Some Random Thoughts: Evidence Synthesis for Health Policy and System (Post 2 / 2019)

Prologue:

One of our esteemed professor, who taught us microbiology at BPKIHS, used to say loud and clear, "If your basic science understanding is shaky, your clinical practice is also going to be shaky." True and this wise statement is very relevant to the current public debate that relates to health education. With mushrooming of medical colleges and with reported poor quality education, this debate is nowadays resonating among Nepalese political elites, policy experts, planners, education experts and all of us citizens. Partly, thanks to Dr. Govinda KC for raising this issue to the forefront of public debate through his persistent fight for quality health education. This brings out one loud question is "how do you we expect any medical professionals supposedly graduated from such a bad school would be able to provide even a satisfactory level health services?" Instead, "wouldn't such health professionals pose a health risk to the population?" Therefore, we all agree in principle and at the personal level that "Quality Health Education of highest standards is the need of the hour if we are to deliver quality health services to all." Our negligence or being complacent at regulating to make sure that we secure high quality in health education would be like carving our own death coffins. So, our way forward to achieve our common vision of "Wealthy Nepal, Healthy Nepal" we must not compromise even an inch in delivering quality education to aspiring health professionals. That is why wise people say, "We get what we plant." Poor seed, poor care would definitely bring a poor harvest.

Our reality:

We can't imagine what goes through a children's mind when s/he is just beginning to explore the world around the Kathmandu valley.  So much chaos, pollution, congested traffic, and suffocation !! All of us complain about it in some way or another. Read about our daily misgivings the way our country is run by politicians and bureaucrats and so on. In a way, we have a galaxy of challenges to face and fix. Sometimes, we wonder how our children have to deal with the future if we are not to fix the ailing Kathmandu valley. This is a huge topic, which I am not going to focus on this blog. However, all in this universe of the complexity of Kathmandu valley that dictates the fate of all, there is one common linkage that we can't ignore and that is our health: our ability to live a healthy life. All that everything around us, be it traffic, nutrition, housing, highway, immigration, legislation, agriculture, security, forest, etc are all interrelated. Therefore, we need to work hard day and night to course correct our path to overall wellbeing and happiness. For this to realize, we need to contribute from all corners and that to the health sector, we need to diagnose the root cause of what is ailing our health system. In this cursory analysis, I am positioning here my argument that if we really want to streamline our Nepal health system, we need to dissect our health education sector and carry out a complete overhaul of health education system. For this, I stress here that we need to build a culture of evidence-based policy decision making with the support of health policy and system research and of course to clearly define a demarcation line between political machine and governance system. 

Realist review in health policy and system research:

Health Policy and System Research (HPSR) is a new term that is a tall order in the global health agenda. In the sea of this new field of system research, one of the approaches of realist review is based on our sound understanding of the local context and its mechanism in the functioning of the health system with the influence of background socio-economic as well as political landscape. The mixture of which and its interplay results in consequences, which could be either positive or negative depending on how well did our homework. In order to untangle the dynamics and its complexity, we need to simplify our understanding of the current health system and for that, we need to lay a solid foundation for the study of health policy and its implementation. We should also remind ourselves again and again that health policy and its implementation research is not an easy task and is said to be of complex nature, which needs perseverance and extraordinary patience to untangle its hidden components, context, and its mechanism. Realist review helps us to unpack, explain and understand the context and its mechanism rather than to determine the effect size of any interventions based on certain policy implementation, so address questions about how, why, for whom, in what contexts and to what extent health systems, programmes and / or policies function, thus providing knowledge useful for its implementation. 

Any complex interventions have multiple components and outcomes that appear to be context-dependent such that some (1) intervention strategies do not bring favorable outcomes. Instead, it could bring change (or not) in the context that matters to the outcomes of interest. Sometimes, (2) we may need to explain how and why context influences outcomes with a complex web of events leading to the final desired outcomes and on top of that, many of times figuring out what constitutes (factors/elements) the context is a challenge (3). To perform reviews of complex health policy and systems interventions, we need to understand the concept of complexity, which is an interplay of multiple, interacting components and non-linear causal pathways/variability in content, context, and mode of delivery as well as the unpredictability of their effects/characteristics (nonlinearity, context dependency, adaptability and interdependence of intervention elements) like there could be intervention complexity/implementation complexity/context complexity/complexity in participant responses. In order to dissect into the complexity, we can institute quasi-experimental studies in health systems evidence synthesis taking into account the issues of external validity and feasibility and cost. However, if we want controlled study then RCT is the gold standard, but external validity would be an issue. In natural experiments, there are "naturally occurring circumstances in which subsets of the population have different levels of exposure to a supposed causal factor, in a situation resembling an actual experiment where subjects would be randomly allocated to groups'. While carrying out such reviews, we need to be cognizance of equity as one of the key principles that should drive health system reviews. Health equity guides us that there is an "absence of avoidable and unfair inequalities in health." For that matter, we need to include equity audits/assessments in the study.  These are particularly essential to inform decision making in the delivery of health care services in a country like Nepal.

We also need to act and for that matter, knowledge production and translation tools are essentially one of the most important components, which we tend to neglect. One of the most important tools is definitely the priority setting exercises, which helps us in framing the review questions, defining the PICOS (population, Intervention, Comparator, Outcome, and Setting) of the reviews and the objectives. Another common but tedious and important tool is to carry out systematic reviews, which address the questions identified in the priority setting meeting/evidence syntheses/scoping review. Once we are able to conduct reviews based on priority setting with a roadmap ahead, we should not forget the development of briefing note (knowledge translation), which will highlight priority issues, synthesized global and context-specific evidence and evidence-based recommendations for action. Finally, we can create a policy opportunity convening of a national policy dialogue (knowledge uptake) sharing the summary report. At the core, we should focus our exercises to secure impact-oriented framework for evidence-informed health policies and practices [in other words - knowledge to practice (K2P)]

Challenges in the context of policy-relevant evidence syntheses:

Key challenges while conducting evidence synthesis in health policy and system research are as follows: (1) limited primary evidence - this is true (what we can do is that we can engage universities and research institutions in this evidence generation activities through students and faculties) (2) access to data such as HINARI Access to Research in Health Programme/Databases (Health Systems Evidence/PDQ - Evidence) / context sensitive and local evidence (which are more important for decision makers) (3) use of local knowledge in policy-relevant reviews - gray literature (government reports) however there are always concern re: quality and validity / WHO programme reporting standards for the design, implementation, M&E of health programmes (4) timeline of reviews - engaging policymakers to generate and maintain an evolving list of policy questions would be beneficial for the country. The list of policy questions to be scheduled and addressed in a timely manner (5) ethical considerations - conflict of interest issue (financial /nonfinancial/institutional) (6) strengthening of capacity for evidence synthesis in HPSR - Global Evidence Synthesis Initiative (GESI), Cochrane, Cambell collaboration, etc., which could be at the institutional level or at the system level.

Fostering the use of evidence synthesis findings in policy and practice:

In our setting such as Nepal, one of the major barriers to health system strengthening and improvement in health outcomes is the inability or poor "know-how" of decision-makers to effectively use syntheses on health systems interventions. Also, compounded by "end-users' attitude and behaviors." Key approaches (insights) to increase the uptake of review findings in health policy-making and health system strengthening are (1) engaging decision-makers (role of knowledge users in evidence syntheses - advisors/expert panel/steering group/team members)/buddying approach (South Africa) (2) enhancing the policy relevance of evidence synthesis (3) improving the format of evidence syntheses (4) using frameworks to support the uptake of reviews - Evidence To Decision (EtD) framework (5) embedding syntheses in complex policy and systems (4 principles - inclusive, rigorous, transparency and accessible).

Note: I have literally taken up the idea and knowledge in this blog reading "Evidence Synthesis for Health Policy and System: A Methods Guide (Edited by: Etienne V. Langlois I Karen Daniels I Elie A. AKL)

2018 Summary _ Baseline for 2028

Here, I would like to acknowledge that regular blogging/writing was inspired to me by Derek Ehrhardt (during his CDC assignment on polio surveillance review in Nepal) and Gates Notes. It is also noteworthy that passionplanner has helped me from the year 2016 to be focused and more organized in what you do on a daily, weekly and monthly basis. Thank you to all these great resources and individuals. 

2018 has been a great year for me in terms of reading and writing. However, it is necessary and realized consistently that I need to consolidate what I read and write in a more organized way such that  OPED or summary note or blog piece or journal articles are a tangible outcome. So, now onwards, it should be my effort to produce a product that will have an impact felt in our fraternity of health science. In my case, knowledge translation or production will be an academic activity in various health policy and system research (HPSR) forum. 

Just as a review of 2018, I would like to summarise key activities successfully carried out and those aspirational goals that I still need to accomplish (in coming years) in this blog post. First, I would like to summarise all those books that I read for a record that I build my future reading and writing guideline. I have broadly categorized the books that I read in the following headings: 

Book of wisdom: Somehow, I had to read this book - "Bhagwat Gita" and was planning to read for a long time. Finally, I finished reading this great book of wisdom. Here, I have to definitely acknowledge my maternal uncle Anil Gauchan (poet), who seriously advised me to read this great book at least once. Well now, I feel a sense of great accomplishment in reading this book but the truth I was unable to grasp the depth of its wisdom. So, I need to read this book again and indulge myself in conversation with subject matter intellect who have at least some understanding of this great book. 

Source: https://www.google.com.np

Historical Political landscape: In this category, I was able to read 2 books. Somebody said, one who fails to read and learn from history will definitely fail the present and their future is shaky. In that line, I have always wanted to understand the present political order and so-called categorization of the rich world and the 3rd world or developed versus low-income countries and so on. On top of that in everyday conversation, be it political, economic or social, what we read and hear is that we are poor or you are a citizen of the poor country.  In a way, this may be partly true but the narrative is so powerful that somehow I feel this kind of social construct have weakened our intellect to a limit that our will to excel or be innovative have been weakened. One example, well we can't accomplish this huge project of hydropower or railways because we are poor and we do not have technical expertise and political will. This kind of stories is daily fed to our newspaper column or news headline or even in the academic article. Now it is high time, our intellectuals must challenge this kind of narrative and deconstruct and explain to our younger generation that they are able, intelligent and capable to do anything they think they can do. So how to bring ourselves out of this quicksand of feeble mindset? for that, we need to read, read and read and another would be to write, write and write. In this effort, I read the following books to understand what is the nature of global order and socio-political dynamic and do we have a role to play? Another read was a book on British colonialism of Indian subcontinent and its subjugation such that all the wealth from this continent was siphoned to fill their coffers in Britain. 

Political Order and Political Decay (Francis Fukuyama): This book tries to explain to us the evolution of global political power and its nexus through the time period starting from the industrial revolution to the globalization of democratic values (free and fair election, human rights). On the other hand, this book also tries to illuminate the changes in global order and its power dynamics. I found this book hard to understand and relate the global nature of globalization and fast pace of international politics in terms of its complexity from the point of economics, industry, information, market, and security. However, this book is definitely a thought-provoking reading material for the journey into understanding what goes on in the global arena of hardcore politics. Among all the chapters in this book, the one on the dimensions of the development is worth remembering and this is relevant in our local context of federalism in implementation with a leftist government in charge. The framework tries to look into the regime through economic, social and ideological dimensions such that we need to understand through rigorous scrutiny the interplay of its key components: economic growth, social mobilization, ideas/legitimacy and political development (the state, rule of law and democracy). For a better and wider understanding, I have realized that I need to read this book again. On top of this, I have added 2 books on a reading list (Social Origins of Dictatorship and Democracy by Barrington Moore and Great Transformation by Karl Polanyi)

Source: https://www.google.com.np

An Era of Darkness (Shashi Tharoor): Reading through this book written by an Indian diplomat who held international as well as the national position of power with the depth of understanding of the history of this subcontinent, I truly felt the anger at such historical injustice inflicted on welcoming people through deception, lies, brute forces and coercion and extortion.  The lesson that we need to learn from this history is that we need to learn to take care of our home, otherwise somebody else will have a ready-made plan for you and it is already too late by the time you realize what has happened. Well, India is better off in terms of economy and one of the emerging global power players in terms of security, while Nepal needs to get disciplined in our internal affairs and lead our country into prosperity. In the 21st century, it is said that colonialism has taken a new form and that is through language and data and of course complete control of your thought process. Maybe that is what is happening now. Somebody brought the new idea or is already prevailing, I do not know, people are talking of "neoliberalism" taking hold of all institutions and development works in our backyards. Lastly, one indicator to remember which the writer project at every forum is "India's share of world GDP was 23 % before the British took control. When the British left it was just above 3 %". Interesting. 

Source: https://www.google.com.np

The landscape of Economics and justice:

Justice (Shushila Karki): This book is written in an autobiography format and is a reminiscence of retired Chief Justice, Shushila Karki, who is known for her stand up against injustice and vigorous political pressure that fell during her tenure at the apex court. This book has educated the general public on the corruption of the highest scale, which is rampant post-2046 popular democratic movement. CJ Karki has illuminated with various anecdote and examples the corruption, coercion, and extortion that political leaders have inflicted on common people. The inference from this book is that our governance structure along with its all branches of government have been so much damaged that it is now a time to course correct and discipline it before it is too late. Otherwise, we are entering into the black hole of uncertainty leading us into the stage of "failed state". I say this is a must-read book by every Nepali youth get educated on which direction our country heading? Also, an important resource re: Special parliamentary hearing committee

Source: https://www.google.com.np

Economy (Sujib Shakya): This is a good read to understand the landscape of economic growth or progress that is visible or hidden in Nepal. I found it encouraging to read a book written by a Nepalese author on the economic situation and its various parameters that affect the national economy as a whole. Somewhere, this book also sheds light on the influence of post-2046 political changes as well as global market force guided by "neoliberalism" and then popular catchphrase "globalization" in every sector in the socio-economic-political climate of the period.

Source: https://www.google.com.np

With the above summary what I was able to read in the year 2018, I leave this post with further space further study and writing, others in the list of books that I read as follows:

• Building Social Business (Muhammad Yunus)
• Development as Freedom (Amartya Sen)
• The Argumentative Indian (Amartya Sen)
• The Idea of Justice (Amartya Sen)
• Animal Farm (George Orwell)

Global health landscape:

• Reimagining Global Health (Paul Farmer et al.)
• Infections and Inequalities (Paul Farmer)
• Aids and Accusations (Paul Farmer)

On agenda setting and stakeholder analysis as a prelude to health policy formulation (Post 1 / 2019)

The human mind is unique to humanity. We can think, imagine, create, memorize, communicate, concentrate, contemplate, and all we can think of. Sometimes, this same beautiful mind can be dysfunctional to a limit that it can get vacant or disruptive. In all these, it is a thought process that flowers an idea which can be developed into a beautiful concept and if we focus and persevere with an organized path forward, then we can create, build and construct whatever we possibly can imagine. Such is our power of a beautiful mind. However, to generate excellent ideas and translate them into the tangible outcome, our mind has to be trained, disciplined and framed in such a way that we know our goal and objectives best guided by a uniform vision and mission. 

After decade long political struggle post-1992 popular movement, Nepalese people have suffered immensely such that we have lagged behind by several decades in socioeconomic scale when we compare ourselves in every metric with neighboring countries. All these upheavals brought so much unaccountable and unmeasurable social sufferings we can't measure and sometimes, it seems we fail to contemplate this aspect of our story. Despite all these hardships and sufferings, Nepalese people have compromised with all the changes wanting peace and prosperity so we are able to fulfill our basic necessity. With these aspirations harrassed by repeated political stalemates  - we have been able to proclaim our basic rights for peace, livelihood, dignity, education, health, food and justice through the new constitution of 2072 BC.

These written rights and responsibilities are of galactic (व्रमांड) nature, but I believe, these basic rights are achievable in our lifetime. We need to work hard, not wasting any time on political bickering, if we want to translate all these rights into tangible benefits in our daily lives such that we do not have to die just because hospital is 2 days away or surgeon is in district headquarter 5 days away or some poor should have to suffer humiliation every day just because he is born with certain characteristics and so on the list is endless. No more such sufferings, we have had enough and our children do not have to bear such hardships again.

Now with the federal restructuring of governance in full swing, we are in the best time to translate basic health rights into action and bring well being in people's everyday life. The question is then what can we do? Well, we have so much potential to transform Nepalese way of doing business within current governance structure and functions in evolution. For this, policymakers have to act smart and work in harmony with elected leadership, who bring people's voice and connect with them. We are such a lucky generation that the advent of the 21st century has brought a flood of technological disruption, particularly information technology (IT) that we can accelerate our path to success and catapult ourselves to the wealthy nation-state in the shortest span of time. Again the question comes back before us: how do we do it? Well, we need smartness in how we manage our home affairs, be it administration or politics. We need to bring ourselves out of the traditional mindset of bureaucracy, which we commonly call it a public service administration. It is right time that we change the narrative such that "public service administration is not rocket science." These are all skill set that comprises social, emotional and political skills and in the heart is your educational qualification and experiences. When I say skills, I like to focus here the field of "policy analysis." We have realized lately that policy expertise is one knowledge area all of us need to master and get well acquainted with.  

Our constitution is a master policy of our country. There are directive principles, policies, and obligations of the state. While translating these principles and policies into programs, we need to guide those programs based on specific sectoral policies which are based on evidence. And the process of generating one giant field of pure science as well as social science, which is a mental exercise of deductive nature or synthesis or even experimentation. My point here is that an idea or concept has to go through the rigorous procedure before we utilize that knowledge to guide our policy and strategies, and translating them into public services like health care delivery in our case. So, if we have preventive measures or tools or say even drugs that have evolved through discovery and development phase, then we need to deliver to the people and save their lives or cure them of life-threatening diseases. All these translational phases from discovery to delivery is so complex that sometimes it is political before we can include them in policy within the government system. 

Source: https://blogs.egu.eu

Here come those skills such as agenda setting,  which is "the process (or processes) by which an issue is brought to the attention of policy-makers and it is the first stage of the policy development process." (Manuela et al. 2016) An issue could be anything - preventive a diseases, educating people through a new method and so on.  In order to inject such issues into the radar of policymakers, there are drivers of policy change or introduction or even review - idea, interest, institution and network or coalition (3 I + N). Someone's interest could be guided based on purely academic in nature, while others could be economical or political or purely humanitarian or even social responsibility. (Manuela et al. 2016) There are various theoretical approaches to agenda setting. One of them is Kingston model that imagines 3 streams of problem, policies, and politics, which are at continuous interplay and we as a promoter of any policy agenda look for a convergence whereby there comes a window of opportunity. In this dynamic of the intense interplay between streams, we need "policy entrepreneurs" or we can call "Policy Champion", who can sense and forsee underlying position and power of players with various interests.  In understanding the game of play, we need to be able to figure out the political landscape so we will be able to formulate policy and adopt in the larger framework of the health system. Here, the meaning of power among stakeholders is dictated by their political authority, financial resources, and technical expertise.

In the effort for policy formulation and its process, we need never forget the importance of stakeholder analysis (SA), which is as an objective assessment tool has commonly been used in business, change management and development. (Makan et al., 2015) SA can be defined as "as a systemic technique for gathering insights relating to a proposed action or reform" by "identifying, categorizing and analyzing individuals or groups that are likely to have a "stake" in a proposed action, and explore opportunities for increased stakeholder engagement." (Makan et al., 2015) This can be conducted by gathering data through document review, media analysis and in-depth interview or by brainstorming with knowledgable participants. (Gilson et al.) Qualitative content analysis, an extension of stakeholder analysis, is also a useful means for summarizing stakeholder interest, power and positions and possible future impact regarding the scale-up of a proposed action and also demonstrated its relevance as a tool to prioritize engagement activities among already mobilized stakeholders.  (Makan et al., 2015) While the force field analysis is helpful in summarising multiple stakeholder analysis (e.g, cross-country stakeholder analysis) done in multiple locations and provide a comprehensive picture of the balance of support and power around a "political management strategy" (Gilson et al.)  SA is also useful in an illuminating host of opportunities available to narrow the gap between research, and its translation into knowledge, including policy and practice. Notably improve the translation of evidence-based research into policy and practice (Makan et al., 2015) and generate better outcomes out of the implemented programs/projects for the improvement of the health system. In this effort, we need to understand the theory of change (ToC), which is "essentially a comprehensive description and illustration of how and why the desired change is expected to happen in a particular context." This can be defined as "a specific type of methodology for planning, participation, and evaluation that is used in the philanthropy, not-for-profit and government sectors to promote social change and defines long-term goals and then maps backward to identify necessary preconditions". In addition, we also need to be able to develop research uptake and communication strategy, which is a good way to prioritize stakeholders for the purposes of strategic research uptake management (Makan et al., 2015) The research uptake is defined by Development Research Uptake in Sub-Saharan Africa ( DRUSSA) as a management process "working with scientific research that has both a traditional focus on building and disseminating the bodies of knowledge created in the academic domains, and a newer and wider focus on maximising the conditions for the application of these bodies of knowledge to achieve outcomes that have a developmental impact." 

On the final note, once we are done with evidence generation, its synthesis, securing funding and champions to always speak for and defend the idea/method, agenda setting and stakeholder analysis part and parcel of policy analysis along with political analysis, the policy is formulated and finally adopted into the health system. In order for the policy to translate into programmatic implementation, the middle of the process of policy formulation and its adoption has to go through at least 7 layered steps as below: (Manuela et al. 2016) 

1. General policy alternatives
2. Deliberation and/or consultation
3. Advocacy for specific alternative
4. Lobbying for specific alternative
5. Negotiation on a policy alternative
6. Drafting or enactment of policy
7. Guidance/influence on its implementation

References:

• Manuela et al. Health Policy Plan. 2016 May; 31(4): 493–503
• Makan et al. Int J Ment Health Syst (2015) 9:27
• Gilson et al. Health Policy and Planning 2012;27:i64–i76 doi:10.1093/heapol/czs007 

Role of Heath Informatics for Universal Health Coverage (Post 24/24)

It is common these days that all of us (policy makers, planners, managers, and even politicians) are advocating for evidence-based management, data-based decision (3D) making, or evidence-based medicine and so on. In all of these disciplines, “evidence base” is the heart of the matter and without which it is hard to push forward an agenda in a world where rationality, accountability, and fairness exist. We can also state here that our statement or any thought processes based on solid evidence is a practice that has been handed over to us since ancient years. In a way, it is a practice of seeking truth or near the truth. And truly, we have arrived at such a juncture of history that we are witnessing a rapid boom in Information technology (IT) that we are now entering into an era of Artificial Intelligence (AI). We hear of automation (autonomous car/rocket/ 3D printing), big data, drones, Internet of Things (IoT), open data, Mars travel, human colonization of exoplanets or more recently of plasma-based engines, space-faring civilizations, ultimate traveling to planets around Alpha Centauri, our nearest star. Why I am bringing these technology-based revolutions that are happening and disrupting the way we do science, simply because we need to catch up and explore in that direction of utilizing these available ideas and tools for our day to day work and activities. For our case in strengthening our health care delivery system from the health information system to hospital management to logistic supply and its delivery to remote parts of our country and improving the lives of our citizens.

We can safely say that IT and health sectors are two fields that have proportionately grown at a fast pace compared to other fields. Just recently (2017), Nepal Telecommunication (NTC) launched 4G/LTE service. Now, we can communicate in video mode and google any information from any towns all of the countries, be it in Simikot or Mugu. Such a fast pace we are moving ahead in this field. Also, we have to stress here that public health services are one of the most widely distributed public services that reach each and every corner of our country. There are numerous challenges that have been discussed for such a long time that we need to fix the ailing health care delivery platform if we are to provide quality health care. It is said that poor quality health care kills more people than communicable or non-communicable diseases. It is very clear in front of us, we can solve many such governances, management, logistics as well as a hospital as well as public health issues utilizing IT as well as informatics integrated into the health system. For this matter, we are so lucky that Health Informatics is a term describing “the acquiring, storing, retrieving and using of healthcare information to foster better collaboration among a patient’s various healthcare providers. Health Informatics plays “a critical role in the push toward healthcare reform.” This field is  “an evolving specialization that links information technology, communications, and healthcare to improve the quality and safety of patient care.”

It is timely to remind us here  and that the Nepal Constitution 2072 in its Clause 51 (Policies of the State) and that relates to Sub-clause “(b) Policies relating to political and governance system of State” also says that:

“to guarantee good governance by ensuring the equal and easy access of the people to the services and facilities delivered by the State, while making public administration fair, competent, impartial, transparent, free from corruption, accountable and participatory”

While Sub clause “Policies relating to development” also reiterate:

“to ensure easy and simple access of the general public to information technology by developing and expanding information technology to the tune of national needs, and make optimum utilization of information technology in the national development”

Whatever we proclaim as fundamental rights in our constitution, we will not be able to achieve such goals if we are not efficient in measuring the inputs, processes, outcome, and impact of any budget and program allocated and implemented through public services. Therefore, it is exactly true when we say, “ if we do not measure then we do not know where we are going”. Compare this scenario to an aeroplane taking off, in flight and during landing, if the pilots are equipped without all those radars and other metrics that measure altitude, speed, direction, fuel gauge, temperature, pressure, wind speed and so on, then we can’t imagine from traveling from A to B in an airplane. So is the similar scenario of health - care delivery.

As we enter the 21st century, the world population is approaching 8 billion and most of this humanity reside in Asia, particularly India and China. In between these two giants  - Nepal is situated with a population approaching 30 million for this small country. We are sustaining to our habits and habitat till now. However, time ahead does not look that easy with increasing population density, climate changes, alarming deforestation, rising poverty, and unemployment rate and brewing conflict with political instability despite a decade long wasted years of people’s war. Despite all these challenges in the vicinity, people have expectation from elected government and our new constitution 2072 have loudly stated that fundamental rights related to health and welfare, education, food security, clean air and water, transportation and so many aspirations are written in letters. In this respect, our government of Nepal (GoN) recently passed public health and safer motherhood acts in order to ensure basic health rights that include emergency care wherever and whenever. Above all, GoN is also a signatory to global health as well as developmental commitments such as Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). The key principle that underlies all these noble endeavors is that “no one should die or fall ill not because one is poor such that no one is left behind”. Therefore, it is the responsibility of the government to provide financial protection from illness or diseases such that nobody has to get trapped in poverty.

For this, the best approach would be the comprehensive approach that SDG has espoused to fight poverty, inequality, pollution, illiteracy. So to be a part of this noble cause of global as well nation’s commitment, we need to implement the key strategies that are e-governance policy of Nepal. For this to be successful, we need to establish a dedicated Health Informatics division within MoHP such as "Health Informatics and Analytic"  as a division to be lead by 11 level or alternatively, we can accommodate this "Health Informatics & Analytic" component into the current Population Management Division to be lead by 11 level health professional or population scientist. For this, we can follow the model of measure evaluation. We need to establish a framework for strong coordination and collaboration specifically to align Policy, Planning, Monitoring, Regulation, Quality of Care, Health Economics and Research wings and carry out following key activities:

• Strengthen data-based decision making, which will feed Evidence-Based Policy and Planning within MoHP
• Provide technical leadership through collaboration at local (provincial governments), national (Other governmental sectors, NHRC/CBC/VBDRTC/Universities/Research Organizations / non - gov organizations etc), and global levels (UN organizations/foundations/universities/research organizations etc) to advance the field of global health monitoring and evaluation.
• Build the sustainable capacity in evidence-informed decision making, which will vitalize evidence-based Policy and Planning within MoHP
• Create, implement, and facilitate state-of-the-art methods for and approaches to improving monitoring and evaluation, health information systems, and data use.
• Establish data derived decision (3D) making framework, which is vital for aligning policy, planning, monitoring and evaluation, quality of care, health economics and Implementation research activities within the broad framework of UHC as well as PHC revitalization.
• Establish a health economy unit (Attention: we should not minimize the importance of the health economy as a discipline)

-->

Minimum Service Standard (MSS) - a stepping stone for Quality Health Service in Nepal (Post 23/24)

Quality of Care (QoC) is currently a hot topic not only among health professionals but this is a national agenda that has touch upon the life of every family in Nepal. True, when we are not feeling well or injured, we have to visit the health center and we expect a decent level of care. With this thought process, every leadership at the Ministry of Health (MoHP) have put on an effort to bring quality health service to the people. Accordingly, the Policy on Quality Health Services, 2064 in its annex has the operational definition of quality health services as “ that produces desired health outcomes and fulfill consumer needs with optimum use of available resources provided by trained and competent providers as per national norms and standards with minimizing risk for providers as well as consumers.” Most recently, the National Health Policy (2071 BC) has envisioned “A provision to provide quality health service as a fundamental right of the citizens shall be ensured.”, which is one of the key principles that guide the National Health Sector Strategy (2015 - 2020). And to stress here again, the issue of quality health services has become the burning issue and the most talked about everyday news headline. Sadly, the flood of negative headlines in the media have caused so much distrust in public health care services, be it private or public, within Nepal.

In this light, let me share an excerpt from “The epidemic of poor-quality care” which is easy to relate with our current health delivery challenges in terms of difficulty providing quality of health care services to all people. It says, “the over 8 million excess deaths due to poor quality health systems lead to economic welfare losses of US$ 6 trillion in 2015 alone. The Commission found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care. These include: Approximately 1 million deaths from neonatal conditions and tuberculosis occurred in people who used the health system but received poor care. Poor-quality is a major driver of deaths amenable to health care across all conditions in LMICs, including 84% of cardiovascular deaths, 81% of vaccine-preventable diseases, 61% of neonatal conditions and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths. Insufficient access to care was a proportionally greater contributor to deaths from cancer (89%), mental and neurological conditions (85%), and chronic respiratory conditions (76%), highlighting the need to increase access to care for these conditions alongside improving quality. Data from over 81000 consultations in 18 countries found that, on average, mothers and children receive less than half of the recommended clinical actions in a typical visit, including failures to do postpartum check-ups, incorrect management of diarrhea or tuberculosis, and failures to monitor blood pressure during labour. A third (34%) of people in LMICs report poor user experience, citing lack of respect, long wait times, and short consultations. Similarly, confidence and trust in health systems are low. For instance, in India, half of the households report bypassing their nearby public facility, with 80% citing at least one quality concern. Poor-quality care is more common among the vulnerable in society. The wealthiest women attending antenatal care are four times more likely to report blood pressure measurements, and urine and blood tests compared to the poorest women; adolescent mothers are less likely to receive evidence-based care, and children from wealthier families are more likely to receive antibiotics. People with stigmatized health conditions, such as HIV/AIDS, mental health and substance abuse disorders, as well as other vulnerable groups such as refugees, prisoners and migrants are less likely to receive high-quality care.”

Source: https://www.eurekalert.org/pub_releases/2018-09/tl-tlg090418.php

In Nepal, there is a serious effort put into exercise to improve the quality of care in Nepal. For this, there is a new paradigm or an approach of Minimum Services Standard (MSS) has been implemented and now, it is being scaled up all the over the country.  In its implementation, there are 3 key area of focus: (1) Governance and management  (2) Clinical Service management and (3) Hospital support system management. In a way, MSS can be taken as quality improvement (QI) tool, which is a part of hospital management program with 8 major areas: (1) Governance (2) Organizational management (3) HR management (4) Financial management (5) Information management (6) Quality management (7) Clinical management (8) Hospital services. This is also an evaluation tool, which is used for the regular periodic assessment. However, there is one burning question being asked everywhere is, “how do we motivate the hospital team to sustain MSS practices? Our experiences say that some hospitals are utilizing this MSS as a management tool with the greatest enthusiasm and have brought a remarkable change in service delivery, while some hospital team are either not that motivated or least bothered and taken as an additional burden to their daily activities. Anyway, ups and downs are the usual stories in the introduction of the noble effort of the good of the public services. With time and learning, every hospitals and clinical team will adopt it into their core hospital practices as a routine activity. In order to push this momentum forward, MoHP is simultaneously developing an implementation guideline for MSS.

Also, we need to understand that the issue of QoC is not only our national issue but this is a global issue where poor quality of care is taken as a threat to efficient and social justice. Therefore, this issue of QoC is an essential function of all government from federal to provincial to the local level. In this respect, all the governance structure for hospitals, there should not be compromised in the quality of recording reporting and recording of services provided along with robust M & E function built within that is coordinated at all levels. Therefore, the role and responsibilities of each level of govt need to be loud and clear and communicated well in advance in writing. So, hospital strengthening and standards improvement should be an important activity and targets in annual policy review as well as program planning and budgeting.

Another point that is often raised and discussed in a various forum is that “fragmented or duplicated  health care delivery and its implementation is a key challenge that we need to address." So, what it means is that there are various different quality frameworks as well as tools being used for a long time through various programs within DOHS. It is therefore high time that we create a single quality of care framework under which all quality related tools or approach has to be integrated so we will be able to integrate the information system ( which is also fragmented !!) under one roof of M & E action plan. This will help MoHP in reducing the confusion, resource wastage and save us from failure or underperformance of many programs so all programs will run in the best interest of our people.  

Not to forget, whatever tools for implementation are introduced after we need to consider in all seriousness the sustainability of it, whether MOHP has all the capacity and resource to maintain and scale it up all over the country? In its elaboration, there are some measures taken by MOHP for in-service quality assurance for healthcare providers and plans for health service accreditation process. For this initiative, all the professional bodies like NMC, Nursing Council, NPHC and Ayurved Council have a major role in in-service quality assurance. We need to clarify upfront that MOHP alone cannot be responsible for all these process and procedures. And for that reason, there are various councils, academic institutions, and research centers.  In nutshell, the provision of quality health care services has to be everybody’s business and national effort.

Federal restructuring and health care delivery in Nepal Post 22 / 24 (October 2018)

Restructuring of the whole governance framework with its all functional structure that includes health care delivery infrastructure is a humongous task and a historical event. In a way, we are lucky that all of us are witness to such a turning point in our Nepal history. At this juncture, however, our government should act “farsighted” and be “proactive” in foreseeing possible consequences, which could be either positive or negative or mixed that might be expected at the different level of health care delivery. For this, our leadership must act responsibly and in concerted effort engaging all stakeholder. This means that all political leaders must act above their party lines. At this crucial hour, let us rethink and reimagine of what should be streamlined ad course corrected in the deliverance of basic health service (BHS) package to all Nepalese citizen. This provision of BHS is stated as a basic fundamental right of every citizen and it's the responsibility of the state to translate those basic services through public health structure. It is therefore stated in Part 3, Section 35 of the New Constitution (2072 BC).

“The State shall direct its international relations towards enhancing the dignity of the nation in the world community by maintaining international relations on the basis of sovereign equality while safeguarding the freedom, sovereignty, territorial integrity, and independence and national interest of Nepal.”

In order to realize, translate and deliver those rights of all Nepalese citizen as basic services in the community, 4 directive principles have been promulgated in Part 4 Section 50 such that these directive principles “shall be the guiding principles for the governance of the State” stated in Section 49 of the same part 4 as follows:

1.     The political objective of the State shall be to establish a public welfare system of governance, by establishing a just system in all aspects of the national life through the rule of law, values and norms of fundamental rights and human rights, gender equality, proportional inclusion, participation and social justice, while at the same time protecting the life, property, equality and liberties of the people, in keeping with the vitality of freedom, sovereignty, territorial integrity and independence of Nepal, and to consolidate a federal democratic republican system of governance in order to ensure an atmosphere conducive to the enjoyment of the fruits of democracy, while at the same time maintaining the relations between the Federal Units on the basis of cooperative federalism and incorporating the principle of proportional participation in the system of governance on the basis of local autonomy and decentralization.

2.     The social and cultural objective of the State shall be to build a civilized and egalitarian society by eliminating all forms of discrimination, exploitation and injustice on the grounds of religion, culture, tradition, usage, custom, practice or on any other similar grounds, to develop social, cultural values founded on national pride, democracy, pro-people, respect of labour, entrepreneurship, discipline, dignity and harmony, and to consolidate the national unity by maintaining social cohesion, solidarity and harmony, while recognizing cultural diversity.

3.     The economic objective of the State shall be to achieve a sustainable economic development, while achieving rapid economic growth, by way of maximum mobilization of the available means and resources through participation and development of public, private and cooperatives, and to develop a socialism-oriented independent and prosperous economy while making the national economy independent, self-reliant and progressive in order to build an exploitation-free society by abolishing economic inequality through equitable distribution of the gains.

4.     The State shall direct its international relations towards enhancing the dignity of the nation in the world community by maintaining international relations on the basis of sovereign equality while safeguarding the freedom, sovereignty, territorial integrity and independence and national interest of Nepal.

Now is the time for all Nepalese citizen to rise as a nation of hard-working people, although the task ahead looks ambitious. To realize our fundamental right, in particular, to deliver BHS to the people, MOHP must be able to provide for free and of quality care. So it is important to think through the content of the package and make it realistic such that our 4 S (system, software, space, supply)  is capable of handling and delivery of those services. However, it is good to be up front and get prepared that there is a risk that MoHp will struggle fighting plenty lawsuits, given that our health care delivery is weak at present and after all the provision of BHS is law and if you do not provide these services, then one has every right to demand the service. So BHS has to be realistic based on current capacity and capability of local health institution to deliver all the elements of health services.

One can see the danger of making the package bulky from the very beginning without certainly of being able to deliver with quality to all from rural municipal of Humla to KTM. Here, we have to be  cognizance of possible risks that MoH has to face in the future if we are to overload BHS. It is here to remind us that MOHP is already providing free services for certain groups for cancer, kidney disease etc. Some commenters are saying that these free care services need not go in BHS package since GoN will not have enough funds to cover such costs. Also, it is said that some diseases have geographic concentration, these need not go into BHS package, while local government could prioritise these diseases and allocate additional resources from their revenue. It  is also shared as an opinion that few disease (KA/Malaria/Leprosy) that are in the verge of elimination may require focused attention and quality must be ensured or else the elimination goal may be off track. Such priorities can be best handled as a dedicated  programs and need not be included in BHS package. For now, health experts have done a good work in defining the services for BHS package, but still it is sad that the list is too long. Financial costing could be one of the way to review the package and come up with a realistic one.