Promoting evidence-based planning by enhancing stakeholders’ understanding of local evidence
Nepal’s transition to a federal system has been challenging, with delays in policy formulation and ambiguity in roles between the tiers of government (federal, provincial and municipal). Within the health sector, the delineated local governments (municipalities) have begun to take ownership and provide health services although there are major gaps in their capacity to manage local health systems and provide quality health services. Kapilvastu Municipality in Lumbini province, is a learning site for HERD International. The district and the municipality are fragile in many ways, demonstrated by the poorly functioning health system, stagnant health service indicators, poor education and socio-economic conditions. The municipality is also prone to seasonal disease outbreaks such as dengue, cholera and typhoid (the open border with India increases vulnerability to the transmission of disease) and extreme weather events such as heat and cold. The district was one of the hardest hit by COVID-19 in Nepal, jeopardizing the system’s ability to cope with chronic stressors and maintain delivery of quality health services.
What problem is being addressed?
Against the background of these challenges, lack of effective planning and implementation with the limited use of evidence in decision making were negatively affecting health system performance and the system’s ability to respond to emerging health needs. Routine data from the health management information system were found to be underutilized at the local level for planning, monitoring, and decision-making. The HERD team identified a need to strengthen the ability of decision makers to analyze, understand and use data, and to persuade them of the value and importance of evidence.
What did we do?
HERD International implemented participatory action research in Kapilvastu municipality using an embedded ‘learning site’ approach. Researchers shared working space with the municipality’s health team, fostering an understanding of the functions, capacity and power dynamics within the municipality, and engaged in the collaborative planning and implementation of health system strengthening approaches. Building relationships, understanding stakeholders’ expectations, aligning research objectives with municipality priorities, and building a shared understanding of the concept of health system resilience were vital early steps in the research. Furthermore, by keeping ‘co-design’ at the centre of the research approach the team was able to foster participatory, need-based and evidence-based planning processes.
Resilience Capacity Assessment
The research process began with an assessment of the resilience capacity of the municipality health system. This involved a review of policies, annual work plans and budgets for the last few years and an analysis of trends in key indicator data. Interviews and focus group discussions were conducted with local stakeholders and community members to understand the gaps and challenges experienced at all levels of the health system. The municipality, with support from HERD, also conducted a long-overdue facility readiness assessment using Minimum Service Standard (MSS) and Routine Data Quality Assessments (RDQA), both of which were introduced by the government to assess service readiness, service gaps, and data quality at health facilities throughout the country. The resilience mapping process revealed the following challenges in the generation and use of evidence:
1. Local policies and plans are largely driven by national priority programmes and previous plans rather than evidence and changing health needs.
2. There is little quality data and limited use of what is available.
3. Data is of limited perceived importance with little capacity to analyze and use local data in planning and decision making.
“It feels like our health system is itself ill and needs treatment.” Ward Chair
Group Model Building workshops
Following the resilience capacity assessment and engagement with stakeholders, the HERD team came to understand the power dynamics within the municipality and adjusted its approach to include Group Model Building (GMB) workshops. Three GMB workshops were organised with different groups of stakeholders from the municipality, allowing individuals to openly share their experiences and problems and seek solutions during facilitated discussions with like-minded people.
“The HERD team has minutely studied the gaps and issues of the health system. This has sensitized us to work together to build plans and strategies, standing alone cannot help to build a resilient health system. There should be input from every sector for better health system.” Section Chief, Municipality
This process helped both the local stakeholders and research team to understand and reflect on skills gaps and areas for strengthening the local health system. Findings highlighted uneven distribution of services, with the government hospital (then a district hospital but now under the jurisdiction of the province) serving as the main provider, while health posts and basic health service centres had limited numbers of service users. This suggested that to improve the overall quality of health services in the municipality, service delivery in the hospital must be strengthened, emphasizing the missing but important role of coordination across the tiers of government. Inequitable service utilization within the municipality was also highlighted. Together, these revelations prompted the Mayor and health team to liaise with the province and district hospital and to initiate discussions to enhance service quality at the district hospital.
The findings from the resilience capacity assessment were shared during the GMB workshops, and using a participatory approach stakeholders identified and prioritised issues. Small groups discussed and identified root causes of problems, leading to strategies to address them, and participants became aware of the interconnectedness of issues, realising that most could be solved through small local actions. Local leaders called for routine health-focused meetings to discuss common issues and to bring them to the municipal assembly for action. Notably, this meeting marked the first discussion on health and health systems issues between elected officials.
“There is a need for joint meetings of all Ward Chairs where they can discuss about health, education and other issues and problems, and also share good practices.” Ward Chair
“This workshop helped in bringing up the issues of health system, which is very good and it will guide the Municipality, health office and other relevant stakeholders to work on it.” Health Office Representative
An analysis of the annual work plan and budget under conditional grant indicated that the plans were not really informed by evidence and so were not responsive to the municipality’s health needs. Municipality stakeholders recognised this and sought technical support from the HERD team to review and strengthen local plans. The municipality health team also requested support in generating and utilizing data for local planning, leading to a household census assessing immunization coverage and growth monitoring of children under two years of age. This process also enhanced the municipality health team and local health workers’ ability to collect data using tablet PCs and to understand the results.
Overall, the municipality stakeholders – the Mayor, section chiefs, Ward Chairs, health workers and female community health volunteers – gained an understanding of the role of evidence in planning and decision-making. Having enhanced their capacity to review and interpret evidence at the system, facility and community levels, and using a co-design and participatory approach, they were able to develop an evidence-based, locally-prioritised action plan. This action plan is now owned by the municipality health team and was formally shared with other municipality officials including the Mayor, Section Chief and district officials. The plan was positively received, and the Mayor committed to including the actions in the following year’s annual work plan and budget. Some activities, such as forming and orienting management committees at local health facilities and improving data quality through onsite coaching of health workers, have already been initiated by the municipality.
There is more on the work undertaken at the learning site and the outputs produced, including an earlier case study, here.
Image: Shophika Regmi of HERD leading a participatory action research workshop with stakeholders in Kapilvastu, Nepal