For an agriculture-based, undeveloped economy like Nepal, progress efforts have been largely driven by foreign aid and INGO funded work. Nepal’s budget for 2011/12 shows that over a quarter of government revenues were provided by foreign aid and loans . Over the period of 2004 to 2009, international aid have made up 40% to 50% of the health budget. This dependency carries risks at a time when concern of corruption within government of Nepal can play into the hands of international donor fatigue [28, 31, 32].
All EDPs that support the Nepali health system support SWAp. They either directly fund the government’s programs or fund INGO programs that support SWAp. This study did not find any instances where a donor only supported vertical programs. This is similar to the finding of a 2010 systematic review of integration of targeted health interventions into health systems. The authors observed that no interventions were fully vertical or horizontal and instead the picture is ‘highly heterogeneous’ .
SWAp in health was started in 2004 in Nepal. Donors as well as recipients prefer this approach to the earlier project approach. It is supposed to reduce duplication, lower transaction costs, improve aid effectiveness, and strengthen national leadership and health system . In our study, EDP KIs admitted that before 2004, vertical projects were being run and that after SWAp, the whole health sector is supported through a horizontal approach. Priorities are set according to national need. The guiding document is the NHSP-IP, which was formulated under the leadership of the ministry of health and population with inputs from EDPs and the civil society.
EDP and government KIs believe that SWAp is working well in Nepal. They credit SWAp for the fact that the health sector performed well even during the years of internal conflict (1996–2006), and also for Nepal winning the Millennium Development Goal (MDG) award for achieving goal five in 2010 . They also say that SWAp has helped reduce duplication of work and has fostered a better relationship between GoN and EDPs. This is further supported by a 2009 World Bank report that states that with SWAp, achievements were made in Nepal in reproductive health service delivery, child health, and family planning and health system strengthening .
On the other hand, KIs also agreed that SWAp’s actual impact can only be assessed after about 10 years of sustained implementation . Similarly, credit for the achievement of MDG goal five also cannot be given to SWAp or to any one donor as health resource tracking in a system where donors contribute to pool funds and give budgetary support is very difficult. When funds are disbursed through the government, they can be allocated freely and interchangeably to various programs making it difficult to attribute them to specific areas .
The leadership role in SWAp is given to MoHP . It should make sure that any intervention in health is complementary to and not a replacement of the existing systems . The opinions of KIs in our study were almost equally divided in this respect with some saying that GoN is a good leader, some saying that it is a bad leader and others saying that it is growing better as a leader. Evidence from other countries show that the leadership role can be ‘problematic’ because of limited leadership capacity as seen in Rwanda, poor relationship with the ministry of finance as seen in Mozambique, and change of senior management as in Zambia . We found the MoHP’s leadership capacity is poor due to the unnecessary presence of two secretaries, poor coordination with other ministries and the SWC and deficient communication between personnel inside the ministry. The frequent changes of personnel due to political instability cause problems with inter- organizational relationships, the transference of information and institutional memory.
Although the norm in a SWAp is for donors to pool funds , in Nepal donors are not obliged to do so. About 17% of health budget is pooled grant money. Grants can also be given directly and not pooled. This is termed ‘direct fund’ and does not form part of the government’s budget. This money is spent after a special agreement between GoN and the donor. It is earmarked for specific programs. One EDP KI said that their organization’s money is not pooled because the GoN does not use the money effectively.
A 2009 article on health aid flow over the last 10 years discusses that even though budget support and sector support are some of the most effective forms of aid, the proportion of aid that goes through these channels is low . We saw that EDPs give various proportions of their grants to the government, spending the rest on projects run by INGOs. One major donor only gives 5% of its grants allocated for Nepal, to the government. Money going to INGOs is not part of the government’s budget but the INGO’s accounting profiles are mentioned in the annex of the budget. Another donor gives one third of its grants directly to the district because it feels that government is not transparent and money given at the central level is not channelled out to the local bodies in a timely manner. In the 2010 Corruption Perception Index score by Transparency International, Nepal is ranked 146th out of 178 countries with a score of 2.2 . On a more positive note, a 2009 study on health aid effectiveness in Nepal states that INGOs are able to spend more of their funds at the community level so that their contribution at that level is more significant than aid provided by donors . However, without proper regulation and reporting, there are doubts as to whether INGO contribution actually helps fulfil national goals.
Government accountability is established when there are pressures from the civil society and service beneficiaries, political pressures within itself, and an independent audit office support . In Nepal, all donors except the UN agencies accept a single government audit done by the office of the auditor general that reports on a four monthly basis. All donors, be it the ones that pool or don’t pool their grants, have signed the JFA whereby reporting for pool funders and non pool funders is done in a joint manner and coordination meetings are held regularly. There is also the involvement of civil society in coordination meetings such as JAR. These facts indicate that there is government accountability in Nepal. However, in our study, most KIs said that JAR meetings are not effective. These meetings have become ritualistic, yield no coherent decisions and decisions that are made are not implemented. People do not come prepared and many issues are missed out. JAR meetings are important tools to assess the sector’s achievements and shortcomings. However, their success depends on the expertise and experiences of the people involved .
For any governing body to function optimally, it must have full knowledge and control of internal and external factors working in its realm. Our government KIs told us that INGOs coordinate with the SWC at the central governmental level. Other government bodies such as the MoHP and MoF do not get involved with issues of INGOs and do not have any knowledge of their work. There is no effective communication between SWC and other government organizations. The MoHP and MoF only deal with donor organizations and their reports do not reflect contributions of INGOs. KIs from all three categories stated that SWC is not competent to handle all INGO because it is understaffed and does not have separate departments to manage INGOs from different sectors. From our interview with the representative from SWC, we learned that personnel there do not know anything about SWAp, and had never heard it mentioned before. SWC is the organization that approves or disproves programs proposed by INGOs. In this context, there is no mechanism to ensure that INGO programs also contribute to SWAp.
Several KIs revealed that the SWC has knowledge only of INGOs that have been registered there. The latest list (Sept 2011) of registered INGOs available at the SWC website shows that of the 199 INGOs registered, 67 work in the field of health . There are organizations that work in the capacity of an INGO in health but are registered elsewhere and follow entirely different sets of rules, having no obligation of reporting their work to SWC. One such organization is registered as a company. The SWC does not have any power to direct these organizations to come through the proper channel. During the course of our study, we came across several INGOs that are currently working in Nepal for health and are not registered at the SWC. KIs from these organizations explained that although they may not work with SWC, they work with other government bodies and keep the government informed of their work.
Both government and INGO sources agreed that INGOs adhere to most rules set by the SWC such as the 80:20 money allocation rule, they all work with local NGOs and community level government bodies. However, dialogues with KIs working at rural government hospitals suggested that at the local level, INGO clinics duplicate work done by government facilities and are diverting skilled health workers from government jobs to better paying INGO jobs. Trainings paid for by donors and INGOs deprive government facilities of health workers for long periods of time. Although all sign the general agreement and prepare project agreements, they generally do not wait for SWC approval before starting projects, as stated by KIs from government as well as INGOs. INGO KIs explained that this was due to long delays in the process. These projects, thus, may not fall within government agenda. INGO KIs, however, explained that they do a full needs-assessment before designing any project to make sure it fits within government plans.
When we categorically asked our KIs about any difficulties they faced in their work in the health sector, most government KIs said that everything was going according to plan. Most difficulties were faced by EDP and INGO KIs, as described in Table 3 and most dealt with shortcomings on the government’s side. This included issues of political instability, government instability, structure, capacity and alignment within government sectors, and competence of government employees. The government KIs who stated problems also stated those dealing with government short comings including political instability, lack of human resources in government, two secretaries in MoHP, lack of coordination between government bodies and difficulties working with local level government bodies.