Citation: NHSSP Lessons Learned and Sustainability Review (2010-15), Aryal and Saville, October 2015

This report has been funded by UKaid from the UK Government’s Department for International Development (DFID); however the views expressed do not necessarily reflect the UK Government’s official policies.

This report is submitted in compliance with NHSSP’s Payment Deliverable M9 ‘Sustainability Review and Exit Strategy’.

Acknowledgements

We would like to thank those who gave time from their busy schedules to participate in this assessment including from the Ministry of Health and Planning, Department of Health Services, development partners, including DFID advisors and the NHSSP advisors. Without the willingness of these officials to express their opinions openly and objectively, this report would not have been possible.We offer our sincere appreciation.

Amit Aryal and Esther Saville

Kathmandu

October, 2015

EXECUTIVE SUMMARY
NHSSP LESSON LEARNED AND SUSTAINABILITY REVIEW

Introduction

The second National Health Sector Programme (NHSP-2, 2010 - 2015) aimed to improve the use of essential health care and other health services, especially by women and poor and excluded people. Technical assistance (TA) to NHSP-2 is being provided from pooled external development partner (Department for International Development (DFID), World Bank, Australian Aid [DFAT], KfW and GAVI)support through the Nepal Health Sector Support Programme (NHSSP). NHSSP is a five and a half year programme in two phases (Phase 1: Sept 2010 to 2013 andPhase 2: 2013 - 2015) funded by DFID and managed and implemented by Options Consultancy Services Ltd and partners, Oxford Policy Management (OPM) and Crown Agents. NHSSP is providing technical assistance and capacity building support to help the Ministry of Health and Population (MoHP) deliver against the NHSP-2 Results Framework.NHSSP has provided support across the following thematic areas:

-health policy and planning; / -procurement and infrastructure;
-health financing (HF); / -essential health care services (EHCS);
-public financial management (PFM); / -gender equalitysocial inclusion (GESI);
-monitoring and evaluation (M&E);
-human resources for health (HRH); / -preparations for HSS 2015-2020[1]
-support to five regional directorates.

Purpose of review

This review aimed to assess overall progress of NHSSP against programme logframes, to identify areas requiring additional support and to describe underlying processes and lessons learned in order to inform the future deployment of TA in MoHP/Dept. of Health Services (DoHS). The assessment includes a quantitative review of progress against targets in the results frameworks, a review of programme documentation as well interviews with a wide range of sector stakeholders (Government of Nepal [GoN] officials, NHSSP Advisers, key pool partners and other development partners [DPs]).

Background

DFID Nepal has been central to health sector development and achievements. DFID is the largest bilateral donor to provide financial assistance to the government’s health budget and UK funds account for approximately 8% of the total health budget. The DFID Terms of Reference (ToR) for the TA to NHSP-2stated that it should “demonstrate credible evidence of knowledge transfer and develop capacity of MoHP on a longer term basis and with broader scope to deliver NHSP 2 results framework and beyond”. DFID’s TA provides an embedded team of mainly Nepali advisers to the MoHP and DoHS to drive best practice and reform in the sector.In Phase 2, the TA also included a flexible fund - the Technical Assistance Response Fund (TARF) - that agencies under the Ministry of Health and Population (MoHP) can use to fund work that is not funded in their annual work plans and budgets (AWPBs).

Based on the results from capacity assessments undertaken by NHSSP, a capacity enhancement[2] strategy was developed with MoHP and development partners to guide and monitor the TA support provided to the sector.NHSSP agreed with MoHP an organisational development approach that placed emphasis on the ‘systems, structures and roles’ of Potter and Brough’s conceptual framework (2004).Ownership by the GoN was identified as a critical factor in sustainable capacity enhancement whereby TA respects and works through existing MoHP governance arrangements and is aligned with existing MoHP policies, strategies and operations.

Contribution of NHSSP TA to NHSP-2

There has been considerable progress across key areas of NHSP-2 as a result of the contribution made by DFID, and, more specifically, as a result of the TA programme. As the DFID annual review stated in 2014 ‘It is rare to find substantive progress on so many health systems and processes within such a politically and capacity-challenged environment, yet maintaining strong leadership and commitment across partners’. The combined investment in NHSP-2 of sector budget support and an associated embedded technical assistance programme is seen to have resulted in a strengthened health system and to represent good value for money, particularly in terms of longer-term systems building and sustainable service delivery[3].

GoN counterparts and DPs reported that the strength of DFID TA is seen to be in core systems strengthening, such as PFM and infrastructure, at a central level embedded within GoN. The DFID TA programme has been a critical force in supporting the MoHP to develop new systems and implementation models, in particular in the areas of technical guidelines, strengthened processes and information management systems which in turn drive efficiencies, transparency and accountability, and enhance the ability of MoHP and its partners to take a more strategic and needs-based approach to planning, budgeting and service delivery.

Areas of significant progress as a result of the contribution of NHSSP include:

  • Improved health governance, financial management and transparency through the implementation of the Transaction Accounting and Budget Control System(TABUCS), eAWPB and strengthened audit clearance and internal control systems.These new systems, processes and tools have been embraced and are largely institutionalised across the sector. These enhanced approaches to financial management and expenditure tracking have improved absorptive capacity and thus, in theory, ability to lobby for a greater proportion of GoN budget to be allocated to health.
  • Streamlined health sector infrastructure planning.NHSSP has contributed to the strengthening of infrastructure planning based on catchment populations and geography, reducing ad-hoc planning and resulting in a more rational approach to new construction and facility upgrading. The introduction of a new building works (infrastructure) e-bidding system, with support from NHSSP, is estimated to have reduced the average price of new contracts by 12%, resulting in around £3.4 million savings in the first year following its introduction alone. Sustainability of these developments, in the absence of appropriate counterparts to take this work forward and ensure tools and systems are updated and maintained, is a critical issue.
  • Strengthening of tools and systems for improved transparency of procurement processes.NHSSP TA has made a critical contribution to developing tools (specifications bank, contract management system, web-based e-bidding) and systems (consolidated annual procurement plan, International Competitive Bidding/National Competitive Bidding [ICB/NCB]) to improve procurement but there has been limited partial use of systems/tools and the procurement process is still slow. The support provided by NHSSP on procurement is recognised by the GoN counterparts and other development partners, and, at least in the short term, capacity substitution is required to support Logistics Management Division (LMD) to develop procurement documents until it has appropriate cadres in place with procurement expertise.
  • Strengthening the use of evidence in planning and strategy development for Essential Health Care Services (EHCS) and broader planning processes.Embedded TA is seen by stakeholders to have played a critical role in building capacity (especially in Family Health Division/Child Health Division) to use evidence for policy and planning and for developing context-specific strategies e.g. integrating the Aama programme and 4ANC (ante-natal care, demand-side financing [DSF] and incentive programmes); improving access to speciality care (i.e. caesarean sections) through improved functionality of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) services; addressing overcrowding in referral hospitals; the expansion of new approaches to family planning to reach underserved populations and the use of data for AWPB.
  • Improved implementation of Aama.NHSSP has contributed to improved implementation and governance of the Aama DSF scheme, increasing institutional deliveries across all ethnicities and castes. NHSSP worked closely with FHD to conduct rapid assessments to strengthen governance of Aama and other DSF schemes and developed tools to monitor implementation of Aama funds which are regularly updated and analysed for planning and budgeting at FHD.
  • Gender Equality and Social Inclusion. NHSSP TA has provided a significant contribution to establishing an institutional structure to communicate and support the introduction of GESI into the health system; provision of tools and, capacity enhancement to build skills on concepts, principles and application of GESI guidelines. GESI interventions including Social Service Units (SSUs), One Stop Crisis Management Centres (OCMCs) and social audit have been piloted and scaled-up with support from NHSSP. A multi-sectoral response to Gender Based Violence (GBV) at district level has also been supported by NHSSP.
  • Health policy and planning DFID TA was designed to focus largely at the central level in terms of supporting the GoN with drafting the NHSS (now approved by cabinet), successfully supporting the GoN to lead the Joint Annual Review (JAR) process, preparing a draft of the Public Private Partnership Policy and developing the National Health Policy. NHSSP is also seen by DPs to have strengthened GoN’s leadership of Joint Consultative Meetings (JCMs)/JARs.

Areas of moderate progressas a result of the contribution of NHSSP include:

Human Resources for Health (HRH).Whilst some of the building blocks for strengthening HRH were established with support from NHSSP (HRH Strategic Plan, costed M&E framework, workforce plans and projections, HRH profile, institutional assessment of National Health Training Centre [NHTC]), a lack of political will within Government limited broader HRH reform and substantive improvements to HRH systems and planning. In addition, the failure to pass an Amended Health Services Act until the end of 2013, resulting in a recruitment freeze to sanctioned posts in the health sector, also contributed to limited progress in this area. In response, DFID did not include HRH in the ToR for the second phase of NHSSP except if drawn down through TARF by GoN.

Added contribution of NHSSP TA beyond the logframe

NHSSP’s advisers are recognised by both GoN and DPs across the sector as engaging in activities that go far beyond work plan requirements on a daily basis including responding at short notice to requests, providing high level strategic guidance and taking on additional areas of work. There were also broader operational or organisational shifts in terms of ways of working that are seen to be attributable, at least in part, to NHSSP highlighted by those interviewed for this review. Some examples are:

  • Embedded TA is well positioned to respond to rapidly emerging needs.The post-earthquake response by NHSSP phase 2[4] demonstrates how embedded TA is able to rapidly respond to support the GoN with emerging situations. NHSSP also took on support to the GoN to implement family planning pilots to expand access to remote areas after an earlier DFID contract to a service provider was cancelled and responded to the drive to rationalise the frequency/number of national surveys conducted.
  • NHSSP has strengthened organisational culture and capacity within the MoHP/DoHS for reform. In addition to strengthening the structures, systems, tools and skills that facilitate an improved health system, NHSSP is seen by development partners to have supported a stronger bureaucratic cadre with a desire to drive reform and a broader way of thinking beyond vertical programming.
  • NHSSP has strengthened TA as a ‘process’ within the health sector. Development partners reported that NHSSP has contributed to strengthening the model of delivery of TA across the sector from a discrete activity or output with limited dialogue to an iterative ‘process’ between the GoN and the TA provider(s).
  • NHSSP facilitates effective contributions from other TA actors. NHSSP was seen to provide a welcoming ‘hub’ of knowledge/’a reference point’; skills and experience of the health system and GoN ways of working, and play a critical role in helping to coordinate and encourage partnership and coordinated and collaborative TA.
  • Embedded TA supports GoN to build partnerships with other DPs/NGOs at district level to support scale-up/implementation of GoN strategies.Embedded TA is seen to play a critical role in leveraging support from development partners to implement GoN approaches at district level. The value of having embedded TA within FHD to provide the technical support to guide implementation and to link with the GoN system was recognised by development partners and advisers.
  • NHSSP has supported establishing effective mechanisms and processes for multi-sectoral working.NHSSP has been instrumental in promoting effective multi-sector working on a range of areas of work, most notably in relation to the development of integrated gender based violence (GBV) guidelines.
  • DFID TA has contributed to effective partnership working and a mature SWAp through building and fostering relationships with GoN and development partners.
  • The embedded TA programme has provided DFID with additional influence and is seen to represent value for money.NHSSP providesboth a mechanism to support the GoN in a relatively flexible and supportive manner and a pathway through which DFID has been able to exercise significantly more influence than it might otherwise have done through direct pooled funding to the SWAp alone.

Lessons learned from NHSSP for delivering sustainable TA

Ensure focus of TA deliverables is relevant, appropriate, aligned to GoN priorities and has senior level buy-in:

  • New systems were best embraced or owned by the GoN when developed alongside GoN, aligned to their priorities, and when there was an incentive for those using the system.
  • TA has been most effective at driving technical innovations in terms of systems and tools that enhance working practices and show results.
  • GoN ownership at a senior level helps to drive forward change.

Ensure the delivery model for TA is appropriate

  • Embedded TA is seen as accountable to GoN, which fosters trust and increases the influence of advisers to advocate for sustainable change.
  • Direct sector budget support, flexibility and responsiveness of DFID TA is highly valued by GoN and DPs.
  • The flexibility that the TARF provides is valued by GoN.
  • Appropriate team composition is critical with size, mix of expertise, experience and age across the advisers all impacting the effectiveness of TA delivery.
  • Building and supporting a coherent team of advisers strengthens the TA approach and enables advisors to better navigate formal and informal political structures and institutions.
  • Using evidence to drive policy decisions and strategy development leads to sustainable change.

Work within GoN systems and structures

  • Ensure TA is positioned at an appropriate level within the GoN structure and is aligned to new federal structures as they emerge.
  • Strengthening and working through Technical Working Groups supports consensus, coordination, harmonisation of TA and partnerships resulting in sustainable change.

Work with GoN to ensure systemic barriers are addressed from the outset

  • Agree with the GoN from the outset a detailed capacity enhancement (CE) plan, including GoN commitment to stable posts, and an exit strategy for TA to ensure the system is able to absorb capacity enhancement sufficiently.
  • Working with GoN to identify the correct institutional home is key to effective CE and sustainability.Where an appropriate division is identified to lead, the potential for longer-term sustainability is seen to be greater.
  • Support GoN to issue multi-year contracts, e.g. for NGOs and human resources, to enable scale-up of interventions and service delivery.

Work closely with development partners to create an enabling environment for TA

  • Aid effectiveness and harmonisation across the TA sector needs strengthening to ensure continued GoN receptiveness to TA.

Recommendations for future TA in transition to NHSS

  • Stakeholders see the strength of DFID TA to be at the core systems reform and policy level. Stakeholders recommended that DFID prioritise TA in the areas of: procurement and infrastructure, public financial management and EHCS. These will remain major priorities for the sector with no foreseeable significant technical assistance being provided by other TA agencies in these areas. Other areas of support where DFID TA is seen as important in the next phase include HRH, health policy and planning, M&E and further support to sustain GESI interventions/GBV response.
  • DFID should continue to actively coordinate with other agencies or NGO partners and build upon their respective comparative advantages to ensure that TA inputs are coordinated across partners to support the NHSS (incl. USAID, GIZ, Save the Children).
  • A dual focus on strengthening central systems and supporting districts to ‘build back better’ should be sustained.In view of the transition and recovery from the earthquake as well as the planned move to federalism, it is critical that DFID TA sustains a dual focus on maintaining central level systems support in key areas (infrastructure, procurement, PFM, EHCS) whilst focusing on district level strengthening of health systemsand services and decentralised planning and budgeting.
  • Ensure equitable access to and functionality of quality essential health services.The aspiration to ‘build back better’, supported by DFID’s TA tothe Health Sector Transition and Recovery programme, will support strategic transition to recovery and restoration of systems and contribute to the expanded availability and functionality of essential health services. This will require, for example, TA to work with Government to ensure that infrastructure assessments inform designs and plans that meet short-term emergency needs as well as longer term strategic rebuilding efforts. TA should continue to provide valuable support for the careful sequencing of infrastructure repairs, with procurement, EHCS and financing activities, to ensure that buildings, supplies and services are in place in a coordinated and timely manner.
  • The impact of the federal structure on health service delivery should be taken into account in the design of future TA.Planned transition to a federal state and devolved responsibility for health services could result in deterioration in the quality and scope of service delivery, in particular to the poor and excluded. Continuing to support FHD/Management Division (MD) to improve quality through the scale-up and consolidation of Quality Improvement systems like the Hospital Quality Improvement Process (HQIP) will be critical as will continued support to translate evidence from pilots into strategies and approaches to improve the scope of services and increase access amongst the poor and underserved.
  • Strengthening district planning and implementation systems.TA has a critical role at central and district levels to support the transition to longer-term health systems planning in line with NHSS and federalism and to ensure that all the components of rebuilding and strengthening the health system are delivered with an evidence-based and coordinated approach across partners. Support to district planning and implementation to build back better systems and services and through the strategic prioritisation of health services will provide valuable lessons to inform planning for decentralisation in the move to a federal structure.
  • Federalism provides an opportunity for critical reform in core areas.NHSS and federalism present opportunity for reform of existing systems within the new structure. TA should engage with the ministry on functions and structures and support the process of devolved planning and decision-making. Further TA support to MoHP budget management and delivery is critical to ensure better absorption of current allocations and negotiation for greater investments. Federalism also presents an opportunity for TA to support GoN to lay the foundations for much needed procurement and HR reform to supporttransparent, rational and effective systems.
  • TA has a critical role to play in harmonising social health protection.TA is required to draw lessons from Aama and to contribute learning to develop the capacity of MoHP to consolidate demand side financing schemes under a social health protection framework.

For detailed findings on the contribution of TA, sustainability of progress and further TA needs across NHSSP thematic areas see Table 3 and Annex 4.