National Health Policy and Plan

Unit II

Kunwar LB

Concept of Health Policy

• Health policy refers to decisions, plans, and actions that are

undertaken to achieve specific health care goals within a

society.

• An explicit health policy can achieve several things: it defines

a vision for the future which in turn helps to establish targets

and points of reference for the short and medium term.

•  It outlines priorities and the expected roles of different

groups; and it builds consensus and informs people.

Health Policy • Health policy is a formal statement or

procedure within institutions (notably government) which defines priorities and the parameters for action in response to health needs, available resources and other political pressures.

• One of the key functions of public health professionals is to influence and shape policy decision at all levels for the benefit of the population.

Health Policy

• Health policy is often considered in a narrow sense, referring specifically to medical care issues and the organization of health care services.

• However, health is influenced by a broad range of policy decisions, not just those in the medical or health field.

• A true health policy should therefore provide a framework for health-promoting actions covering the social, economic, and environmental determinants of health.

Health Policy

• The modern health policy in its broader sense is striving towards a continual process of improving the population health.

• It represents the formal statements or procedures within the government and institutions by which the priorities and action parameters are defined as response to health needs, available resources, and various political pressures.

Evidence-based health policy

• Evidence-based health policy attempts to maximize the use of empirical research, evaluation, and structured analysis as key inputs into the policymaking process.

Component of Health Policy

1. Policy content, 2. Policy process,3. Policy context and4. Policy actors.

Policy content

• Systemic – structure of the health system.• Programmatic – set for interventions and

operational guidelines for service delivery• Organizational - structure of institutions

responsible for policy implementation.• Instrumental - generating information to

enhance the functioning of the health system.

Policy process• Rational model : that the process of policy

formulation is rational & based on correct information.

• Incrementalist model : that the policy process is more incremental, consists of slow bargaining between different interest groups to select priorities

• Mixed scanning model: broad review of the policy field without engaging in the detailed exploration of options as suggested by the rational model.

• Punctuated equilibria model: which has recently been applied to priority setting in the international health policy arena.

Policy context

1. Quality of technical analysis; 2. Amount of political stability and support; 3. Capacity, motivation and support of the

bureaucracy;4. the nature of culture and civil society5. And the influence of international actors.

Policy Process

• Policy Formulation• Policy Implementation• Policy monitoring

Policy Actors

• The role of actors and their power relationships, as policy-making often depends more on political compromise than on rational debate (stakeholder or political mapping can be useful in detailing these power structures, and helps illuminate actors’ agendas).

Policy Cycle

Agenda Setting

Policy Formulation

Policy Legitimation

Policy Implementatio

n

Policy Evaluation

Policy Terminate or

Change

Health policies of Nepal

• First Long Term Health Plan 1975• National Health Policy1991• Second Long Term Health Plan, 1997-2017 • Strategic Analysis to Operationalize SLTHP (2000)• Local Self-Governance Act, 2055 (1999)• Tenth Plan Poverty Reduction Strategic Paper (2002-07)• Three Year Interim Plan (2064/65-2066/67)• Free Health Care policy 2007• National Ayurveda Health Policy 2052(1996)

Health policies of Nepal

National Drug Policy 1995National Medicines Policy 2007Safe Motherhood PolicyNational Policy on Safe birth AttendanceNational Safe Abortion Policy 2003Vital Registration Act 2033National Oral Health PolicyMental Health (Treatment and Protection) Act 2006Policy on Quality Assurance in Health Care Services

2064

Health policies of Nepal• Health Care Technology Policy 2006• Water Resource act 2049• Nepal National Policy on Sanitation• National Policy on Rural Water Supply and Sanitation

2004• Policy on NGO participation in WATSAN Program1996• Natural Disaster Management Act• Natural Calamity (relief) act 1982• National Blood Policy 2050(1993)• National Health Research Policy

National Health Policy

National Health Policy

• The national health policy was adopted in 1991 ( FY 2048 BS)

to bring about improvement in the health status of the people

of Nepal.

• The primary objective of the National Health Policy id to

extend the primary health care system to the rural population

so that the people get benefited from modern medical facilities

and trained health care providers

The National Health policy addresses the following areas.

• Preventive Health services• Promotive Health Services• Basic Primary Health Services• Ayurvedic and Traditional Health Service• Organization and Management• Community Participation in Health service• Human resource for Health development• Resource Mobilization in Health service• Private Non Government Health services and Intersectoral

Coordination• Decentralization and Regionalization• Blood Transfusion Services• Drug Supply

Current Five Year Plan in Health Services

Five year plans of Nepal

• Documented and systematic planning is not available before 1956 in Nepal. After Rana regime, the democratic government started to develop and implement medium term plan obviously for 5 year duration.

Plan Period (in AD)

The Pre plan period 1951 - 1956

First 5 year plan 1956 - 1961

Second 3 year plan 1962 - 1965

Third 5 year plan period 1965 - 1970

Fourth 5 year plan 1970 - 1975

Fifth 5 year plan 1975 - 1980

Sixth 5 year plan 1980 - 1985

Seventh 5 year plan 1985 - 1990

Eight 5 year plan 1992 - 1997

Ninth 5 year plan 1997 - 2002

Tenth 5 year plan 2002 - 2007

Eleventh 3 year interim Plan 2007 - 2010

Twelfth 3 year Interim Plan 2010 -2013

Thirteenth 3 year Interim plan 2013 - 2016

First 5 year plan (1956 – 1961)

• Establishment of Malaria eradication program 1958

• Establishment of MoH in 1956

• Construction of first maternal hospital in 1959

• Production of nurses.

Second 3 year plan (1962 – 1965)

• Small fox survey in 1962

• Leprosy control 1964

• TB control in 1965

• 450 people were vaccinated against smallpox in

Kathmandu

• 3 hospitals and 8 health centers were added.

Third 5 year Plan (1965 – 1970)

• Stress on establishment of vertical projects, i.e

Leprosy eradication projects, smallpox

eradication project 1967, FP/MCH

project1968

• Establishment of Central Health Laboratory in

1967.

Fourth 5 year plan (1970 – 1970)

• Integrated Basic Health service was started in 1971

• Contemplation of First Long Term Health Plan

• Community Health and Integrated Division under MoH was

set up

• Maternal Child Health Programme was initiated around fiscal

year 1973/74

Fifth 5 year plan (1975 – 1980)

The primary health objectives of the fifth plan was to raise life expectancy through reduction in death rates, maintain regional balance in the provision of health services and control population.

• Integration of Vertical programmes in to health infrastructure• Nepal Signed the Alma – Ata declaration in 1978

• Adopted PHC strategy for achieving Health for All 2000

Sixth 5 year plan (1980 – 1985)

Primary objectives of the sixth five year plan incorporated similar health objectives of the fifth plan, including for the reduction of people suffering malnutrition and creation of healthy environment through promotion of clean drinking water and sanitation.

• COMBINA (Child spacing, Oral rehydration, Maternal health, Breast feeding, Immunization, Nutrition) was mooted

• Stressed on increasing food supply and provision of clear drinking water.

Seventh 5 year Plan (1985 – 1990)

• The primary health objectives of the seventh five year

plan was to promote, physical, mental and community

health of general public and to prepare healthy

manpower to provide maximum number of people with

basic health services and to reduce the death rate,

increase longevity through promotional, preventive

and curative health services, population control and

extending maternity and child services.

Cont..

• Increased number of hospitals, hospital beds, health centers,

health posts and Ayurvedic Dispensaries.

• Give emphasis on Basic Minimum Health Need to achieve HFA

by 2000

• National Health Information System has been functioning 1988

• Guidelines was formulated for established Health Post (walking

distance, population, accessibility)

• Five regional health directorates of health services were

established .

Eighth 5 year plan (1992 – 1997)

The primary health objective of the eighth plan was to

increase rural access to basic primary health and

doctor’s service to rural population, effective

implementation of population control through

mother child health and family planning service

and development of specialized services within the

country.

Cont..

• Target of establishing SHP, PHCC, Ayurvedic dispensaries,

reducing TFR, leprosy were set

• Launched polio drop services since 1996/97 for 0-5 years

children

• Implemented DOTS strategy in 10 districts to reduce

morbidity and mortality of TB

• Leprosy Control Programme was expanded nationwide

while target was to expand in 71 districts from 56 districts

• Integration of DPHO and District hospital under DHO

Ninth 5 year Plan (1997 – 2002)

The primary objectives of the ninth five year plan was

to ensure preventive, promotional, curative and

rehabilitating health and family planning services as a

part of human right to bring about a perceivable

improvement in health status

Cont..

• Increased number of SHP and PHCC

• Essential Drug Lists were prepared for SHP, HP,

PHCC AND District hospitals.

• Reproductive Health Clinical Protocol was prepared

• Concept of PPP (Public private partnership) was

emphasized

• Human Organ Transplantation Act 1998 was

prepared.

Tenth 5 year plan (2002 – 2007)

The primary objectives of tenth plan was to increase

services for poor and backward and marginalized

community and people

• It is Nepal’s poverty Reduction Strategy Paper(PRSP)• Following the Local self government Act 1999,

started to handover SHP, HP AND PHCC to local budies

Cont…

• Developed national capacity to produce human resource in health sectors

• Started bottom – up planning• Set the targets and meet most of the targets

Interim plan (2007 – 2010)

Bridge between 10th and 11th plan maximize effort to attainment MDGs

• Provision of free services in peripheral levels• Provision of free obstetrical services..• Aama Surkshya Program

12th third Year Plan (2010 -2013)

• Emphasis on quality health care service.• Increase on access of quality health service.

Strategy• Strengthening the human resource,

construction and reconstruction of health infrastructure.

• For control of Malnutrition, multisectoral nutritional policy has been launched.

For detail follow the page no. 193 to onwards

Overview of Health Planning process in Nepal

Introduction • National Planning Commission (NPC) is the apex body for

formulating development plans and policies of the country

under the directives of the National Development Council

(NDC)

• Planning functions at the central level are widely scattered

over a number of institutions. At least, five

institutions/agencies are directly involved in the planning

process

Cont..1. The Cabinet

2. The National Development Council which is sometimes

referred to as "Development Parliament" (NDC)

3. The National Planning Commission (NPC)

4. Development Ministries, and

5. Departments and the Regional/Zonal Offices of Ministries

Each of these institutions does play a varying role at different

stages of the planning process.

Development plans are prepared for fix period

1. Long term plan (10-20 years)• based on longer-term growth prospects with general

targets based on only rough approximations of the likely supply of, and the demand for, resources

2. Medium term plans• A medium term plan-a five-year plan in the context

of Nepal indicates total investment and investment by sectors for the entire plan period and the targets to be achieved at the end of the plan period

3. Annual Plan

• Operational/ strategic plan

• Effective guides to action, output and expenditures

must be determined for each year.

• Based on medium-term plan objectives and programs

for implementation

National Planning Commission

(Final recommendation for budgetary allocation)

Line agencies/ministries

Recommendation for budget

District Council

Prioritization coordination, integration, fund allocation, forwarding

Ilika Planning workshop

Coordination between projects, integration, and prioritization

Settlement

Need Collection

VDC CouncilVDC Plans, prioritized project, resource allocation

Top- down

Process

Bottom up

process

Ministry of Finance Resource allocation

INGOs/Donor agencies

Resource allocation

Fig: Health Planning Process of Nepal

• DOHS get the budget from MOHP and goes in NPC in first

Kartika than goes to lower health organization.

• current planning system of Nepal is started from SHP by

organizing VDC meeting and detect the required material then

send to PHC/HP and it conduct the same meeting and make

annual plan send to include HP plan and send to the district

level and make annual plans

• This plan has to be approved in the district community meeting

before the plan is sent to region by the end of 30th Falgun.

• Then region collect the report and make annual plan sent to

center on 15th of Baishaka in the one way planning take place

Macro level Planning process of central level planning

• National Planning Commission (NPC) is the apex body for

formulating development plans under the direction of the National

development council

• NPC prepares the draft of Approach Paper for the forthcoming

development plan

• Initially, the main objective and targets are determined for the

plan period

• Financial plan is prepared

• Preparation of sector planning, the principal outputs of sector

planning the sectorial chapter in the five year plan or may be

Interim Plan

Cont..

• Sectorial chapters lay the basic foundation of the plan’s

objectives and sectorial targets

• A draft Approach Paper prepared and presented to the

NDC for suggestions.

• NPC revise the Approach Paper according to the

suggestions given by the NDC

• The detailed plan document is prepared based on the

Approach Paper

Micro level planning process of central level planning

• Basic sectorial planning process is undertaken by the

respective development related ministry based on the plan

document

• NPC’s various sectorial taskforces review the plan and

present sectorial report

• After the preparation of the detailed plan document, it is

put forward to the cabinet for its approval

• The plan is executed after the Cabinet approval

Types of Health Planning

Health Planning

• Health planning is process of deciding in advance what health services are to be delivered in order to achieve the greater health goals.

• Planning in health sectors from DoHS to SHP

Characteristics of Planning

• Planning is a process• Planning is future oriented• Planning is pervasive. It is a function of every manager.

Its nature and scope differ according to the level of managers

• Goal – focused: Planning not only sets goals but also selects actions to achieve them.

• Decision – oriented: planning involves decisions at all level, of management. Decisions in respect of objectives, activities and resources are prime concern of planning.

• Efficiency – Oriented: Planning is directed toward efficiency at all level of management. Efficiency means greater output at lower cost, doing thing right.

TYPES OF HEALTH PLANNING

Health planning includes several specific, often connected,

types of planning:

1. Health services planning

2. Health system planning

3. Health goals planning

4. Population health planning

1. Health Service Planning

• Health services planning relates to the planning in a

specific type of service or sector- maternal health

service delivery for example.

• This type of planning can be undertaken by

government or devolved (delegated) to providers.

• The Task Forces Groups formed by DoHS are a good

example of taking a specific sectoral approach to

service planning.

Cont..

• The Task Forces’ work is a strategic planning

exercise that produced several options for

system design and implementation approaches.

• This planning may be an output of the strategic

directions of the organization, but is usually

considered as program or operational planning.

2. Health System Planning

• In every nation, a recognized goal of government will

form an efficient and well-organized health system.

• The system itself is usually planned at national

government level, and by such Department of health

services. Health “system” implies:

Client access to a range of appropriate, and

appropriately connected/integrated, services

Operational efficiency and a sustainable operation.

Cont..

• A well-organized and functioning system of health services is like the connectivity of the human body system. Both require:

Command centers A supportive contextual infrastructure and A series of linked and inter-supporting activities.

There are two essential phases of health systems planning:

The design and system development phase Implementation of the system management and

operations components.

Cont..

• A health system cannot be achieved via a one-time organization of providers. It is necessary to establish mechanisms for the ongoing running and adjustments of the system.

• A health system planning has the most potential for payoff in improved health because it can include both health services and population health within its strategic directions.

3. Health Goals Planning

• National government is responsible for identifying

the goal of the health sector of a country.

• The health sector goal of a country is based on the

health status and existing health problems which a

government wants to achieve through its long term

plan.

4. Population Health Planning

• The World Health Organization’s definition of health is relevant to all health planning, but particularly underlines the population health approach.

Steps In Health planning

1. Analysis of Health Situation.

2. Establishment of objectives and goals

3. Assessment of resources

4. Fixing priorities

5. Write of formulated plan

6. Programming and implementation

7. Monitoring

8. Evaluation

1. Analysis of health situation

• It involves the collection, assessment and interpretation of information in such a way as to provide clear picture of health situation.

• In this step generally following items of data are analysis:

i. Population, its age and sex structure

ii. Statistics of morbidity and mortality

iii. Epidemiological distribution of different diseases

iv. Medical care facilities and other health agencies, both public and private

Cont…

V. Technical manpower of various categories

VI. Attitude and beliefs of the population towards diseases.

2. Establishment of objectives and goals

• Objectives and goals are guide the effort, with out

objectives established, there is likely to be haphazard

activity.

• Objectives not only for the guide to action it also

measure work after it is done.

• Objectives should be established according to need of

people.

• The term resources implies the manpower, money, materials, skills, knowledge and techniques needed or available for the implementation of the health program.

• Resources should be assessed and a balance is struck between what is required and what is available or likely to be available in terms of resources.

3. Assessment of resources

4. Fixing Priorities

• Community and political interest • Financial constraints• Mortality and morbidity data, diseases which can be

prevented at low cost.

Once priorities have been established ALTERNATIVE PLANS for achieving them are also formulated and assessed in order to determine whether they are practicable and fasible.

5. Write – up formulated plan

• The next major step in the planning process is the preparation of the detailed plan or plans.

• Plan must be complete in all respects for the execution of a project, the resource (inputs) required are related to the results (outputs) expected.

• Each stage of plan is defined and costed and the time needed to implement is specified.

• The plan must contain working guidance to all those responsible for execution.

6. Programming and Implementation

• Once the health plan has been selected and approved by the policy making authorities, programming and implementation are begun.

• Plan execution depends upon the existence of effective organization.

• The organizational structure must incorporate well defined procedures to be followed and sufficient delegation of authority to and fixation of responsibility of different workers for achieving the predetermined goal, objectives.

Cont.. • The main considerations at the implementation stage

include:

a) Definition of roles and tasks

b) The selection, training, motivation and supervision of the manpower involved

c) Organization and communication

d) The efficiency of individual institution such as hospitals or health centers.

7. Monitoring

• Monitoring is the day to day follow up activities during

their implementation to insure that they are proceeding

as planed and are on schedule.

• It is a continuous process of observing, recording, and

reporting on the activities of the organization or project.

• Monitoring, thus, consists of keeping track of the course

of activities and identifying deviations and taking

corrective action if excessive deviations occur.

8. Evaluation

• The purpose of evaluation is to assess the achievement of the

stated objectives of a programme, its adequacy, its efficiency

and its acceptance by all parties involved.

• Evaluation measures the degree to which objectives and targets

are fulfilled and the quality of the results obtained .

• It measures the productivity of available resources in achieving

clearly – defined objectives.

• It measures how much out put or cost effectiveness is achieved.

• It makes possible the reallocation of priorities and of resources

on the basis of changing health needs.

Program Planning

Introduction

• Program planning is a multi-step process that

generally begins with the definition of the problem and

development of an evaluation plan. Although specific

steps may vary, they usually include a feedback loop,

with findings from program evaluation being used

for program improvement.

Terminology in Health Planning

1. Objective: Is planned end point of all activities Is precise Is concerned with the problem itself

2. Target: Permits the concept of degree of achievement, so it often refers to a discrete activity such as the number.

3. Goal: is defined as the ultimate desired state towards which objectives and resources are directed.

• To known whether the goal is accomplished or not various objectives and targets are formulated and accomplishment of such objectives and targets signals accomplishment of the goal.

3. Goal: Ultimate desired state towards which objectives and resources are directed

Is constrained by time or existing resources Is necessarily attainable

4. Mission: is a description of fundamental principle of existence of a programme

Is usually not time bound Is a statement of purpose

5. Impact : is an expression of the positive effect of a program, service or institution on the overall health development and on related social and economic development

Planning in Health Sector

• Planning is a future oriented process of setting goals/objectives/target and choosing the best way to achieve these goals

• In Planning we decide Objectives and then we decide the Activities to be executed and then resources which are used during execution to obtain the objectives.

Types of Planning

There are various type of plans the types of plan depend on the complexity of operations and nature of organizations

According to managerial hierarchy:

1. Long term plans

2. Medium term plans

3. Short term Plans

According to use:

4. Single use plans

5. Standing use plans

Pre Planning

Pre planning is preparation for planning, the important preconditions are:

1. Government Interest

2. Legislation

3. Organization for Planning

4. Administrative Capacity

1. Government Interest:

Any plan for the health and welfare of a country must be based on a strong “political will” as manifested by clear directives or policies given the political authority.

2. Legislation:

The social and health policies formulated may have to be translated in to legislation as an example may be cited the enactment of the medical termination.

3. Organization for Planning:

There should be an organizational structure for the preparation of the various parts of the plan.

4. Administrative Capacity:

One of the essential pre conditions of planning is administrative capacity for proper coordination of activities and implementation of the plan at all levels.

Importance and Purpose of Health Planning

• Planning provides a roadmap to achieve the goal or to reach destination.

• Planning provides chronological orders of different activities, assigns different jobs and duties

• Planning help us to spend resources efficiently. Resources are limited in nature in developing countries like Nepal, we have to achieve lots of objectives and on other hand we have scarcity of resource also.

Purpose of Planning is :

• To match the limited resources with many problems• To eliminate wasteful expenditure or duplication of

expenditure• To develop the best course of action to accomplish a

defined objectives.

STEPS IN PLANNING PROCESS

1. Stating the mission, or purpose of the organization/programme,

2. Analyzing the external environment,

3. Assessing internal strengths and weaknesses and external opportunities and threats (SWOT analysis),

4. Establishing goals,

5. Selecting activities for each objective; developing detailed work plans,

6. Preparing a financial plan,

7. Introducing a monitoring and control system.

Problem Solving

What is problem solving

• Problem solving is a mental process and is part of the

larger problem process that includes problem finding

and problem shaping.

• Problem solving occurs when an organism or an

artificial intelligence system needs to move from a

given state to a desired goal state.

Characteristics of difficult problems

Difficult problems have some typical characteristics that can be summarized as follows:

1. Intransparency • Commencement opacity • Continuation opacity

2. Multiple goals• Opposition• Temporary

Cont..

3. Complexity (large numbers of items, interrelations and decisions)

• Innumerability• Connectivity (hierarchy relation, communication

relation, allocation relation)• Heterogeneity

4. Time considerations• Temporal constraints• Phase effects• Dynamics unpredictability

Basic Guidelines to Problem solving and Decision Making

There are many approaches to problem solving on the nature of the problem and the people involved in the problem.

1. Define the problem

2. Look at potential causes for the problem

3. Identify alternatives for approaches to resolve the problem

4. Select an approach to resolve the problem

5. Plan the implementation of the plan

6. Verify if the problem has been resolved or not

1. Define the problem• Defining the problem means writing down a short

description of the problem in terms “of the following happening” writing such requires answers of some questions like:

a. What can you see that causes you to think there’s a problem

b. Where is it happening

c. How is it happening

d. With whom is it happening

e. Why is it happening• Verifying your understanding of the problem• Prioritize the problems• Understand your role in the problem.

2. Look at potential causes for the problem

• Find out the potential cause of problem through talk with the those people who are effected by it and who notice the problem closely.

• Write down a description of the cause of the problem and in terms of what is happening, where, when, how, with, whom, and why.

3. Identify alternatives for approaches to resolve the problem

• Brainstrom for solutions to the problem• Through brainstorming collect the ideas as

much as possible.• Then Screening them to find the best idea.

4. Select an approach to resolve the problem

When selecting the best approach, consider:

• Which approach is the most likely to resolve the

problem for the long term?

• Which approach is the most realistic to accomplish for

now ? Do you have resources? Are they affordable ?

Do you have enough time to implement the approach?

• What is the extent of risk associated with each

alternative?

5. Plan the Implementation of the best alternative (This is your action plan)

• Carefully consider “ what will the situation look like when the

problem is solved ?”

• What steps should be taken to implement the best alternative

to solving the problem? What systems or process should be

changed in your organization, e.g. a new policy or procedure?

Don’t resort to solutions where someone is “just going to try

harder”.

• How will you know if the steps are being followed or not ?

(these are your indicators of the success of your plan)

Cont..

• What resources will you need in terms of people, money and facilities?

• How much time will you need to implement the solution? Write a schedule that includes the start and stop times.

• Who will primarily be responsible for ensuring implementation of the plan?

• Communicate the plan to those who will be involved in implementing it and, at least, to your immediate supervisor.

•

6. Monitor implementation of the plan

Monitor the indicators of success:

• Are you seeing what you would expect from the

indicators

• Will the plan be done according to schedule?

• If the plan is not being followed as expected, then

consider: Was the plan realistic? Are these plan

sufficient resources to accomplish the plan on

schedule? Should the plan be changed?

7. Verify if the problem has been resolved or not

One of the best way to verify if a problem has been

solved or not is to resume normal operations in the

organizations. Still, following things should consider:

• What changes should be made to avoid this type of

problem in the future? Consider changes to polices

and procedures, training, etc.

Cont…

• Lastly consider “what did you learn from this

problem solving ?” consider new knowledge,

understanding and/or skills.

• Consider writing a brief memo that highlights the

success of the problem solving effort, and what you

learned as a result. Share it with your supervisor,

peers and subordinates.

Decentralization Policy

Basic concepts and Difinations

WHO

Decentralization is transfer of authority or dispersal of

public planning, management and decision making

from the national level to sub-national levels [1990]

Promotion of primary health care was seen as

incompatible with centralized systems of health care

Cont..

World Bank

Transfer of authority and responsibility for public

functions from the central government to subordinate

or quasi-independent government organizations

and/or the private sector

Cont..• Decentralizations restructuring of authority so that

there is a system of co-responsibility between

institutions of governance at the central, regional and

local levels according to the principle of solidarity,

thus increasing the overall quality and effectiveness

of the systems of governance, while increasing the

authority and capabilities of sub-national levels.“

UNDP

Rational Improve efficiency? allocative and production

efficiency

Improve equity?

Improve quality of care?

Improve financial soundness?

Improve local accountability

Types of decentralization

1. Political2. Fiscal3. Market4. Administrative

De-concentration Delegation Devolution Privatization

Administrative Decentralization

• “is the transfer of responsibility for planning,

financing, and managing certain public

functions from the central government to

lower levels” (Rondinelli 1999).

Deconcentration - shifting power from the

central offices to peripheral offices of the same

administrative structure e.g. provincial department of health

and its district offices

o Functional: field officers are directly linked and controlled from

centre;

o Prefectoral: there is a layer [PREFECT] in between – commissioner

or governor; Salient features

Shifting of power from the same structure; Semi-autonomy to field officers in routine decision making; Some planning functions according to central guidelines;

Administrative Decentralization

Delegation - shifts responsibility and authority to semi-autonomous organizations;

Salient featureso Functions are shifted to regions or functional bodies or

special project units;o Independent from central government rules and

regulations in personnel, recruitment, budgeting and procurement;

o Examples: Social security institutions, separate regulatory commission or accreditation commissions;

Administrative Decentralization

Administrative Decentralization

Devolution – transfer of functions or decision making authority

to legally incorporated local governments such as states,

provinces..etc ( Collins 1994);

Shifts responsibility and authority from the central offices (MoH)

to separate administrative structures still within public

administration ( Bossert 1995)

• Responsibilities for services to local government

• Local governments elect their own representatives

• Raise their own revenues and

• Independent authority to make investment decisions

Decentralization in Nepal

• Decentralization and local self-governance have been made

operational in Nepal since the 1960s.

•  In 1987, the centre (MoH) underwent change and as a result—

Regional Health Directorates were established in five

development regions in Nepal

• In 1999, Nepal enacted a Local Self-Government Act (LSGA)

• This Act, whose monitoring committee was chaired by the

Prime Minister, laid the foundation for establishing a local self-

governance system adopting a broad-based and cross-sectoral

approach.

Cont…

• This Act recognized the role of local self governance and

devolution of authority and responsibility to make local

authorities more responsive and accountable to people.

• The rationale for this Act was both philosophical and

practical and involved legislation, institutional provision,

resources (both financial and human) mobilization and

considerations, i.e. autonomy and equality