The Fog Lifts

When you're in the eye of the storm things look peaceful and the pace of what is happening in the hinterland may be deceptive.  From the eye, it's easy to believe that not much is happening and so too is the life of a consultant working with the Health Ministry in the Federal Democratic Republic of Nepal.

Despite all the games of musical chairs, dodge ball and other political shenanigans, we've set out to affect substantive change to the healthcare system in this country.  There are days that I think that this is not possible, not much is happening and long term change cannot be affected.  But, as I move from the eye to the balcony (a term served up by Ron Heifetz who offers new ways of looking at leadership), I can see that the swirl of activity that we have put into motion is beginning to have an impact.

On some days it's the simple things - ensuring that key personnel are equipped with the tools that they need to operate more efficiently - like computers.  Believe it or not, I've been working with a team of locals who have shared a computer among 6 people in one segment of the department - just imagine the bottleneck that this has caused - little wonder the procurement plan for essential drugs and medicines is late every year.  Well, last week the team finally received computers!  Can they use them? Well, that's another story, but I am confident that our 'capacity enhancement' efforts will make considerable progress in this area soon.

More than 50 suppliers submitted bids and showed up for the bid opening for medical equipment this month.

The drug supply that comes into Nepal through central procurement has lacked quality systems - little wonder there are so many concerns about feckless pharmaceuticals and medical products that fail to meet basic standards.  And when it comes to medical equipment, department directors (Family Health, Child Health, Maternal Health, Epidemiology and Disease Control, National AIDS Center, etc) have been requesting and seeking equipment from specifications that were developed twenty, fifty and in some cases a century ago.  It is hard to imagine - but now I know why when I step into a public health facility, it is like stepping back in time.  Why would a country do this? For one reason, those responsible for requesting equipment have not been aware that technology has evolved in nearly every aspect of medicine - anesthesia equipment, x-ray, ultrasound, beds have evolved from manual crank to hydraulic (a term that terrifies those in rural settings), imaging equipment has evolved from film-based to digital based and diagnostic testing has evolved from reagent based single test to multi-test, throughput based.  We have now implemented a system where a sustainable update of medical technology specifications can be built into the procurement process.

Archaic equipment in a rural hospital O.R.

A Quality Specialist will be coming to devise a plan where pharmaceutical testing - including chemical composition - will occur not only pre-shipment into the country, but at various points in the 5 regions and potentially a sample of the 75 districts.  There have been reports of cartels interfering with the supply chain and replacing free drugs purchased by the government and donors with sub-standard items and then selling the 'free drugs' on the open market.  Other corrupt practices have interrupted the drug supply and caused many to go without essential medicines.

Nepal is fortunate that the HIV/AIDS population is small - under 10,000 affected people in a country of 30million, however, the supply of medicines and services was interrupted as a result of a failure to act among government officials.  Essential services to provide care and medicine to many of the disadvantaged groups around the country - migrants and families, sex workers, prisoners, intravenous drug users - will be affected putting greater populations at risk.  The management of the supply of medicines will be moving to the Logistics Management Division where capacity is still being developed to include - basic forecasting skills, accessing global reference pricing, updated specifications and quality medicines.

In addition, the base of suppliers who will consider competing for the government's business are beginning to return after turning their backs on a government that proved to be too corrupt and undeserving of their time and attention.  Local and international suppliers are once again beginning to show up to bid in a more transparent process for Nepal's business.  They appreciate that fact that we now have a formal Complaint Handling and Dispute Resolution procedure and a Code of Ethics that will guide (if not ensure) the process.  This is encouraging despite the seemingly slow progress.

The data that is obtained from health facilities and districts that indicates consumption and usage patterns around the country offers little insight on what is actually happening.  The analysis of this data will provide further insight to the nature of the problems and the interventions that must be implemented to improve forecasting, planning, budgeting, etc.

When I step back and consider where change has been affected. I am pleased with the progress, the transparency and the loopholes for potential untoward actions that have been closed.  The fog is lifting off the mountains now, monsoon season is passing and with each day it appears that we can see with greater clarity and chart a more direct course toward an effective healthcare system with an improved access to essential medicines and services.