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The power of a systemic approach towards Universal Health Coverage (UHC) in Nepal

Nepal team discussing way forward at Tokyo L4UHC module

How the Leadership for UHC (L4UHC) Programme helped improve drug availability in Nepal

The team of Nepalese leaders participating in the L4UHC programme tackled one of the country’s major health-care bottlenecks: the lack of essential drugs in primary health facilities. The story of this initiative illustrates that advancing toward UHC is not a simple and straight path, but committed leadership, adaptability and perseverance can go a long way towards getting there.

Nepal is one of seven countries participating in the 2016-17 cycle of the P4H Network’s Leadership for Universal Health Coverage (L4UHC) programme. In three face-to-face modules participants interacted with one another and with expert facilitators, and discovered the UHC experience of their host countries. Once back home, each country team applied these lessons in leadership to develop a 100-day Collective Action Initiative as a small, but practical step on the road to Universal Health Coverage. Nepal’s team developed a multilevel initiative – on ministry level and in three districts – whose results could mean a breakthrough in improving availability of essential drugs, which are provided free of cost in public primary health facilities. What was accomplished and how?

Deciding which challenge to tackle

Shortly after the first module in Manila, a diverse group of 14 motivated individuals, from central level, district level and civil society, met in Kathmandu to share the L4UHC experience and brainstorm on what they could do to promote UHC in their country in the context of Nepal’s ongoing reforms – transition to a federal system and the introduction of Social Health Insurance. Their team leader, Dr Lohani, was himself head of the new insurance scheme.

The lack of free essential drugs stood out as a major national issue compromising the government’s promise to provide free basic health care: a 2015 survey found less than 5% availability of free essential drugs in public health facilities. This obliges patients either to turn to the private sector with high out-of-pocket payments, or in the case of poorer families, to forego treatment altogether. 

The Nepalese government is trying to reduce out-of-pocket payments by progressively introducing Social Health Insurance in selected districts, where in future poor households’ membership is to be subsidised. Social Health Insurance covers diagnostic tests at primary health centres and both in- and out-patient care in hospitals, including a list of additional drugs which are not procured and supplied by the Ministry. These health-insurance listed drugs are to be procured by the facilities themselves from the private sector, where they are readily available. 

Enrolment in health insurance is, however, hampered by the low credibility of the public health services, eroded by the lack of essential drugs.

To rehabilitate citizens’ access to basic health care and build trust in the public sector, the team concluded that they would focus their Collective Action Initiative on promoting availability of drugs in the public sector.

Planning the Collective Action Initiative in a systemic way

Child receiving polio vaccination
Child receiving polio vaccination

In developing their vision, the team reflected on the root causes for the lack of drugs in the public health services. They recognised that the bottleneck was due to a combination of factors on different levels. Drug procurement on central and district level is hampered by low local production, difficulties in international tendering and delay in budget release. Another problem is not ordering needed drugs in time due to inefficient stock-keeping and incomplete filling out of order forms in Nepal’s Logistics Management Information System. On health facility level, drug management also suffers from irrational prescription practices. While hospitals can run their own pharmacy, no such provision exists for primary health centres.

Being composed half and half of leaders from central level and from outside the capital, the L4UHC team felt it was in a unique position to tackle these multiple challenges from different angles. They decided on a composite Collective Action Initiative, operating on central level and in three districts, each with its own sub-team interacting in a complementary way with the three others.

The central level team would focus on setting up the preconditions for decentralised drug procurement. The three district teams would work toward improved availability of free essential drugs in the health facilities by respectively tackling the problems of irrational drug prescription, stock management, and proper ordering. The Minister of Health officially launched Nepal’s L4UHC Collective Action Initiative in January 2017.

Tackling drug shortages at central and district level with the right team

As the presence of drugs in public facilities was expected to positively impact enrolment in Social Health Insurance, for their operational-level activities the team targeted three districts that were piloting this reform. Each district developed its own approach to improve drug availability in primary health centres, focusing on different aspects of this challenge:

  • Achham District surveyed prescription practices and carried out trainings to raise staff and community awareness about irrational drug prescription.
  • Ilam District focused on enforcing standards of completeness and punctuality in using the Logistic Management Information System for re-ordering essential drugs.
  • Palpa District laid emphasis on complete and frequent filling out of drug stock reports, and started with weekly submission of these reports. When this turned out to be an excessive administrative burden, the rhythm was changed to two-weekly reporting.

Adjustments were made in the team composition to reflect the geographical (3 districts) and thematic focus (drug availability and logistics) of the initiative. The three district sub-teams were enlarged beyond the District Health Officer to include other members of the District Health Management Team, particularly those responsible for drugs and logistics, as well as community representatives. Ministry of Finance representatives were active participants in the three L4UHC modules. Strategic additions were the director of the Health Ministry’s Logistics Management Division, responsible for procuring and supplying the essential drugs throughout the nation, and a representative from a Regional Health Directorate – particularly relevant in the context of Nepal’s federalisation reform.

The Nepal team remained eager to reinforce the complementary relationship between Social Health Insurance and free basic health care, and since the insurance reform was high on the political agenda, this also leveraged ministry support for the targeted districts and the Collective Action Initiative.

On central level the team was likewise flexible in its approach. Recognising that major reforms in procurement and supply chain management were beyond its capacities, the team worked toward reform of the country’s Pharmacy Guidelines, and advocated with the ministry and drug manufacturers for publishing the price of drugs, so that districts in particular could directly purchase drugs from the manufacturer, saving time and money by cutting out the drug distributors.

What was achieved?

At a local pharmacy
At a local pharmacy

At central level, dialogue and advocacy with high-level decision-makers were key to creating a steering committee for UHC, in which the L4UHC country team plays an active role, and to amending the Pharmacy Guidelines to allow primary health centres to run their own Social Health Insurance pharmacies – a disposition that the three districts immediately applied in seven primary health centres.

The team likewise persuaded the Minister of Health to make available on request additional budgets enabling districts to buy essential drugs directly from suppliers. Furthermore, the team, along with the ministry’s Department of Drug Administration, advocated with the Nepali drug manufacturers to publish their price list. This will ease the procurement process by allowing central-level and district teams to buy drugs for up to 20,000 $US directly without a tender process, whereas previously it was only 5000 $US.

At the district level, health facilities are increasingly able to ensure improved availability of free essential drugs year-round thanks to new instructions, appropriate training, close monitoring and supportive supervision. The main changes and their results include:

  • In Palpa District, insisting on prompt and complete filling out of stock level reports has increased free essential drug stock in the district hospital and two primary health centres from 40% to 70.3%.
  • In Ilam District, strengthening the use of the Logistics Management Information System through timely and complete reporting has helped to reduce stock-outs in four primary health centres.
  • In Achham District, surveys and trainings have reduced irrational prescription from 45% to 20% in the district hospital and two primary health centres.

The Nepal L4UHC team advanced cautiously, but steadily. As a member explains, ‘Small steps led to the goal and brought larger impact.‘

Insights from Nepal’s Collective Action Initiative

A motivating objective will garner support. Availability of free essential drugs is a topic so fundamental to Nepal’s health system that it mobilises multiple stakeholders.

Target the highest-level decision-makers to maximise impact. The central level L4UHC leaders were well positioned to enlist the Health Minister and Secretary in favour of their Collective Action Initiative. The 100-day initiative, which promised quick results, particularly appealed to the Minister, who had been appointed for just nine months, and he even extended the approach, asking all divisions and hospitals to develop 100-day plans. The Minister’s support gave the initiative high credibility, facilitating the team’s contacts with other top-level ministry officials and with the drug manufacturers.

See the big picture – take a systemic view and approachRather than treating the unavailability of free essential drugs as an isolated problem, the team tackled it in its context, including the issue of free and Social Health Insurance drugs being dispensed in the same health facility under two different regimes. This led the team to develop a constellation of complementary activities on central and operational level.

How did the L4UHC programme contribute?

The L4UHC programme is seen by the Nepal team as a game changer: it brought together people who did not previously work with one another to focus on a common goal. Strong central-level decision-makers were balanced with dynamic district stakeholders, as well as civil society representatives whose contribution is appreciated as ‘bringing spice’ into the reflections.

In the modules, the Nepal team appreciated the hands-on experience, exchanging with the other country teams and discovering the UHC challenges of the host countries. They also appreciated learning about systems thinking – understanding UHC from a broader perspective, examining linkages and interactions between different stakeholders, observing dynamics at play in their country, discovering underlying structures and patterns (including mental models and perceptions) and challenging their approach to UHC to champion interventions that may be seen as unpopular. In this complexity, it became clear to them that to advance UHC they need not only technical solutions but ‘adaptive’ skills – they were emboldened to learn new ways of doing things, to change their attitudes, values and norms and adopt an experimental mind-set. The Nepal team was motivated to work for change – even if that meant not to focus on their individual priorities. For instance, although their team leader was head of Social Health Insurance, the L4UHC group took a broader perspective, analysing the problems and solutions in the context of the overall health system. This led them to recognise the lack of free essential drugs as an immediate problem hindering both roll-out of health insurance and functioning of public health services.

The support of Nepal’s GIZ Health Programme and the World Bank was crucial for the country team’s success. GIZ provided both technical and logistic support for their participation in the L4UHC modules and for organisation of their Collective Action Initiative. The World Bank hired an independent, non-technical ‘coach’ who accompanied the country team from the start, appreciated as highly useful in keeping the team ‘on track’ while pursuing their initiative.

The way forward for Nepal’s L4UHC team

After the successful conclusion of their Collective Action Initiative, the L4UHC team is pursuing next steps on Nepal’s road to UHC with the same drive. In the three districts the effective new drug management habits are being maintained, and they are now planned to be further extended to the level of health posts, reaching an even broader segment of the population. After endorsement of the revised pharmacy guideline, a number of primary care facilities outside the three districts have started to operate their own pharmacies.

On the central level, the team is continuing discussions to identify long-term solutions for improving drug availability, and pursuing its advocacy efforts for publishing drug prices so as to avoid the cumbersome tender procedures.

The unique set of methods used under L4UHC for diagnosing problems and dealing with them is applicable in any situation. The team’s oft-repeated motto is: ‘If there is a will, nothing is impossible.’

Juliette Papy & Mary White Kaba, November 2017

© GIZ Nepal
© GIZ/Thomas Kelly
© GIZ/Manuel Nagel
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