Oped»
Do it right
MAY 01 -
Recently, the World Bank has extended a major loan to Nepal, to the tune of US $ 129 million, for another five years of health, nutrition and population and HIV/AIDS project. While this is an enormous sum, there are many more donors similarly engaged with the Ministry of Health and Population (MoHP) and are theoretically committed to help the Ministry deliver at least the very basic health services to the people. So, if the MoHP is unable to deliver proper health care to people, it has not been for want of resources.
To be sure, health administration in Nepal remains largely unable to deliver even the basic health services as mandated, and the frontline government health institutions namely, the health posts and sub-health posts, remain mostly without drugs and paramedics. For instance, The Kathmandu Post, quoting a MoHP source, had reported on Jan. 27, 2010, “85 percent of health institutions providing free health services have been without stock of essential medicines”. Last year, the largely preventable and easily treatable diarrhoeal disease was allowed to grow into colossal human tragedies in Jajarkot and surrounding region in Mid Western Nepal. This year too, Rukum district has been the latest to report of “lack of medicines and shortage of health workers exacerbating the situation in parts of the district affected by diarrhea” (TKP, April 27, 2010).
The politicians themselves use such tragedies more for their apparent political gain. For instance, Prime Minister Madhav Kumar Nepal made the widely reported helicopter sortie to the region immediately upon returning from his Egyptian sojourn last year, raising hopes of some far-reaching reforms to follow. But nothing happened. Now that the disease has revisited the region, the prime minister is reported to have “directed” the health minister - an NC politician known for his insubordination to the UML prime minister - “to adopt necessary measures” to bring the outbreak under control. But by experience, we know that PM’s “directive” is designed more to placate public opinion. Given such a situation, the WB project’s stated intent “to support the government’s programme to respond to the people’s expectation of inclusive and accountable public services” would indeed be a very tall order.
Despite such grim readings, however, the donor officials find it fit to flatter the health bureaucracy in superlative terms (read: chakari in Nepali). Apparently, due to advances made in the reduction of Infant and Under-Five Mortality Rates, Nepal has been rated as “only one of the seven developing countries on track to achieve MDG 4 and the only country that is ahead of schedule for meeting its target before 2015”. This, however, is a chance development. Miracle drugs such as various immunisations, polio drops, Vit A capsules etc. that enhance child survival prospects are amenable to being administered by low level functionaries; Nepal has a domestically innovated nationwide network of 48,000 Female Community Health Volunteers (FCHV), who are accountable to their own communities and bring these drugs to the doorsteps of people in no time.
But the tragedy for Nepali children is that while they are living longer owing to these drugs, they continue to suffer from severe levels of malnutrition at the same time. The Child Health Division of the MoHP reported in 2007 that four out of ten under-five children were underweight in Nepal due to Protein Energy Malnutrition (PEM), and conceded that given very slow progress in this field, “it will take another 100 years to reduce the prevalence of malnutrition to the desired level”. But, in 2009, Unicef, Save the Children, WHO and AusAid put out a press release, applauding the “strong leadership of the Ministry of Health and Population…. the policymakers and programmers who developed good policies, the untiring health workers and the female community health volunteers who have been instrumental in conducting the child health programmes”. If so, many of our health problems would not have been there.
Clearly, donors are as much of a problem. The WB’s own record as an effective agent for change has been mixed. For instance, it had crucially contributed to laying the groundwork for the universally applauded success in community forestry in Nepal. By mid-1980s due to sustained depletion of forests, possible desertification had become a major concern (despite the WB-funded Community Forestry Project implemented in 1978). At the time, at the counsel of a government anthropologist, the World Bank mission for Structural Adjustment Programme adopted user management of forests (as required by the then Decentralisation Act of 1982) as one of the conditionalities for the proposed loan of $50 million. That forced the recalcitrant Ministry of Forest to introduce Forest User Groups (FUG) in April 1988. Today, there are more than 15,000 FUGs managing Nepal’s rejuvenated forest wealth.
But the same thing is not true when it comes to WB’s water and sanitation (WATSAN) or microfinance initiatives, the former crucial for better health in the communities and the latter for increased income and nutritional status of the people. In WATSAN, instead of helping the government to redefine the role of the Department of Water Supply and Sewerage (DWSS) in line with that of the Ministry of Forest vis-à-vis the FUGs, the Bank simply “dismembered” the agency’s integrity by setting up a parallel outfit, the Rural Water Supply and Sanitation Development Fund Board (RWSSDFB), generally known as the Fund Board, under the effective control of its own officials. The Board now operates in 71 districts through a network of generously funded NGOs. Incidentally, a few years later, another donor came along for the Agricultural Perspective Plan and further dismembered the DWSS, by helping create DOLIDAR (Department of Local Infrastructure Development and Agricultural Roads), which also attends to WATSAN in all 75 districts. As a result of such adventurism, the attainment of the MDG and National Goals in WATSAN remains a far cry in Nepal.
Similar is the story with the WB’s poverty reduction initiative. The government and NGO-promoted and spontaneously organised microfinance institutions (MFI) have by now more or less saturated the country. But most of them suffer for want of sufficient capacity and funds to make significant dents on the problems of poverty in their communities. The WB-promoted (and controlled) Poverty Alleviation Fund (PAF) with a loan fund of $100 million could have made a world of difference by choosing to backstop this nationwide network of MFIs. But instead, it now runs a parallel programme of its own which has now come under increasing and widespread criticism for gross misuse of resources. Like the Fund Board programme, the PAF too remains to be independently evaluated.
Given such a context, the starting point for the meaningful utilisation of this enormous WB loan for health, should be to have the MoHP devolve authority, as in the case of the Forest User Groups, to the local communities to manage their own health posts and sub-posts. In 2006, the UNFPA had funded the formulation of Population Perspective Plan under the leadership of late Dr. Harka Gurung that had strongly recommended for the devolution of authority to the local mothers’ groups to manage the village health posts. But even after four full years, the Plan has made no headway, and the UNFPA itself seems to have all but forgotten about it. In specific terms, this WB project must ensure that the local communities themselves are able to hire their own paramedics and procure their own medical supplies, and be able to plan and implement a more integrated package of health interventions including nutrition in their own communities.
Posted on: 2010-05-03 02:20
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