Executive Summary
A mid-term review was conducted from October 25th 2015 to November 7th 2015 of the WHO Country Collaboration Strategy (CCS) 2013-2017 for Nepal. The main objectives of the review were to assess the relevance of WHO CCS in terms of responsiveness to the needs and national health priorities, to determine the effectiveness of WHO cooperation of its program implementation and analyze the sustainability of WHO-supported results and strategies. The MTR was asked to focus on the WHO response to the national health objectives, coherent and results oriented strategies supported by biennial programs and partnerships. A specific question on WHO’s response during and following the earthquake of April 2015 was included.
The methodology applied was to review and analyze relevant documentation and conduct semi-structured interviews and focus group discussions with key informants. A protocol including questions to guide the interviews was used. The preliminary findings, conclusions and recommendations were discussed with senior officials in Ministry of Health and Population and the Country Office to verify findings, observations and test the validity of the conclusions and recommendations. A rapid survey was conducted among the interviewees on their assessment of WHO’s performance in Nepal according the organization’s core functions.
The strategic priorities of the Country Cooperation Strategy 2013-2017 are still valid and relevant, but need to be more focused to avoid that WHO is overstretched in too many areas, and to adapt to the changes in the country, in particular the new Constitution, National Health Policy 2014 and the National Health Strategy 2015-2020. MTR recommends a shift with an increased priority to health system strengthening and non-communicable diseases.
WHO should strengthen its capacity to support and monitor universal health coverage and to address inequity in access to health services. The new Constitution implies restructuring of the state through federal form of governance with special emphasis on decentralization and strengthening local health governance. It calls to restructure central and local authorities to make them more responsive to health needs and provides an opportunity for addressing weaknesses in the current health care system and improve service delivery. WHO should be prepared to assist the Government at this important juncture and play a leading role in advising and coordination of the technical support from the external development partners. Health system strengthening should consequently become a core area for WHO support to Nepal. The health system support up to now has been too fragmented and requires a more holistic approach and enhanced technical capacity within the country office.
The development and finalization of the National Multisectoral Action Plan for Prevention and Control of Non-communicable diseases 2014-2020 has been completed. To operationalize the Multisectoral Action Plan will require an effective follow-up, continued advocacy and technical support. WHO therefore needs to work with Ministry of Health and Population (MoHP), Department of Health Services (DoHS,) other government agencies, civil society, academic and teaching institutions to move forward the NCD agenda. MTR recommends that NCD prevention and control should be a key strategic priority for WHO in Nepal.
The post-earthquake situation and a prolonged fuel crisis may also require reprioritization in the work plan 2016-2017, in particular for monitoring of the health situation and service delivery. Nepal UNDAF 2013-2017 Outcomes have been articulated in WHO CCS Strategic priorities and are linked to the strategic approaches and the main focus areas. SEARO’s flagship priorities are well aligned with the Country Cooperation Strategy.
The six strategic priorities of the Country Cooperation Strategy are to a large extent reflected in the biennial work plans. However, the majority of financial resources for activities have gone to achieve communicable disease control targets, while the other strategic priorities have received limited funding.
Weaknesses in the organizational and administrative structure of the country office has reduced the effectiveness of WHO’s work in Nepal. The administrative services have been decentralized to program teams resulting in an increased workload and difficulties in the management of administrative procedures. Many national staff are on continuous short-term contracts, and this is not providing the ideal environment for optimal work performance and pursuing technical excellence. The new leadership in the country office has already taken some steps to address these challenges. However, there is a need to relook at the organizational structure of the office to increase the effectiveness of technical support, program planning & management and administrative services. The organizational structure should reflect the key strategic priorities, an optimal mix of international and national staff with predictable time-limited posts to ensure best work performance.
The Technical Assistance Matrix developed with technical support from WHO used by all external development partners is perceived as a positive step. Although national counterparts perceive most technical assistance provided by the organization as satisfactory, WHO and the country office need to focus and strive towards technical excellence. Staff can spend more time on technical support and building of national capacity. Furthermore, to pay more attention that the technical assistance is fully adapted to the national context and that the recommendations are doable in Nepal. The MTR team has not been able to obtain a list of WHO technical missions for the current biennium,suggesting that the management and the follow up of technical assistance are not sufficient. The large field operation with SMOs for the surveillance of AFP and vaccine preventable diseases is providing an important national function, but needs to be handed over in a phased manner to the MoHP & Regional Health Authorities, and expanded to address integrated disease surveillance. This is important to ensure the sustainability of the WHO support in this area.
The continuous and sustained significant support to communicable disease control by WHO in the current work plan may suggest that not enough efforts have been done to institutionalize and hand-over some of these programs to the Government. MTR proposes that this may be assessed as part of reviewing the organizational structure of the country office.
WHO is considered by all stakeholders as a trusted partner working closely with MoHP. The good and close collaboration with MoHP/DoHS is one of the main WHO comparative strengths in Nepal, but the organization is perceived by partners as having difficulties in challenging the Government when needed. Many stakeholders, both within the Government, UN and other stakeholders, suggest that WHO could play a more significant role in providing leadership on matters critical to health, coordination and partnerships. The new management in the country office appears to recognize this and is taking a more active approach on health leadership and coordination.
WHO is participating in and hosting the EDP meeting, but the partners suggest that WHO could play a more active coordinating and advising role. WHO also needs to be more engaged in Joint Annual Review (JAR). MoHP and development partners have concern that WHO has not been able to unwind and mediate to solve the problems related to the GF grants. WHO has had limited engagement with professional societies, academic institutions and civil society.
The WHO’s response to the earthquake in April 2015 working with the Government and other partners was considered very satisfactory by all stakeholders. Efficient deployment of experienced WHO staff from the country office, SEARO and other offices shortly after the earthquake and effective coordination with MoHP and other partners are the main reasons for this achievement. WHO as an organization and EHA staff had taken on board the lessons learned from previous disasters effectively serving as lead for the Health Cluster and carrying out disease surveillance and other tasks as expected. Sustained disaster preparedness activities over several years had created a strong commitment from the key decision makers in MoHP and a platform for collaboration with the health partners. The recent establishment of the Health Emergency Operation Centre (HEOC) at the MoHP was shown to be effective and operational because of the preparatory work done.