Reading Between the Lines

Whenever in a different country where your mother tongue is not the native language there are many things that are subject to interpretation - the turn of the head, the wave of the hand, shuffling of papers, a bare foot pointed in the direction of the host, etc., so knowing the meaning of these subtle gestures can only help to assess a situation that can be somewhat tenuous.
Government politics is a lot like the interpretation of subtle gestures...but on steroids.  Every nation is built on a history of actions and reactions to events and while people form their opinions, cultures formulate their mores or, what is culturally acceptable.  Take the custom of bakshish, for example.  Who said it's wrong to pay off an official because he was kind enough to award you with a lucrative contract? It is after all, just a gesture of appreciation, is it not?  When do acceptable cultural norms become inappropriate, distracting and potentially dangerous? Who's to say?
One's frame of reference underlies the decisions s/he makes and influences what s/he tolerates from others, so when a government is comprised of an interconnected network of cultures, castes and political ideologies, it's little wonder that the tension behind the decision making process is so strong it leads to deadlock.

This is, in essence, what has happened in Nepal in the post conflict error.  It's a contradiction in a way; the country claims that it is working hard to bring gender equality and social inclusion to its operations, yet people are careful to point out when they have been raised Brahmin (the top echelon of the caste system) or when they disapprove of someone who accepted an inter-caste marriage between say a Dalite and a member of a higher order caste.
Nepal has established a minimal healthcare package for its public health facilities - an honorable and rather difficult task whereby the health ministry must consider the greater good.  In the process of weighing the economic situation, burden of disease and potential health risks of the population, it determines what it can (and must) provide as basic services.  Once defined, all other goods and services are incremental to the basic plan.
In addition to the basic plan of essential drugs and medical services offered by the government, the health ministry, comprised of a number of divisions run by physicians who lead different healthcare programs, offers a variety of goods and services on a national basis.  These divisions include; maternal health and safe motherhood, family health division, child health division, emergency and disaster relief, national center for aids control services, the leprosy unit, etc.
Historically, each of these programs defined, forecasted and procured medicines and services for their own health initiatives - sometimes (quite often in fact) with the support of various donor agencies, they determine what they can offer and they make arrangements to deliver these items nationally with the support of the logistics management division which does general forecasting, planning and procurement for the bulk of the public goods for health.
What goes on behind closed doors of division leaders and those who work directly with suppliers outside of the logistics management division (and even within the LMD), has been the subject of ample controversy over the years.  Some say that because procurement of goods can be so lucrative (for those of a particular moral persuasion), that centralized procurement under the careful watch of international consultants with the interest of the donors in mind, must replace all decentralized efforts.
If you read between the lines, this means that someone needs to aggregate and harmonize the national need and foster transparent practices that lead to more efficient, cost effective and streamlined outcomes.
If you were asked to step in to change such practices in a culture on the other side of the globe, would you accept?  

Making a Plan

It's been nearly two months now since I arrived in Nepal, and the fascination with what is different is beginning to take a back seat to the focus on what needs to be done.  Much of what needs to be done is the creation of systems and processes that can be followed and used to guide good businesses practices - and when even the term "good business practices" is foreign to your audience, you can imagine the challenge in helping them to embrace concepts like transparency, accountability, data management, meeting discipline, etc.

Pharmaceutical Suppliers meet at the Ministry for a 'Bid Opening'

The Nepal healthcare system services the healthcare needs of 30million people - it's not a huge country - so on the one hand it seems manageable, but the flip side, its relatively small size makes it more challenging to attract suppliers to provide products and services to satisfy the needs of this small developing country.  When you couple the size with the geographic challenges and limited economic and natural resources it's a perfect recipe for being overlooked as a market for the private sector.  Add to this the potential for leaders who could potentially be in 'rent-seeking' positions and suppliers really need to think twice about doing business in Nepal - or similarly challenged nations.

The concept of 'rent-seeking' is used to describe a practice whereby political appointees pay their superiors for the 'honor' of serving in a government post.  To earn the funds to pay the rent (so to speak) they often engage in practices that enable generation of funds outside of traditional (or acceptable) or "good business practices".  Now I don't want to implicate Nepal by suggesting that this kind of behavior takes place here - but just wanted to share an example of what happens in some developing countries to cast suspicion on government officials and causes private sector organizations to be wary of doing business in such settings.

Little wonder that the survival of such nations is so dependent on the generosity of donor organizations who seek to improve the lives of the poor and marginalized by creating programs that build infrastructure and systems that aim to build a foundation for growth.

One such program was introduced by KfW - a German organization that has generously underwritten a program to record, track and maintain medical equipment in the two most geographically remote regions of the country.  Leaders within the Ministry of Health participated as the contracted organization shared their plan for service and maintenance.  This is a great step forward, but it will be months before we know how effective this pilot program will be in improving functionality and the overall life of medical equipment.

To strengthen the skills of those entrusted with managing donor and government resources, we are holding regular meetings on a variety of topics that 'enhance the capacity' of political leaders and their delegates.  These range from reporting systems, accountability, working with suppliers, creating and managing budgets, using data to make informed business decisions and general analytical skills.

In the next few weeks we will be coordinating efforts to create a complaint and dispute resolution system; demonstrating how international supply partnerships can reduce costs and improve efficiencies; harmonizing division needs for essential medicines and healthcare products and building the skills of biomedical engineers to provide global insights to medical technology innovations designed specifically to address the needs of developing countries and their healthcare systems.

Every day there are more needs and more gaps that need to be addressed and, while daunting, it's exciting to help people find a way forward.  On the surface the obstacles seem insurmountable, but in reality it can be managed by coming together and Making a Plan.

If  your plan includes going out for a nice glass of Cabernet and a taste of Stilton cheese or perhaps a fine Sauvignon Blanc with a side order of mussels poached to perfection, ....by all means, plan on having a glass for me!  Enjoy the day!

Hard-working Nepali's use their heads when it comes to tackling particularly difficult problems.