Background
Governance principles | Broader themes included in the study |
---|---|
Strategic vision | Facilitative factors and barriers to development and implementation of plans and policies |
Participation and consensus orientation | Facilitative factors and barriers to coordination and consultation with service providers, service users and other sectors outside of health |
Rule of law | Facilitative factors and barriers to the development and enforcement of laws, as well as synergy between laws |
Transparency | Facilitating factors and barriers to ensuring transparency in resources allocation, decision making, appointment and transfer of staff |
Responsiveness and integration of care | Facilitating factors and barriers to integration of mental health in the health facility as well as in the community. Burden of mental illness, priority given to mental health |
Equity and inclusiveness | Facilitating factors and barriers to mental health financing, access to services and anti-stigma programs |
Effectiveness and efficiency | Facilitating factors and barriers to human resources capacity building, mental health infrastructure development and supply chain management of psychotropic drugs |
Accountability | Facilitating factors and barriers to ensuring effective enforcement of accountability measures. The role of press, elected bodies and judiciary in ensuring accountability |
Intelligence and information | Facilitating factors and barriers to mental health data recording, reporting, analysis and dissemination |
Ethics | Facilitating factors and barriers to service user satisfaction and quality assurance, as well as mechanisms for safeguards against unethical research |
The Nepalese health governance context
Methods
Setting
Sampling
Characteristics | Respondents n (%) |
---|---|
Gender | |
Male | 23 (82.14) |
Female | 5 (17.85) |
Total | 28 (100) |
Profession | |
Psychiatrist | 4 (14.28) |
Human rights worker | 4 (14.28) |
Public health officer | 8 (28.57) |
Psychologist | 2 (7.14) |
Ministry representative | 4 (14.28) |
Primary health care in-charge | 4 (14.28) |
Researcher | 1 (3.57) |
Police officer | 1 (3.57) |
Total | 28 (100) |
Procedures
Data analysis
Governance principles | Summary of challenges and enabling factors | Recommendations | ||
---|---|---|---|---|
National level | Health policy formulation level | Policy implementation level | ||
Strategic vision | Interim constitution 2006 recognizes health as a fundamental right | National mental health policy 1996 exists; no revisions to date | Lack of implementation of 1996 mental health policy | Integrate mental health policy provisions in 5 year health plan; establish an accountable mental health unit in MoH |
Participation and consensus orientation | Lack of participation of civil society, private sector and government departments in mental health decision making | Increasing consultation with NGOs and other stakeholders in mental health policy formulation | In some districts, the District Public Health Office and NGOs are partnering to provide mental health services in primary health care centers | Establish coordination and collaboration within and beyond health sectors; build consensus among stakeholders regarding involvement of service users in policy, planning and service delivery |
Rule of law | Consumer Protection Act 1998 bans the production and sale of goods which are harmful to consumers’ health | Fourth revisions of draft mental health act, but no official endorsement | Mechanisms to monitor misuse of psychotropic drugs in place but rarely implemented | Ratify mental health legislation in line with national and international human rights laws and legislation, and strictly enforce legal provisions in practice |
Transparency | Ranked 126 out of 175 by Transparency International on corruption perception index | Processes and mechanism for ensuring transparency in mental health resource allocation and expenditure not well defined | Performance assessment, promotion and transfer of district health manager and district health staff differ in policy and practice | Develop mechanisms and procedures for monitoring and supervision of mental health programs to ensure transparency in health sector |
Responsiveness to patients’ health needs | The government policy and programs (2014) state the provision for national insurance program | Health Policy 2014 recognizes the need to increase state’s investment to cover all health care expenses of disabled people, including psychosocial disability | In the absence of clear policy guidelines to address responsiveness, the medical and non-medical expectations of populations not met | Arrange motivational incentives and facilities for health worker retention in rural areas; strengthen mental health information use for the allocation of budget |
Equity and inclusiveness | Social security allowance is given to elderly, widow and disabled, including psychosocial disability | Nepal Health Policy 2014 mentions that health services will be provided to poor, marginalized and vulnerable population on the principles of equity and social justice | Knowledge about existence of disability allowances for people with mental illness is low, so very few people have received allowances | Disseminate information about services available in the community for treatment of mental illness and benefits provided by the government |
Effectiveness and efficiency | Limited coordination, communication and consultation between bureaucrats and technocrats (clinicians) | Frequent turnover of policymakers; no mental health unit under MoH for policy and planning | Other support systems, such as supply of psychotropic drugs and regular supervision and monitoring, are lacking | Regulate policy on staff turnover; provide training to health workers; ensure regular supply of essential psychotropic drugs and arrange separate counselling room within primary health care facilities |
Accountability | Public accounts committee of the parliament looks after accountability | Mechanisms and processes for overseeing financial and administrative adherence in place | No evidence on the effective enforcement of accountability measures | Implement existing mechanisms and processes to make the health system accountable to the population in need of mental health services |
Intelligence and information | No national level study on mental health conducted | The HMIS data not used in mental health policy, planning and service provision | Mental health data collected from Out Patients Department registers maintained in district health facilities | Build capacity of government staff for systematic record keeping, and monitoring and evaluation of mental health programs |
Ethics | Ethics of mental health research is monitored by Nepal Health Research Council | To ensure bioethics, Nepal Health Research Council has an ethical review committee, and a monitoring and evaluation section | Nepal Health Research Council monitoring team makes field visits to oversee the research activities of the organizations | Sensitize researchers and health workers towards more ethical practice in the field of mental health research and service delivery |
Results
Strategic vision and rule of law
“If you see Nepal Health Sector Program II (NHSP II), we have kept Mental Health as an important pillar in the Non-Communicable Disease chapter thinking that it is important component…..but we have not been able to move forward in this process as we had to….” (National Representative 02, Male).
“There still exists discriminatory provisions in existing laws such as Civil Code of Conduct, NGOs registration act. The discriminatory laws related to mental health should be removed. State should be playing the role of guardian and ensure the right of all the citizens including people living with mental illness” (National Policymaker 11, Male).
“No matter how much it [government] says that it isn’t [the situation of mental health services], evidence shows that in 20 years it is still similar. Another thing is, generally, mental health problems are not visible. In our Nepal, they say in the villages that ‘Ban dadheko sabaile dekcha, maan dadheko kosaile dekhdaina.’ [Everyone will find out if the forest is burning but no one will find out if a heart is burning]” (National Policymaker13, Male).
Transparency and accountability
“Since there is no clear budget allocation for mental health, it cannot be said that the programs and budget are transparent.” (National Representative 05, Male).
Monitoring of mental health services and policies
“We haven’t been able to monitor all the organizations fully. This is one weakness. We aren’t able to go to the field and do the monitoring. We are working on improving this part.” (National Representative 15, Female).
“Public Health Administration, Monitoring Evaluation Division under Ministry of Health monitors overall health system” and ‘Integrated Supervision Program’ does the overall monitoring and supervision of all health services in general.” (National Representative 05, Male).
Responsiveness and integration of care
“During the monitoring, no such type of mechanism was seen which listened to the complaints or grievances regarding mental health…” (National Representative 11, Male).
Participation, coordination and collaboration
Involvement in policy and planning
“Without their involvement, policymaking would be incomplete.” (District Representative 09, Male), “Since they are the one[s] who are facing the problem, their input is a must” (District Representative 01, Male), and “‘Nothing about us, without us’. So I think participation will come as a first condition.” (National Representative 11, Male).
“If we plan to involve them at the initial phase of policy making, then it would sound like, ‘Tauko le Puchar hallaune ki puchar le tauko hallaune’ [Whether head shakes the tail or tail shakes the head - it is always the head that shakes the tail, so that involvement of service users in policy and planning seem irrelevant]” (National Representative 09, Male).
Involvement in service delivery
“Service is delivered in consultation with sectors like VDC [Village Development Committee], police or teacher.” (District Representative 09, Male).
Effectiveness and efficiency
Human resources capacity
“Clients do openly share their problem [with FCHVs]… Since they work at community level, they are more aware of peoples who show abnormal activity.” (District Representative 03, Male).
Budget allocation and utilization
Supply of psychotropic drugs
“There is no provision of supplying additional drugs… It is even difficult to supply adequate amount of [general] medicine within our budget; in this case, if mental health drug is added, then the situation turns worse.” (District Representative 01, Male).
Equity and inclusiveness
Access to services
“Sakne Raja ko ma janu nasakne deutako ma janu’ [‘Those who can, they go to the King and those who can’t go to God’]. While doing the treatment, it is similar thing. Those who can afford, go to medical doctor and those who can’t, go to traditional healer.” (National Representative 13, Male).
“To reduce stigma and discrimination, community-level health workers can be involved because they are directly in touch with the community … They can play a vital role in the rehabilitation process.” (District Representative 06, Male).
“With the known trainer, they develop trust about what s/he just mentioned because they knew s/he had been a sufferer in the past.” (District Representative 02, Male).
Ethics
“If any cases regarding violation of rights of the patient comes, then ministry forms a committee to address the issue and based on the report of the committee it takes necessary actions.” (National Representative 05, Male).
Mental health information system
“As no research [at national level] has been conducted, we do not have background information. So we are not aware of our priority. Government can develop priority area with the help of research of community status.” (National Representative 08, Male).
“I don’t think we have good monitoring system… it is haphazard.” (National Representative 01, Female). Another participant said, “case incidences and prevalence are never discussed nor are meetings conducted for discussion.” (District Representative 03, Male).