Deja 2

The more confounded the situation becomes, the more difficult it is to capture it in a blog. Today I write you regarding a new chapter in the reform of the Nepal healthcare system.  Today I write you without concern for reprisal or retribution. Today I write the truth - unplugged and hope that it stirs something in you to welcome a new level of understanding, to accept that things are not always what they appear and to contemplate the 'good' that donors do around the world with the hope that you will also consider the role of international aid - particularly as it pertains to the health of the poor, the underprivileged and the marginalized.
In prior entries, I wrote about how Nepal as a post-conflict country under Maoist rule is endeavoring to create a constitution focused on the peace process; how it should be building a constitutional assembly that rules by consensus and how the various parties and castes in the country harbor ideologies so disparate that coming together seems impossible.  In many ways, the needs of a government body are much like a marriage - and, at the risk of taking too many liberties, there are two things that can make it work - (1) Stakeholders must want the same things in the end - i.e. a healthy population, a productive population, a population driven to innovate, to build infrastructure, to spread equality, etc., and (2) Stakeholders must be at the same intellectual level in order to facilitate communications that are clearly understood and respected.
When there is a clear gap in 'wants' and 'intellectual capacity' (in my opinion), reaching common ground is akin to traversing a chasm without the appropriate equipment.  This, ladies and gentlemen, appears to be the situation in which the government of Nepal finds itself.
In August, after considerable strife, internal conflict and public squabbling, Prime Minister Khanal resigned.  Within a week, a new prime minister was selected.  This was initially viewed as a 'must happen' event - albeit tragic since it appeared to result in a vacuum in leadership.  When Prime Minister Bhattarai was elected, however, there was a renewed sense of hope as his academic credentials and personal image was one of a thoughtful leader despite being known as the architect of the Maoist insurgency that led to a war in which more than 12,000 were killed, shifting the course of history in Nepal.
I do not write this to offer a history lesson of which I know very little, only as background to what I see as a potential miscarriage of justice to the Nepali people and potentially a mechanism to hoodwink donor organizations around the globe. (Keep in mind that Bhattarai is the 4th Prime Minister in Nepal in 5 years).

Shortly after his election, Bhattarai, like those before him, shuffled the political deck by replacing many of the Ministerial posts, creating yet another leadership team.  And with new ministers - including a Minister of Health (Nepal's 4th since the start of calendar year 2011) who would be soon under suspicion for bribery - a host of department leaders were appointed including Directors of many health ministry posts thereby bringing to a halt much of the progress our team had been making by establishing new systems, procedures and guidelines to bring transparency to governance structures in the health sector.

This, my friends, caused me to reconsider my role as a reform agent in Nepal.  But before making any rash decisions, I met with a local supplier who claimed to have something to say regarding corrupt practices within the healthcare sector's procurement practices.  In this session, I was able to confirm leaks to 'preferred suppliers' and practices that led to bribery and unfair influence of government officials.  And while such activities have been going on for quite some time, the network of activities that underpinned this was broad and complex.  A colleague of mine and I shared this with the donor organizations who seem interested in leveraging these findings to affect change, however, a perverse incentive arrangement between country leaders and their donor organizations suggests that success is measured in money spent, not in averting funds distribution.  Alas, the challenge reaches a new level of complexity.  Now, we not only need  to manage national governance within a fluid and feckless government system, but the trigger to affect change - donor organizations and their power base - the ability to disperse donor funds - hangs like a piece of rotten fruit before a hungry mob.  You want to get the mob to eat it before someone smells the stench on your hands.  This was an alarming epiphany.

A few months ago, I was informed by a contact at one of the world's largest consulting companies of a book called Megacommunities and the concept of leveraging key stakeholders to get things done.  In his book, Reggie Van Lee describes how the engagement of stakeholders in key sectors is important in affecting long term change with a focused mission.  His conclusions could have a profound affect on the way that donor funds are managed if implemented properly.

Back to what makes a marriage work: (1) Wanting the same things out of life.  If the government of Nepal is truly vested in outcomes for the country, it should engage in honest dialog not only with donors who are making care and infrastructure possible, but the advocacy groups (another key stakeholder) should have a seat at the table.  This makes a lot of sense given that when civil society groups in Nepal would rise up and let their voices be heard - typically in protest - the government would respond - with a 'too little' too late response, but it would create some form of action.  And (2) suggests that these groups should be allowed to offer their insights and experience to affect change and to balance the power base - in the process this brings transparency to the table.

I conclude this blog today by removing myself from the madness that has become the reform of Nepal's healthcare system. Sadly, it is my opinion, that the government is not ready for reform that utilizes resources that have become increasingly scarce from developed countries like ours.  Not only should the government set metrics for how it will utilize donor funds, it should - in good faith, and with the engagement of civil society - establish SMART objectives [Specific, Measurable, Achievable, Realistic and Time focused] as do the world's most successful private sector organizations.

Deja vu 2 is no longer a suitable endpoint. Donor governments need to act swiftly and with authority before the source of funds - people like you and I, stand up and interrupt the budgeting process.

It has been a pleasure to share my experience with you. Thank you for your interest.