Digging In

Digging into the work for the Nepal Health Sector Support Program (NHSSP as it is known) includes getting to know how the system works on a number of different levels - the overall government (currently operating without a constitution), the health ministry and all that goes with it including the politics, how political appointments are made, the struggles over creating a new constitution, the political factions - including the communist - Maoist - incumbent party, and the challenges that a living caste system brings to the mix.

International Development programs are currently working through a transition from a programmatic approach - the funding of specific needs with focused programs (i.e. Women & Children; HIV/AIDS; Healthcare financing; or Gender Equity and Social Inclusion) to the new approach, known as the Sector Wide Approach or [SWAp] which calls for international development programs to operate broadly across government institutions (finance, health, education, etc.) rather than merely implement a specific thematic program.  This means that programs are more integrated, and must consider how each affects the whole.  This is a good thing since in the past, a Leprosy (yes it still lives) or an HIV/AIDS program could be supported by NGOs (non-government organizations) that do not typically account for their contributions to a country's overall healthcare plan making it difficult to plan funding and determine gaps in need.  This has led to problems with duplication and waste of precious resources.

So, bottom line, SWAp is good, but can be daunting to manage across a team of program-specific experts.

The NHSSP team is basically tasked with revising the healthcare system of Nepal - including financing of the public sector, defining the Human Resource needs - both on a clinical and administrative level, scoping the job descriptions of public sector employees, developing educational programs that 'build' or I should say 'enhance' capacity - that's code for teaching people how to do the jobs that they have.  [To say 'building capacity' implies that it is not there at all, so the politically correct term is 'enhancement' - suggesting that there is something there to build on - now this remains to be seen.]  And finally, the area that I am focused on is procurement and dissemination of the medical products across the public drug supply system.

In Nepal, apparently, procurement in the healthcare sector is a point of interest for donors since public procurement has historically been fraught with potential for fraud and abuse.  There are numerous stories of cartels operating within the system that have had support from various officials to interfere with the drug supply.  One of our challenges it to put an end to such practices by creating policies and procedures that raise the transparency of everything and everyone that is associated with the procurement, distribution and management of the drug supply.  Where to begin?!

This week has been focused on discovery - meeting with various government advisors who have first hand knowledge of how the system works to build a foundation of understanding so that when I travel to the rural regions I can plan my approach and consider policy options in the context of the most challenging geographic settings (my first excursion is scheduled for the week of May 7th to a remote mid-western mountain district).

Another aspect of the drug supply sector involves suppliers who have, in the past been associated with 'undue influence' on government officials.  These suppliers are periodically invited into the government logistics management facility to ask questions regarding tenders that they plan to bid on.  Because of questionable historic practices - no one can be trusted.  While it is not a pleasant way to do business, it is one of the harsh realities of this operating environment.  The photo shown here was taken during a recent inquiry of suppliers regarding an open bid. The men in the photo are all competitors so holding one's cards close to the vest is part of the game.  One could cut the tension with a knife.