoto topi sets, while Pokharathok has been providing the wrappers free of cost.

Picture 3: Wrapper for newborns at HF


“The committees of EC 2 are gaining momentum in social mobilization for health service promotion and utilization. We wanted to do something new, therefore we discussed it with HFOMC members and health staff and fi nally decided to provide wrappers to newborns free of cost. We have managed it from incentives received by the HF for institutional delivery, therefore it is sustainable.”

- Member Secretary, Pokharathok

The committees identifi ed diffi cult terrain, lack of transportation to the facility, and fi nancial barriers as important bottlenecks preventing women from delivering at the HFs. Considering the importance of appropriate and timely referral to specialized care to improve the outcomes of mother and child during pregnancy and labor, HFOMCs have arranged for stretchers, created an emergency reproductive health fund, and established a maternity waiting home. Subarnakhal and Siddhara provided stretchers while Pokharathok, Siddhara and Subarnakhal set up emergency reproductive health funds. The funds can be used as a loan without interest so that women in need can afford transportation to reach an appropriate center to receive care in time. HFOMCs of particular HFs have developed their specifi c guidelines to implement the fund in a way that is easily accessible to the person in need.

“Emergency Reproductive Health Fund of Rs 20,000 (about 200 USD) has been created at Siddhara. For the women convenience the total amount has been divided into three places, Rs.10,000 at area nearby HF managed by HFOMC member, Rs. 5,000 each at Harre and Laure village to be managed by FCHVs. Rs 1,500 is provided for transportation from community to local HF and Rs 5,000 for referral from HF to higher center. Loan taken from the emergency fund has to be returned within 15 days without any interest.”

- HFOMC chairperson, Siddhara

KIIs and FGDs with HFOMC members revealed that the stretchers and emergency funds have been used extensively by the community. Table 5 presents the details about the amount of emergency reproductive health fund, sources of fund, and its utilization.

Table 5: Emergency Reproductive Health Fund Mobilization

Health facility Amount Source No of times used

Pokharathok 29,000FCHV’s fund, VDC, community forest users group

29

Siddhara 20,000FCHV’s fund and HF internal resource

3

Subarnakhal 15,000FCHV’s fund and HF internal resource

3

With an aim to address barriers like diffi cult terrain, lack of transportation, and lack of hotels and lodging near the HF for accommodation of women and care takers to deliver at HF, Siddhara established a maternity waiting home in one room of the HF building. The idea of the maternity waiting home is entirely new in Arghakhanchi. The waiting home can accommodate one pregnant woman with two caretakers. Establishment of the maternity waiting home is appreciated by the DHO, which envisions extending the idea to other VDCs.


“We decided to establish maternity waiting home immediately after our decision to establish birthing center because the HF is inaccessible to most of the communities. People need to come from distant areas; we do not have transportation facility or the hotels where people can stay. We have managed maternity waiting home in one room of HF building; we can accommodate two care takers. We counsel pregnant mothers about it during ANC and encourage them to come one or two day before EDD or as soon as abdominal pain starts.”

- HFOMC Chairperson, Siddhara

“Siddhara established a maternity waiting home, with a view to provide quality MNH service. This is a very good initiative. HWs can closely monitor the health of mother and baby during their stay at maternity home. This is very important to prevent newborn death. DHO is exploring resources to strengthen waiting home of Siddhara and have a thought of extending it to other VDCs by strengthening committees.”

-District Public Health Offi cer

`Though the maternity home is of great importance in improving maternal and newborn health, its utilization has not been as effective as anticipated. The HFOMCs have thought seriously about ways to increase its utilization; they have been sharing about it in FCHV meetings to publicize it, have held community interaction meetings, and are exploring resources to strengthen it.

“People do not feel comfortable staying here; they are not used to it as it is a new concept. As it is a concrete building they fear being cold. Only three people have used it during summer after its establishment. Our community has the culture of staying by a fi re immediately after delivery and during the postpartum period; this is not possible in our waiting home. Therefore, people usually reside at the home of their relatives immediately after delivery before going home. We need to make the room warm by provision of room heater to increase its utilization which is not feasible at present due to lack of electricity. We are lobbying with community leader for good capacity solar panel…we are ensured to get it in near future. We hope with room heater people will be willing to use it.”

- Member Secretary, Siddhara

HFMSP activites resulted in increased service utilization, namely ANC visits and HF delivery, yet there is still room for improvement. All interviewed HFOMC members, DHO, PHO and research offi cer noted that there has been a gradual increase in utilization of available maternal and newborn health services. Figure 3 and 4 presents the detailed picture of the trend of utilization of ANC and Health Facility delivery in the intervention HFs.

Base line (Feb 010-Jan011) 2’nd year (Feb 012-Jan013)1’st year (Feb 011-Jan 012)

400

350

300

250

200

150

100

50

0

Figure 3. Four ANC visit status of Five HFMSP implemented HFs

157137

129

43 37 7025 40 44

16 2968

28 3746

269280

357

Thada Siddhara Narapani TotalSuwarnakhalPokharathok


Apart from planning and implementation activities, the HFOMCs have made great advances in their ability to monitor and supervise health programs. HFOMCs have developed a system for regular supervision through provision of supervision schedules with division of roles and responsibilities for health facility, EPI clinics, PHC-ORCs and other national health programs and campaigns, by using the supervision checklist included in the training manual. The committees have found the supervision system very effective in identifying gaps. Committees present the gaps identifi ed during supervision in their monthly meetings and solve them on a priority basis. Some examples are: after supervision, committees arranged for curtains at PHC-ORCs to maintain privacy for antenatal checkups, procured furniture for the waiting area of ORCs, installed racks in the storeroom, renovated staff quarters, and changed PHC-ORC sites. They also found health workers motivated and focused on providing quality care after supervision.

“We realized the importance of supervision during fi rst follow up review workshop. During the workshop, we developed a supervision schedule and implemented it. We found it very useful. Problems along with their causes are better identifi ed through observation, which also gives us the impetus to solve it as early as possible. At present we table most of our agenda during our meeting from the fi ndings of supervision visits.”

-Member Secretary, Pokharathok

3.5 Resource MobilizationThe HFMSP approach empowers committees to identify and mobilize community resources for strengthening health programs and health services. Considerable improvement was observed in HFOMCs’ ability to generate and utilize resources, both cash and in kind. Resources were generated by coordinating with DHO, DDC, VDCs, local forest users group, community groups, community leaders, and local NGOs, the major source being the VDCs. All HFOMCs were able to allocate resources from their VDC for health facility management and the trend is increasing (table 6).

Table 6: Resources generated by HFOMC

Health facilityCash support from VDC

2010/2011 2011/2012

Thada 1,00,000 3,00,000

Siddhara 1,25,000 2,55,000

Subarnakhal 1,17,000 1,65,000

Pokharathok 151,000 2,56,000

Narapani 71,600 87,000

TotalRs.5,64,600

(about USD 6,000)Rs. 10,63,000

(about USD 11,400)

Thada


Siddhara Narapani TotalSuwarnakhalPokharathok

250

200

150

100

50

0

Thada


Siddhara Narapani TotalSuwarnakhalPokharathok

250

200

150

100

50

0

Figure 4. Health Facility Delivery status of Five HFMSP implemented HFs

50 51 49 55

2034

0 0 1 34

24

2

89

127

103

167

239


Some HFs have started their own income generating activities with a view to become independent. Thada and Pokharathok HFOMC decided to collect user fees and developed a scheme for OPD charges and police cases (for alcohol testing). It is also providing extended services like 24 hour emergency service using a user fee scheme. This has helped in generating resources for the health facility as well increasing access to services. HFOMCs have also used HF property for generating resources like renting out the canteen (Thada), HF blocks (Subarnakhal), and selling unused HF property (e.g. fi rewood). Subarnakhal HFOMC has planned for sustainable resource generation activities like planting cash crops (banana and coffee plants). The cash generated by HFOMCs is mainly used to recruit local staff, as well as activities to motivate HWs including FCHVs, renovation of infrastructure, and purchase of essential medicines and equipment. HFOMCs have managed accounts in the names of the HFOMC secretary and chairperson, and deposit all HF incomes into the account. Apart from cash support, HFOMCs have also received in-kind support like construction of water supply tanks, latrines, placenta pits, buildings, land donations, and house rent.

“At present the HFOMC includes the VDC chairperson as HFOMC secretary. Other HFOMC members like dalit, female, social worker, and school representative are also under the network of VDC and play a major role in budget distribution during VDC council. The needs of HFs are jointly prioritized during the meeting with active participation of all members. The committee members play an active role in generating funds for the HF. Apart from this, the forest users group of Siddhara has been helping the HF. The community group of Narapani has bought 3 ropani land worth NRs, 3 lacs”.

- District Public Health Offi cer

3.6 Essential Medicine and EquipmentThe HFMSP program entitles HFOMCs with the role of managing essential medicines and equipment for smooth functioning of the health facilities. There have been signifi cant changes in management of medicine and equipment since the project began. Through regular supervision and interaction with HWs at PHC-ORCs, EPI-clinics and HFs, they have been able to identify the gaps hindering smooth service delivery. The identifi ed gaps are solved through discussion at their regular meetings. HFOMCs have provided racks for storing drugs, weighing scales, delivery beds, hospital beds, steel cupboards, solar arrays for light, vacuum delivery sets, room heaters, bed sheets, and wrapper delivery sets. In addition, HFOMCs have coordinated with DHO for regular supply of essential medicine and equipment for their HFs, especially for their newly established static clinic. They have managed to ensure a regular supply of drugs from the DHO for the static clinic, at the same level of supply as an SHP. The DHO has committed to provide essential medicine and equipment for smooth delivery of service.

“We are happy with HFOMCs work of resuming PHC-ORCs, establishment of static clinics and birthing centers. We encourage them for new innovations and have committed to provide essential medicines and equipment for smooth delivery of services”

- District Health Offi cer, Arghakhanchi

The Siddhara HFOMC also identifi ed the potential disease outbreaks that usually occur during rainy season and have purchased extra medicines for their appropriate and timely management.

In depth interviews with the HFOMC chairperson and secretary revealed that shortages of medicines and equipment have not hampered effective delivery of service. HFOMCs have been responsive to the gaps identifi ed by HWs and they try to manage it as soon as possible. This has resulted in the development of trust and good relationships among HFOMC members and HWs. The support thus received has been motivating HWs for smooth service delivery.


3.7 Human Resources ManagementHuman resources management is one of the crucial parts of a health care delivery system. The HFOMCs have internalized the concept and have played an active role in human resources management. As such, HFOMCs have been actively involved in recruiting the required staff. They have developed a system to coordinate with the DHO for timely fulfi llment of vacant posts well before potential transfer or departure of current staff. HFOMC’s have also used a signifi cant portion of the newly generated resources in recruiting human resources. Table 7 illustrates the details of the HFOMCs’ efforts to recruit staff at a local level.

Table 7 Status of human resources recruitment by HFOMCs

Health facility Staffs recruited Source

Thada1 ANM, 2 AHW, 1 Lab Assistant (La), 1 Offi ce Assistant (OA)

ANM - DHO,

Siddhara 1 ANM, 2 AHW ANM - DHO, AHW - Committee

Narapani 1 ANM, 1 OA Committee

Subarnakhal 1 ANM, 1 OA ANM - DHO, OA - Committee

Pokharathok 2 ANM, 1 Ahw, 1 OA ANM - DHO, AHW & OA - Committee

Total 6 ANM, 5 AHW, 1 LA, 4 OARs. 10,63,000(About USD 11,400)

Though HFOMCs have made great advances in recruiting human resources at the local level, retention of locally hired staff has remained a major challenge. All HFOMCs have to depend on VDC grants for providing salaries to locally hired staff; therefore, their continuation depends on the availability of funds and VDC priorities. The lack of a regular funding source was the main challenge for continuation. In order to overcome the challenges, HFOMC began exploring options for local support, such as NGOs, Forest users group, community groups, and leaders, but none of them were adequate.

HFOMCs of Siddhara and Pokharathok have developed systems of performance appraisal and motivational activities based on appraisal to encourage HWs and FCHVs to provide quality services. The motivational activities included cash prizes, certifi cates, and dosalla/swal. HFOMCs have also been regularly encouraging HWs by providing fi nancial incentives for HF delivery, conducting ORC clinics, providing blouses and dhotis to offi ce assistants, responding in a timely manner to problems shared by HWs, and verbal encouragement.

Similarly, HFOMCs have been motivating FCHVs to attend their regular monthly meetings. FCHVs are provided an incentive ranging from NRs.100 to 200 for attending each meeting. FCHVs of Siddhara and Subarnakhal are also encouraged to bring women to the clinic for attended delivery with incentives. The provision of incentives was effective, so for further encouragement, the incentive was increased to NRs.200 per women attended at the HF. FCHVs of Siddhara were also provided with motivational and educational tour to other district for encouragement.

“After establishment of the birthing center, with a view to increase HF delivery, fi rst we provided incentive of Rs 100/FCHV/attendance to deliver women at HF. We found it effective and realized that increase in HF delivery also means increase in resources to HF, as government through HF is provided Rs 1000 per HF delivery….so for further encouragement we increase the amount to Rs 200.”



Picture 4: Static clinic at Lamidamar

3.8 Physical InfrastructureAvailability of basic infrastructure is indispensable for smooth functioning of health service delivery and serves as a strong basis for smooth implementation of the health care system. It is also essential for improving quality of services, safety of staff and patients, and to some extent works as a motivational factor for health workers. HFOMCs are obliged to maintain the basic infrastructure of the HFs. As such, they have made noteworthy improvements in the development, expansion, and maintenance of physical infrastructure at their HFs.

HFOMCs have developed a feeling of ownership and belonging with their HFs. As a result, they perceive protection of HF property as their responsibility. The perceived needs for development and maintenance of infrastructure are usually identifi ed during meetings and through supervision of facilities and clinics. HFOMCs have been very responsive in managing physical infrastructure that has been identifi ed as having needs. Some of the HFOMCs’ activities for infrastructure development and maintenance are briefl y described in table 8 below.

Table 8 HFOMC’s effort for Infrastructure Development and Maintenance

Health facility

Thada

Siddhara

Narapani

Subarnakhal

Pokharathok

Infrastructure development and maintenance

Solar array for light; placenta pit; heater for delivery room; maintenance of lodgings

Furniture for birthing center and maternity waiting home; water tank for HF; constructed building for static clinic

Purchased land for static clinic; water tap inside HF; made a waiting room in the HF; bought gas set for sterilization; provided table, bed, and curtains in each PHC-ORC clinic

New building for HF is under progress; purchased 14 stretchers; managed curtains in ANC, delivery, and offi ce rooms; purchased bed, pillow, and bed sheets; construction of waiting room area

Cleaning of HF and surroundings; provided chairs, racks, and curtain to static clinic; constructed one room and waiting area for static clinic; provided racks for storeroom; partition and maintenance of lodging; solar arrays for birthing center


3.9 Good GovernanceGood governance incorporates elements such as fi nancial (internal and external) and social audits of the health facility, display of the citizen charter, and social inclusion in health services. Audits (fi nancial and social) are important to understand the facility’s fi nancial status and improve accountability and transparency towards the community.

HFOMCs were encouraged to perform social audits during the second follow up review, however, the practice of auditing was not found to be widely used across the intervention area. This was due to a change in an act, which does not allow the HFOMC alone to conduct a social audit. It involves a lengthy process and can only be changed at the district level. The act requires formation of district audit committee under the chair of the Local Development Offi cer. The district audit committee then selects a local NGO to perform the social audit through competition. The selected NGO performs the social audit in the health facility, coordinating with stakeholders. Only Pokharathok had once performed a formal internal audit, which they found to be very useful.

The committees are interested in the accountability and transparency of the HFs, however they feel incapable to perform audits as they lack basic accounting skills. Therefore, they have developed the practice of presenting income and expenditure reports in their meetings to be aware of fi nancial status.

Display of the citizen charter was observed in every health facility visited. The annual HFOMC work plan, and listings of HFOMC members’ names and photos were also displayed in every HF.

“The practice of audits is very low across the HFs because knowledge about accounting is essential to perform audits which is not usually found among HFOMC members. An audit was possible only in Pokharathok because one member of committee was former bank staff and he had good knowledge about accounting systems.”

- Research Offi cer, MIRA


4. OPPORTUNITIES FOR SCALING UP AND SUSTAINABILITY The project incorporated a sustainability plan from the planning stage and implemented it accordingly. Representatives from DHO, DDC, and Women Development Organization were trained as district trainers so that the HFMSP program could receive continuous support.

KIIs with the DHOr and PHOr revealed that DHO has acknowledged the roles of HFOMCs in strengthening health facility management and health programs at the local level. DHO has perceived the need to sustain the achievements and believes they have the ability to maintain the changes as the DHO oversees the district trainers. The DHOs also believes the program will sustain because he feels that the HFOMCs of Arghakhanchi have entered an era of social momentum. By seeing the HFOMCs’ achievements in the intervention area, HFOMCs in non-intervention areas have also started strengthening health facility management and health programs on their own. Furthermore, the DHO has been exploring resources for sustaining the changes and to further scale up the program in all VDCs of the district.

“The follow up review developed impetus for doing audit as it provided us knowledge about it’s importance and process of auditing…however the process it stated was tedious and we could not follow it accordingly. Our one member is former bank staff, with his help we were able to perform audit. We disseminated the fi ndings among the committee, staff, FCHVs, and representatives of “wada nagarik manch (ward citizens forum)”…. It was very helpful…we were aware about our fi nancial status; it helps prevents corruption. Most valuable is that the community developed faith towards the HF and services provided.”

- Member Secretary, Pokharathok

KIIs and FGDs revealed that HFOMC members were aware of their roles and responsibilities. Many HFOMC members commented on the value of being volunteers. They felt they had learned a lot through training and believed that training was the key factor to their achievement and motivation.

In general, there are several potential resources for sustaining the HFOMCs’ achievement. The key seems to lie with the foundation of capable HFOMCs that have internalized feelings of ownership and belonging towards their HFs. Once HFOMCs are aware of their needs and have the ability to document and plan for their needs, they can then approach resources to fund them, either within the government structure or outside of it. Many are also doing income generating activities and lobbying for more resources within their communities.

“I think the HFOMC program of Arghakhanchi will show good achievements in the future. GoN should plan to make Arghakhanchi a model district for HFMSP. It is very inspiring that HFOMCs of electoral constituency one (EC-1) have learned by seeing HFOMCs’ achievements in EC-2; they have started taking ownership of their HFs. Further, we are planning to request that new projects include HFMSP in their activities. We have coordinated with DDC to ensure new NGOs having health programs coordinate with DHO, so that we can request that they include this component. In the future we are planning to launch HFMSP in all HFs of EC-2 and extend it to EC-1 in a phased manner. It is not diffi cult for us to do so as we already have suffi cient district trainers, all we need is material support.”

- District Health Offi cer


5. LESSONS LEARNED

The commitment of the District Health Offi ce (DHO) team, especially the DHOr and Health Facility in-charge, is crucial to make HFMSP successful. Their success largely depends on the extent to which the district provides regular supervision support, delegates responsibility to them, and provides supports to materialize HFOMCs’ innovative ideas and action plans.

The HFMSP training, particularly the sections on the decentralization process, importance of HFMSP, Healthy Life “our health our responsibility”, and three year vision, help HFOMC members to create a sense of ownership and belonging towards their HFs.

Self-assessment of HFOMC capacity helps HFOMC members to know and understand their existing capacity and gaps, particularly in the areas of organizational capacity, HF management, and health services. The subsequent action plan should be in accord with identifi ed and prioritized problems and gaps and feasibility of addressing them, rather than adhoc basis.

Even though this capacity building process is supposed to shift responsibility for health management to the community level and create a bottom up approach, in actuality it is a long involved process and initially requires more support from the DHO. This means that once HFOMCs have been trained, they still need on-going supervision support from the DHO in order to use their knowledge and skills and sustain their motivation.

Understanding of and support for the community capacity building process by the district health offi ce is key to the success of these interventions. For example, the commitment expressed by the DHOr to manage essential medicines and equipment for the birthing centers and static clinics motivated the HFOMCs to establish additional birthing centers and static clinics.

Capacity building should not be equated with training. It should be understood as a process. The fi ndings of KIIs and FGDs revealed that it is very important to regularly follow up on the HFOMC monthly meetings. All stakeholders should internalize it as a continuous process and not a onetime event. It requires continuous support, follow up, refresher, and promotional activities.

As inclusive an HFOMC committee as possible should be sought, including geographical representation, in order to better identify health problems, generate resources, and maintain a spirit of active voluntarism and group empowerment.

Regular coaching of Dalit and female HFOMC members on their roles and responsibilities is needed to increase their participation in the HFOMC meetings and community awareness activities in their communities.

Big and long term support like building construction of health facilities would be motivating factors for HFOMC and HF staffs for further works and improvements.

Coordinating with the Forest Users’ committee to support the HF could be very fruitful in those areas where they have forestry as a good income source (e.g. Siddhara).

Taking a step-by-step approach, moving from comparatively simple activities to more complex ones, is an effective approach to slowly build HFOMC capacity over time. This approach helps create milestones to mark and celebrate small, incremental achievements.


6. CHALLENGES and CONSTRAINTS

KIIs with DHO, PHO, research offi cer, and health right district team revealed that HFOMCs are heavily reliant on VDC resources for gearing up their activities. Though they have been initiating their small income generating activities, thus far they are not adequate. Lack of a regular income source is the major constraint for sustaining HFOMCs’ efforts.

Most of the interviewed members emphasized that the visits by district supervisors are very necessary to update their technical knowledge and boost their work effi ciency and morale. The challenge is how to ensure that this important task is conducted in a sustainable way.


7. RECOMMENDATIONS

DHO should ensure the continuation of regular monitoring and supervision visits in order to encourage and sustain the HFOMC initiatives.

Provide opportunities for HFOMC members to update and enhance their knowledge about their roles and responsibilities, through regular refresher trainings, workshops, and exposure visits.

A focal person at DHO should be designated with the overall responsibility of managing HFMSP.

MOHP should allocate matching funds equivalent with VDC support, as well as HFOMCs themselves generating regular and sustainable income, to sustain the changes.

Additional administrative and management training like audit and social audit skills is essential to make the HFOMC capable in fi nancial management and transparency.

A mechanism should be sought for continuous encouragement of dalit and female participation.


REFERENCES

1. Nepal Family Health Program II. Health Facility Management Strengthening Program, Journal Article. 2012 [cited 17]; Available from: www.nfhp.org.np.

2. Nepal Family Health Program. Review of activities undertaken by NFHP and its partners to strengthen the partnership between Community and Health Facilities. 2007.

3. AKHS Kenya Community Health Department. Policy Brief No.4 Best Practices in Community-Based Health Initiatives.

4. Nepal Family Health Program II. Health Facility Management Strengthening Program, Trainers Guide. June 2012 [cited 17]; Available from: www.nfhp.org.np.

5. G. Gagan. Capacity building is not an event but a process: lesson from health sector decentralization of Nepal. Nepal Medical College Journal 2009;11(3):2.

6. Government of Nepal Ministry of Health and Population Department of Health Services National Health Training Center. Trainers guide, Health Facility Operation Management Committee Capacity Building Training2067.

STRENGTHENING HEALTH FACILITY OPERATION AND MANAGEMENT COMMITTEES TO IMPROVE MATERNAL AND NEWBORN HEALTH STATUS IN PERIPHERAL HEALTH FACILITIES OF ARGHAKHANCHI, NEPALStudy Team membersChandra Rai 1

Hari Rana 2

Mohan Paudel 3

Dr. Dharma Shrna Manandhar 4

Jyoti Shrestha 5

Dhruba Adhikari 6

August 2013

1 Project Director/Country Representative, HealthRight International2 Training and Operation Coordinator, HealthRight International3 Monitoring and Evaluation Coordinator, HealthRight International4 President, Mother and Infant Research Activities (MIRA) 5 Research Coordinator, Mother and Infant Research Activities (MIRA)6 Research Offi cer, Mother and Infant Research Activities (MIRA)

This publication is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of the Partnership for Maternal and Neonatal Health Project, HealthRight International in partnership with Mother and Infant Research Activities (MIRA), and do not necessarily refl ect the views of USAID or the United States Government.

STRENGTHENING HEALTH FACILITY OPERATION AND MANAGEMENT COMMITTEES TO IMPROVE MATERNAL

AND NEWBORN HEALTH STATUS IN

PERIPHERAL HEALTH FACILITIES OF ARGHAKHANCHI, NEPAL

Partnership for Maternal and Neonatal Health an Innovation of the Child Survival and Health Grants Program

hri report 2_hfmsp

Documents