Technical Brief - Nepal Family Health Program II

Nepal Family Health Program
Technical Brief #17
Community and Health Facility as Partners
Participatory game for team building among members of
the health facility operation and management committee.
BACKGROUND
The foundation of any effective health program is
engaged members of the community. They are
important as users, in mobilizing local resources, and
reaching out to segments of the population which
have not benefited from existing services.
Communities have a right to quality health care and,
at the same time, a responsibility to support
government efforts in developing more effective
community health services.
The vision of the Government of Nepal (GON) for
health and development focuses on self-reliance,
community participation, and involvement of the
private sector and nongovernmental organizations
(NGOs). In 1999, the government passed the Local
Self-Governance Act, based on which the Ministry of
Health and Population (MOHP) decided to
decentralize health service management to local
bodies. The intention of this initiative was to
encourage local communities to take greater
responsibility in managing local health facilities and
health programs.
Since its beginning in late 2001, the Nepal Family
Health Program (NFHP) has been involved in
strengthening the interface between communities and
health facilities and service providers. This support
has enabled the community to be more involved in
managing their health programs and services and
thus benefit from local health services.
The Nepal Family Health Project, mainly though its
partners, Save the Children, US (SC/US) and CARE-
Nepal, provided support to GoN in the initial formal
hand-over of health facilities to their communities in
its 17 core program districts (CPDs). Nationwide,
this process was conducted in 27 districts and
involved 1433 health facilities. Approximately half
of these (736) were supported by NFHP. Following
this formal process, a three-day capacity assessment
and strengthening training was given to 502 members
of these new Health Facility Operation and
Management Committee (HFOMC). In most of these
(422) support also involved use of the “partner
defined quality” (PDQ) approach. This process
involved assessing quality issues from the
perspective of both health facilities and the
community and then jointly prioritizing and
developing action plans. Through these inputs, NFHP
has sought to empower local communities to manage
health services at the community level and strengthen
the partnership between the community and the HF.
In 2006, NFHP assessed its input in this area over the
first five years of the project and learned key lessons:
• Community members (including HFOMC
members and HF staff) were generally not
sufficiently well informed to take up these new
roles as envisioned by the new government
policy. Lack of clarity on the expected functions,
roles and responsibilities of various players (e.g.,
Village Development Committee (VDC), District
Development Committee (DDC) and District
(Public) Health Office (D(P)HO) resulted in
some confusion.
• Mere ‘hand-over’ of health facilities to local
bodies did not ensure achievement of the
objectives of this initiative. Once HFOMC
members were provided with support, enhancing
knowledge, skills, and motivation, they were able
to manage their HFs more effectively.
• The hand-over process and strengthening
program and other community mobilization
initiatives need to be understood and
implemented as a process not merely as a series
of events.
• Active linkages between DDCs, D(P)HOs, VDCs
and HFOMCs are indispensable for mobilization
of local resources.

• HFOMCs require technical guidance if they are
to focus to improving health (and health programs)
rather than focusing only on developing
physical infrastructure.
• HFMOC need support and confidence-building
to effectively support Dalit and janjatis (highly
marginalized/ disadvantaged peoples) and
women.
• Programs and activities implemented under
different names by different organizations were
working in isolation. Consolidating efforts and
developing an effective common capacity
building package have helped to improve and
streamline services.
To adequately address these issues, more effort is
needed to mobilize community support for health
services and community participation in publicsector
health facilities. Based on lessons learned from
the NFHP study, NFHP further refined its approach
and in the final year has developed a modified
package called Community and Health Facility as
Partners (CHFP) which has been implemented in 8
core program districts.
STRATEGIC APPROACH
Community and Health Facility as Partners
NFHP’s Community and Health Facility as Partners
approach seeks to improve the health of the
community (with special focus on marginalized and
underserved people) by empowering community
members to manage their local HFs and other health
programs. Key features of this approach include:
• Tailoring support that responds to the specific
local situation.
• A focus on social inclusion and good governance.
• Intensive follow-up and monitoring in order to
measure progress and identify opportunities for
improvement.
• A simple, streamlined performance appraisal
system developed for use by HFOMCs, using
simple indicators and scoring system.
• Creating linkages between the DDC, VDC and
HFOMC, which has helped bridge resource gaps
at the local level.
• Dalit/women members are targeted for special
coaching support (see below).
PROCESS
Startup Activities
Eight districts were selected out of NFHP’s 17 core
program districts (CPDs), prioritizing those with
weaker health services performance and lower
human development index status. From each district,
12 to 20 Village Development Committees were
selected for special focus—120 altogether. HFOMCs
in the remaining VDCs continued to receive limited
support.
Once districts and VDCs were selected, all NFHP
field officers and D(P)HO staff were oriented and all
approaches and tools/guidelines were pre-tested
before implementation. Similarly, a central-level
support group consisting of different technical teams
was formed to support program implementation.
District-Level HFOMC Profile
In all program districts, a detailed profile of existing
HFOMCs was prepared to characterize membership,
resource mobilization and organizational capacity.
Two-day Interaction Meetings with HFOMC
A curriculum for a two-day interaction meeting was
developed, based in part on the previous NFHP
approach (HFOMC orientation and strengthening,
PDQ) and in consultation with a wider group of
stakeholders. Two-day meetings were conducted to:
• Inform HFOMC members of their rights and
responsibilities.
• Increase mobilization of local resources in support
of the HF and its health programs.
• Improve social inclusiveness in access to and use
of health services.
Interaction sessions were designed to be very
participatory and responsive to locally identified
needs. Methods used include discussions, meetings,
class room teaching and are tailored to the local
situation.
Technical Support Visits
After the 2-day interaction sessions, NFHP field
officers, together with D(P)HO staff, conducted
technical support visits to observe, coach, and
facilitate meetings of the HFOMC. Community
mobilization activities are observed, findings are
shared with health facility staff, and interaction
meetings reported on in HFOMC meetings and on
progress made against action plans. Similar followup
is done in all VDCs, though less frequently in
non-focus VDCs.

Capacity of Dalit and Women HFOMC Members
Though the current composition of the HFOMC is
intended to be inclusive, dalit and women members
have tended not to actively participate. Therefore,
strengthening the capacity of dalits and women
members is given a high priority through assessment
and coaching.
Community Mobilization Activities
During the 2-day interaction meetings, a detailed
action plan is prepared. NFHP provides technical
support to HFOMC members to help implement their
identified priority activities. They have tended to
focus mostly on increasing use of services by those
who are underserved.
Advocacy Meeting at District Level
Advocacy programs with DDC and VDC secretaries
have been organized semi-annually to orient them on
the CHFP approach and to advocate for resource
mobilization for local health services.
HFOMC members participating in 2-day interaction meeting.
RESULTS
As this revised approach has only been implemented
since October 2006, it is still rather early to
determine impact. However, some key achievements
by NFHP and its partners over the preceding five
years include:
• Technical input was given to HF staff, HFOMC
members, and other members of the community
during the PDQ process and have contributed to
visible improvements in quality of services and
improved skills and competency in service
delivery, planning, monitoring and supervision.
• Health facility staff better understand their own
responsibilities, accountability and the role of
HFOMCs.
• There has been an increased sense of ownership
of HF programs among HFOMC members.
Communities also have frequently been
supportive in improving the physical facilities
of HFs – helping to construct buildings, erect
compound walls, procure furniture and
medicines, make arrangements for water
supply, electrification, etc.
• In a number of HFs, the HFOMC has prepared
a list of poor and marginalized people and has
given authorization for them to receive health
services, including drugs, free of cost.
LESSONS LEARNED
• Local bodies can take longer than anticipated
to pick up all the functions envisioned under
decentralization. To help facilitate this process,
expected roles need to be clearly communicated,
support is needed to build capacity, and the
process must be regularly monitored during the
initial phase. Decentralization needs to be
understood and implemented as an ongoing
process rather than an event.
• Health facilities need on-going support after
decentralization. DDCs, VDCs, and
municipalities generally have not given sufficient
support to health facilities once they have been
handed over to local boards. There is a need to
further develop capacity of these local boards.
• A continuous focus on quality is critical. Most
HFOMC meetings have focused on issues of
drug purchase, infrastructure development and
human resources. Important as these issues may
be, they have overshadowed health programs and
provision of quality health care services.
• Targeted support for marginalized populations
is key. Regular coaching for dalits and
female members on their roles and responsibilities
has been very productive. The scale of
such capacity building measures needs to be
increased.
• Self-assessment by HFOMCs is helpful not
only in helping to orient their work, but also
in building self-efficacy thus promoting longterm
sustainability.
CHALLENGES
• In the current political environment, in which
there is an absence of locally elected bodies,
VDC secretaries have been chairing meetings of
the HFOMC. As they are government officials
who, in many cases, are not fully integrated in
the communities where they are based, this has
undermined local HFOMC members taking a
significant leadership role.

• In the coming year or two, there is a possibility
of revival of local governments and restructuring
of HFOMCs. New members of local government
will need to be orientated.
• There are many stakeholders—governmental and
non-governmental—participating in handover
and in implementing decentralization. These
organizations need to work together coherently
to avoid duplication and confusion.
This technical brief is one of a series seeking to capture key lessons learned from the USAID/ Nepal bilateral
project, the Nepal Family Health Program (367-00-02-00017-00), 2001-2007. The document was produced with
support from the American people through the U.S. Agency for International Development.
The views expressed in this document do not necessarily reflect those of USAID.
The Nepal Family Health Program is implemented by JSI Research & Training Institute, Inc.,
in collaboration with EngenderHealth, JHPIEGO, Johns Hopkins University/ Center for Communication Programs
(JHU/CCP), Save the Children, Nepal Technical Assistance Group (NTAG), Management Support Services (MASS),
Nepal Fertility Care Center (NFCC) and, for a period, CARE and ADRA.