Nepali Times
Public participation in public health  


Name Please: A representative from a local mother's group takes down the names of the participants at the social audit.
With the monsoon at its peak, the rice planting season is in full swing here in the plains of western Nepal. But the paddy fields around Chaumala and surrounding villages are empty.

The locals have all gathered under the shade of a large mango tree in the premises of Chaumala Primary Health Care Centre (PHCC) and are engaged in intense discussion about their pressing health concerns.

It is called 'social audit day', a programme introduced by the Ministry of Health and Population (MoHP) in 2009 to strengthen local participation in decision-making, accountability and transparency in health services. It provides a platform for healthcare workers to build trust and discuss issues concerning the community with the public and VDC officials.

"We are here because we want to tell the health officials there is a shortage of iron pills and condoms in the villages and that is affecting our work with the community," explains Sabitri Aryal, a local health volunteer, when asked why she attended social audits.

Local participation in decision-making has helped health providers identify and respond more urgently to local needs. "The audit is making it easier for us to identify problems, as well as come up with solutions through the full participation of the community," says Shova Mani Bhatta, an Auxiliary Nurse Midwife at the Chaumala primary health centre.

As the discussion proceeds, it is clear that the audit doesn't just encourage locals to communicate their community's health needs, but also allows service providers to explain their side of the story.

At Chaumala, locals complain about being mistreated by health professionals which discourages them from visiting the centre. Kaushila BK, a Dalit woman, says she was sent away with her pregnant daughter-in-law because of lack of facilities. "How are we going to take care of ourselves when government health facilities meant for poor people treat us like cattle?" BK asked the health centre officials. Other participants, many of them mothers with toddlers in tow, nod in agreement.

Manager Ram Chandra Panday admits there is poor quality service, but says it is due to lack of infrastructure and health professionals. "Our hands are also tied. The drugs do not reach here on time and the doctors appointed for PHCC fail to show up on a regular basis," Panday explains to those gathered.

The budget and expenditure of the Primary Health Care Centre is also made public during the audit. "We want to make the workings of the Centre as transparent as possible and gain the community's trust," says Panday.

By promoting good governance at health centres, the project helps fill the vacuum created by the absence of elected VDC representatives. In 2011, the District Health Office with support of the German aid agency, GiZ, started the social audit programme in 16 villages in Doti district.

"As we had decided during last year's audit we conducted regular awareness programmes on cholera prevention and cut down on staff leave so that we could closely monitor cholera related cases," says Bhakta Singh BK of Durgamandau Health Post. Durgamandau VDC in Doti is one of the many areas where commitments made during SA have helped supply drugs on time and counter cholera outbreak.

"Social audits provide people with a voice to hold local health supervisors accountable in a positive environment," explained Susanne Grimm of GiZ.

Back in Chaumala the discussion gets livelier as people start voicing their opinions with greater confidence. The meeting concludes after health managers promise improved health services. As participants walk away from the health centre, it is clear the participatory approach works.

But locals are also worried that health officials always have an excuse when things don't work: lack of budget, qualified personnel or facilities. And there are always promises that are never kept.

Sabitri Aryal stays till the end, and tells us with a sigh: "I hope the commitments made today won't just remain on paper and we get to see improvements."

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Remote control

Achham district has one of the worst health parameters in Nepal, largely because of low literacy, poor drinking water and lack of basic health facilities. It has the highest incidence of HIV in Nepal, and one in every five children is severely malnourished.

But in the last three years, the government's neglected Bayalpata Hospital has been managed by a US-based group who set up Nyaya Health. Established by two doctors from the Harvard Medical School, it runs Bayalpata Hospital under a unique public-private partnership with the Ministry of Health.

The 15-bed hospital has a staff of 54, many of them volunteers, and provide free, quality healthcare to the people of Achham and even neighbouring districts. With a new surgical ward in place, Bayalpata has already made a dent in Achham's poor health statistics, especially by enabling C-sections to be performed for complicated pregnancies.
"The hospital is god-sent for us," says Kare Bhul, 58, of Chandika VDC who was diagnosed with HIV three years ago and has been receiving anti-retroviral treatment here. "Had it not been for Bayalpata Hospital many of us would have died by now."

Working in a remote district like Achham is demanding for the team at Bayalpata, and the major challenge is recruiting and retaining doctors to stay. "Given the remoteness the application for many crucial positions including physicians and surgeons hasn't been robust," says Gregory Karelas of Nyaya Health Nepal.

Nevertheless Karelas is hopeful that this unique model of reaching to the poorest of the poor with quality healthcare will be replicated in other areas of Nepal and attract motivated doctors to serve in rural areas.

Bhrikuti Rai in Achham

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(11 JAN 2013 - 17 JAN 2013)