Tackling Human Resources for Health (HRH) Crisis in Nepal through Informed Policy Decisions and Actions

Background   
This midterm review was conducted during the month of September – October 2012 after the completion of 18 months of implementation of a 30 month long EU funded project titled “Tackling Human Resources for Health (HRH) Crisis in Nepal through Informed Policy Decisions and Actions”, and implemented by the Save the Children country office Nepal. The overall objective of the project is “to set the issue of HRH into the wider context of health system reform by engaging civil society organizations (CSOs) and non-state actors (NSAs) towards building the knowledge base for all and policy advocacy”.

Purpose/objective (including evaluation questions)    
 The main objective of this review is to share learning and challenges among HRH partners and stakeholders, look over the progress and process of intervention, the efficiency and effectiveness of the project team in implementation to achieve results.

Methodology   
The review process consisted of reviewing the documents, meetings and key informant interviews, FGDs, with partners at the project districts, with key officials of MoHP and other stakeholders and obtaining critical information from Save the Children team particularly the HRH team. Three districts were visited and observation done in two health facilities in each districts. The review findings in this report are structured around the key result areas as defined in the project document.

Key findings   
The current project is very relevant and its launch was received very positively by stakeholders including the MoHP. Moreover, up until now HRH issue had not been a serious agenda of action among the non-governmental actors, this project along with other has established the fact that HRH in public sectors should be and can be a developmental agenda of NGOs.
 A challenge for project management was to carefully align the project activities with the National Strategy on Human Resource for Health already being implemented, to avoid duplication with ongoing activities while at the same time spending the resources where there is best value for money. The implication of delay in project start up date and the time taken to speed up the implementation has reflected on various areas of project activities.
Despite number of achievements made over the period of one and half years, considering the relatively short project duration of 30 months, some of the project targets are  ambitious, particularly in the new concepts like Diaspora engagement, setting up ombudsperson for HRH and role of (and expectation from) CSO/NSA Alliance.
Of the total budget for 2012 (EURO 329,927) nearly 70% is allocated to central level activities which also included research and trainings to district Alliance members and 30% to specifically to project districts. In 2012 (as of September) the overall programme spending (excluding salary of project staff) was 31%. At the beginning the spending was quite low, but over the period steady progress was recorded.

Alliance of CSOs and NSAs for HRH
The first period of the project focused on preparatory work and the formation of Alliance of CSO and NSA for HRH at three project districts and at the centre followed by number of capacity building inputs for its members. During the same period, series of meetings and dialogue were conducted by SC HRH team and Alliances with government officials towards national HRH strategy development process.
Alliances (central and district Alliance) have started conducting monitoring (at district level) and advocacy activities at different levels. Its presence has been felt and there are mixed responses and reactions to its role in HRH. Alliances have developed its work plan or working guideline – but resources required for implementation is not yet identified and all are expecting SC to provide it. Leadership and group dynamics (including group management) is emerging but did not indicate strong enough (Siraha, Bardiya and Doti) to be able to organise and drive the Alliance. The diverse representation in Alliance is certainly strength, but institutionalising and managing such diversity into a functional group and driving it after the project inputs are over in June 2013 is a challenge.

Knowledge base on HRH issues through operational research
HRH situation (three districts specific) and a national assessment were completed and findings disseminated. Mostly based on secondary data (MOHP or DHO data) these documents are good resource of compiled data on health and HRH. Utilisation of data and findings at local and at central level appeared limited to none existent. Despite delay, HRH research has begun with new partner (Development Research Centre) for which inputs and support for research design and training was received from NHRC. The project document has a plan for conducting operational research on HRH, but so far research of standalone nature has been conducted due to lack of clarity in the project document in operational research.

Continue policy dialogue on HRH at different level
Alliances at the districts have made some efforts to initiate dialogue with District Health Office, and to a limited extent to DDC/VDC. National Alliance was regularly engaged in CCF during national HRH strategy development process where there was opportunity to influence the strategy development process. Similarly, central Alliance conducted number of sessions with policy makers of the Ministry of Health and other stakeholders. The impact of such advocacy effort is difficult to measure or even if the impact is seen, that cannot be easily attributed to any particular advocacy effort.
Advocacy and dialogue with policy makers by default appeared to have largely remained the responsibility of Alliance. Given the current organisational structure and lack of funding, Alliances particularly the district Alliance so far has limited results in its advocacy effort. HRH team at centre were regularly involved in national HRH Strategy development process where Save the Children was asked to review the content of the strategy.

Capacity of public sector for HRH
The project is supporting salary of locally recruited health workers in the project districts. In Bardiya district there is cost sharing mechanism whereas other districts are fully dependant on the project. Funding support for local recruitment is much appreciated and has certainly ameliorated some of the problems of shortage of HRH in the short run, but in the long run this is not an answer to HRH issue in the country. There is already a policy and practices to recruit health workers locally with support from DDC/VDC or from other local sources.
The project also supported the most needed training of Skill Birth Attendants in the project areas. Similarly, a number of trainings (HRH management, research, advocacy skills) were organised for government and non government partners, international training and exposure was organised for HRH team and govt officials.
Inputs were also provided to HuRIS at the Ministry of Health making its web search interface user friendly and interactive. This is much appreciated by MoHP officials. A Human Resource portal is being developed with the aim of linking it with existing HuRIS. The portal is being designed to provide details of HR working under MoHP in all 75 districts.
Towards sustainability, the project had anticipated a Critical mass of CSO/NSA – leading to local and decentralised management of HRH. Despite training inputs and supports provided by SC, district Alliances are fully dependant on Save the Children for coordination and other functions. Some form of collective leadership and group dynamics is emerging, but it is yet to demonstrate its strength, credibility and sustainability.
Signing MoU with MoHP, bringing NHRC on board and engaging representative of Ministry of Federal Affairs and Local Development are strategically well placed as these agencies have strong influencing role in policy making and monitoring its implementation.

Recommendations   
•  Given the delay in initiation of the project and some ambitiously planned activities, coupled with slow spending rate, consideration should be given for extension of project period beyond June 2013.
• An exit strategy needs to be developed, while so doing, Save the Children should explore the possibility of linking this project (i.e. Alliance of CSO/NSA) into its other ongoing projects so as to ensure continuity.
• More facilitation and mobilisation support to Alliance members is required to build its group dynamics and leadership. Some financial support is needed to conduct district level activities and help leverage additional resource mobilisation by Alliance.
• The current ongoing research is a standalone activity in nature, though according to project document and logframe it is part of operational research. Clarity on current standalone research and operational research is necessary
• Explore for more sustainable funding support for local recruitment of health staff under DHO. Build cost sharing elements in Doti and Siraha as well
• GIS in district – ensure it is not a burden and does not clash with district IT need and is aligned with MoHP plan.
• Ombudsperson and Diaspora engagement  – preliminary exploration and concept paper could be possible in remaining period

Follow up (with reference to Action Plan)