Implementation Guidelines Main text English Sept.2010nfhp.jsi.com/Docs/LHGSP_ImplementationGuidelines.pdfSN Selection Indicators Score Scoring formula 1 Remoteness 20 Average travelling

Approved by the Steering Committee on September 3, 2010

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Local Health Governance Strengthening Programme (LHGSP)

Implementation Guideline-2010

Government of Nepal Ministry of Local Development Ministry of Health and Population

July-2010


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Acronyms

CO: Community Organization DAG: Disadvantaged Group DDC: District Development Committee DDF: District Development Fund DHCC: District Health Coordination Committee DHO: District Health Office DIMC: Decentralization Implementation and Monitoring Committee DLHG: Decentralized Health Governance DoHS: Department of Health Services DPHO: District Public Health Office DTCO: District Treasury Comptroller Office EDP: External Development Partner FCHV: Female Community Health Volunteer GoN: Government of Nepal GTZ: German Technical Cooperation HF: Heath Facility HH: Household HMC: Health Management Committee HP: Health Post LB: Local Body LBFAR: Local Body Financial Administration Regulation LGCDP: Local Governance and Community Development Programme LHGSP: Local Heath Governance Strengthening Programme LSGA: Local Self Governance Act LSGR: Local Self Governance Regulation MCPM: Minimum Conditions and Performance Measures MDF: Municipal Development Fund MoF: Ministry of Finance MoHP: Ministry of Health and Population MoLD: Ministry of Local Development NFHP: Nepal Family Health Programme NGO: Non Governmental Organization NHSP-IP: Nepal Health Sector Support Programme-Implementation Plan NPC: National Planning Commission O & M: Organization and Management ORC: Outreach Clinic PHC: Primary Health Care Centre PO: Programme Officer RHD: Regional Health Directorate SDU: Social Development Unit SHP: Sub Health Post TA: Technical Assistance TT: Technical Team TYIP: Three Years' Interim Plan UC: User Committee VDC: Village Development Committee


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Table of Contents

1. Introduction 1 1. Background 1 2. Legal Base 1 3. Brief Title and Commencement 1 4. Definition 1 5. Objectives of the Guideline 2 6. Users of the Guideline 2

7. The Programme 3 8. Principles 3 9. Programme Objectives 3

10. Programme Execution 4 11. Selection of Programme VDCs 4 12. Sectors of Investment 4 13. Plan Formulation and Implementation 5

14. Annual Planning Process 5 15. Budget Ceiling 7 16. Work Plan 7 17. Plan Implementation 7

18. Steering Structure 8 19. National level Committees 8 20. Local Level 9

21. Human Resource Management 9 22. Coordination and Synergy Effect 10

23. Role and Responsibility of Stakeholders 11 24. Central Level Government Agencies 11 25. Regional and Local Level Agencies 12 26. Technical Support Agencies 13

27. Resource Mobilization 15 28. LHGSP Account 15 29. Fund Flow 15 30. Local Contribution 15 31. Financial Auditing 15

32. Monitoring, Evaluation and Reporting 16 33. Monitoring 16 34. Social Audit 16 35. Reporting System 16

36. Progress Reports 16 37. Programme Completion Report 16

38. Action Research 17 39. Programme Evaluation 17

40. Amendment on Guideline 18


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1. Introduction

2. Background

The Government of Nepal (GoN) through its plans, policies and the declarations is committed to devolve some of its functions at the local level. In line with the GoN priorities, the Ministry of Health and Population (MoHP) made decision to pilot a Local Health Governance Strengthening Programme (LHGSP) in Nepal. Accordingly, MoHP in cooperation and coordination with the Ministry of Local Development (MoLD) and the External Development Partners (EDPs) designed to implement LHGSP as per its devolution policy in some of the districts and Municipalities on a pilot basis. The Local Bodies (LBs) as District Development Committee (DDC), Municipality (Muni) and Village Development Committee (VDC) are devolved with some of the authorities and functions of MoHP to implement LHGSP. A Memorandum of Undersatnding (MoU) has been signed between MoHP, MoLD, Technical Assistance (TA) partners and respective DDC and DHO/DPHO to implement LHGSP on March 17, 2010.

3. Legal Base

Local Health Governance Strengthening Programme Implementation Guideline-2067 (2010) has been taken into force to support in implementing LHGSP and “A Package of Health Sector Devolution Framework-2067” (2010). The guideline has been developed based on the policy and legal provisions for health sector in Nepal, the Interim Constitution of Nepal-2063 (2007), Three Years Interim Plan (TYIP) of Nepal, Nepal Health Sector Strategy-2003, Nepal Health Sector Programme Implementation Plan (NHSP-IPII), the National Health Policy-1991 and Local Self Governance Act-2055 (1999).

4. Brief Title and Commencement

(1) This implementation guideline is called as "Local Health Governance

Strengthening Progarmme Implementation Guideline, 2067 (2010). (2) This implementation guideline shall commence by the date of approval of

the MoHP1 in consultantion with MoLD.

5. Definition

Unless the subject or context otherwise explains, in this implementation guideline:

a) "Framework" means the Package of Health Sector Devolution Framework, 2067 (2010).

b) "Local Body" means the District Development Committees, Municipalities2 and Village Development Committees in Nepal.

c) "Minimum Indicator" means the milestones and indicators mentioned in this implementation guideline.

d) "Health Facilities" means the Rural/Community Hospital, Primary Health Care Centre (PHC), Health Post (HP) and Sub Health Post (SHP) functioning in the piloting district, municipality and VDC.

e) "Stakeholder" means the organization that shall have direct or indirect influence or participation or contribution or involvement for the implementation of this guideline in the selected districts.

1 This implementation guideline has come into force with the MoHP approval on ……………

2 For the purpose of this operational guideline, Municipality means the Metropolitan City,

Sub-Metropolitan City and Municipalities of Nepal.


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6. Objectives of the Guideline

Followings are the objectives of this implementation guideline:

(1) Guide and support the local bodies, local health facilities and the concern stakeholders, in implementing the framework and LHGSP effectively and efficiently.

(2) Support the implementing agencies, service providers and stakeholders for their coordinated functioning and synergy development strengthening the concept of decentralized local health governance.

(3) Facilitate and support making uniformity in process and outputs of LHGSP.

7. Users of the Guideline

MoHP, MoLD, DoHS and TA partners in the centre and the LBs, local HFs and Health Management Committee (HMC) in the piloted districts are the principle users of this guideline. It is expected that the guideline would be useful for the NGOs and other stakeholders at the local level.


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8. The Programme

1. Principles

LHGSP in general, is designed based on the principle of decentralization and local governance and it intends to promote the process of democratization, equity, people's participation and effective service delivery at local level. It demands the transfer of authority, power, functions and functionaries and resources to the local levels. In this context, LHGSP is framed considering the principle of subsidiary, that believes on the effective and efficient service delivery in general and health service delivery in particular through the institutions of LBs who are in close to the people at grass roots level. Community lead and ownership, use of local skills, knowledge and innovation, participatory planning and management and flexible financing are the key guiding principales of LHGSP. MoHP through the framework has devolved some of its administrative, financial, managerial and regulative authority to the LBs.

2. Programme Objectives

The Local Health Governance Strengthening Programme (LHGSP) aims to address current decentralization and governance issues to strengthen health governance at the local level. It also intends to generate hands on experiences and provide empirical evidences for restructuring of health systems under the federal setting of the country. Followings are the specific objectives:

a) support enhance the capacity and strengthen collaboration among the stakeholders in providing health services effectively, efficiently and equitably,

b) support strengthen health management system and procedures in place at local level to ensure downward accountability and local ownership in providing health services;

c) support improve the policy framework and strategies in place to function MoHP as a facilitating agency at centre and;

d) support stakeholders in attaining the minimum indicators defined by this implementation guideline.


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9. Programme Execution

3.1 Selection of Programme VDCs

The concerned DDC shall select VDCs for LHGSP implementation. Considering the budget availability and capacity of the LBs and DHO/DPHO it is suggested to select 30 to 40 percent VDCs/wards of the districts/municipalities for the implementation of LHGSP based on the following indicators. But, there must be at least four HP and two PHC in the selected VDCs. However, LBs can implement programme in more VDCs on their internal resources. SN Selection Indicators Score Scoring formula

1 Remoteness 20 Average travelling time from VDC office to the all weather roadhead: < 1 hr=10, >1 hr and < 2 hrs = 12, 2 to 3 hrs = 18 > 3 hrs = 20

2 DAG VDCs 20 DAG 1=10 DAG 2= 15 DAG 3= 18 DAG 4= 20

3 VDC Population (As per HMIS)

20 �3000=12 3000-4000=15 4001-5000=18 >5000=20

4 VDC commitment for resource allocation and implementation of LHGSP

15 Matching fund (total of the LHGSP fund) <3%=4 3-5%=6 6-8%=10 >8%=15

5 Prone to communicable diseases, disease epidemic and disaster

15 DDC judgment on past experience: Very high prone=15 High prone=12 Low prone=10 No prone=7

6 No. of development partners and the programme for health supported by TA agencies other than GTZ and USAID

10 Existence of INGOs and EDPs 0=10 1=8 2=4 >2= 2

The concerned DDC can further breakdown the indicator considering their local condition.

3.2 Sectors of Investment

The fund available for LHGSP shall strictly limit to the implementation of LHGSP plan and programme as endorsed by the council of concerned LBs. Some of the sectors of investment are given below. However, based on the local needs and priorities the DDC may find more areas to invest.

a) Capacity development

• human resource management specifically staff recruitment, motivation and mobilization,

• health sector planning and programming,


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• community mobilization, awareness and information, communication and dissemination,

• training, workshop, logistics and empowerment of local HFs, LBs, HMCs, and FCHV,

• promotional activities for the local innovations,

• preparedness and emergency resque for mother and child healthpromotion and controlling the disease outbreaks,

• TT meeting and management including coordination, supervision and networking,

b) Drugs & equipments and the physical facilities

• procurement of essential medicines, medical equipment and accessories, furniture and fixtures for the HFs applicable for the local level health services,

• procurement of health logistics,

• minor repair and maintenance of HF buildings, birthing centre, health care waste management, water supply and electrification and similar infrastructure,

c) Accountability

• review, monitoring and evaluation,

• social audits and public hearing,

• performance based management,

d) Quality assurence

• HF level quality improvement programme,

• monitoring, supervision and observation,

• promotional indicators for quality health service delivery,

3.3 Plan Formulation and Implementation

As per the LSGA-1999, clause (43, 111 and 195) every LB shall develop their periodic plan incorporating subject-wise plan and programmes including the health sector. The LBs, who already have periodic plan in operation, need not to develop a new one, but it must have addressed the health sector plan, policy and programmes. However, the LBs have flexibility in developing such plan by the end of LHGSP first phase. As a sector-wise agency DHO/DPHO shall be responsible for developing health sector periodic plan in coordination and cooperation with concerned LBs. Key matters to be addressed by the periodic plan is given in Annex 4. The health sector annual planning process is described as below.

3.3.1 Annual Planning Process

The planning of LHGSP starts from the community level. Members of the community groups, Local Health Management Committee (HMC) and the people in general need to have their participation during the process of plan formulation to help them identify their own needs. The participatory plan formulation procedure at the local level has following phases.

1. VDC/Municipal Level

a) Budget Forecasting and Guiding Principle: Every VDC/Municipality shall start to formulate plan at ward/tole/settlement level by allocating budget for the health initiatives based upon the budget ceiling and guideline provided by the LBs, DHO/DPHO and the central level institutions.


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b) Need Identification: The requirements at local level should be identified through

participation of representatives from HMC, FCHV, Community Group (CO)/CBO and the LB representatives including HFs. The people and/or the group of people will separately meet, fill the project request form (Annex 2) and formulate proposed plan through discussion, and will submit it to VDC/Municipality through the village/municipal level integrated planning committee.

c) Selection of Plan: VDC/Municipality shall select plans based on the available

resources, among the proposals after a joint meeting with HMC. The concerned local body council will make the project selection decision.

Each of the VDC/Municipality shall submit their health plan to DDC through DHO/DPHO. DDC will incorporate such plans in its annual district health plan.

2. Ilaka Level

Plans and projects benefits more than a VDC/Municipality including HP, PHC and Rural/Community Hospital (R/CH) and the plans prioritized by VDC/Municipality but cannot be supported with its resources need to present filling the project request form (Annex 2) at the Ilaka level planning meeting/workshop organized by concerned DDC. As all the partners at district level will participate in this meeting, mainstreaming of health sector plan and programmes can be done. In such meeting, participation of HMC and the local HFs need to be ensured. Plans and programmes prioritized at the Ilaka level planning meeting shall be submitted to subject-wise planning meetings at district level.

3. District Level

Health sector related plans and programmes including LHGSP, which have been proposed by the Ilaka level planning meeting has to be streamlined according to the following district level plan formulation procedures.

a) Subject-wise Plan Formulation Committee: Health related plans and programmes basically fall under social development committee, hence plans referred by Ilaka level planning meetings should be presented to this committee. Apart from this, if the plan needs to be submitted to another committee, it has to be sent accordingly to the respective committees. Such committees will prioritize the submitted programmes and submit it to integrated plan formulation committee to incorporate in the annual district development plan.

b) Integrated Plan Formulation Committee: Plans that have recommended by concerned plan formulation committee needs to be discussed at integrated plan formulation committee. The committee may review over plans and programmes being within the limits/boundaries of current act, rules, by laws, directives and operational guidelines. The committee shall request DDC to include the plans in the annual District Development Plan.

c) District Development Committee: Plans and programmes recommended by Integrated Plan Formulation Committee shall be included by concerned subject-wise offices including DHO/DPHO and other partner organizations, and the DDC shall select the plans on the basis of technical and economic feasibility and submit them to the District Council for their final approval.


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d) District Council: District Council has the authority to approve plans, programmes and budget submitted by the DDC along with its recommendations. The council may approve them with revision as it has such authority. For operation of LHGSP, the annual programme and budget at VDC and municipal level shall be approved by the concerned Council and plan at district level will be approved by the District Council. Thus, the plan approved by District Council shall become the district LHGSP related annual plan.

4. Central Level

In the case of plans that have to be approved and implemented by the central level, the MoHP in co-operation with MoLD, Ministry of Finance (MoF), other sectoral ministries and the development partners shall provide its consent with budget, on proposed LHGSP Plans incorporated in the district development plan.

3.3.2 Budget Ceiling

Concerned DDC shall allocate the available resources as per the following ceiling. However, the DDC council reserves rights to decide budget ceiling based on health plan and local conditions.

S.N. Health Facilities Budget Ceiling (NRs)/ Year Remarks

Minimum Maximum 1 SHP 50,000 150,000

2 HP 80,000 300,000 3 PHC 100,000 400,000

4 R/CH 100,000 400,000 5 Other HFs 50,000 200,000

3.3.3 Work Plan

Detail work plan should be submitted by the implementing agency before signing the implementation contract. The work plan shall contain the followings.

• Details on the approved plan/project,

• Detail breakdown of the activities, time schedule, physical and human resource management and responsibilities.

3.3.4 Plan Implementation

Implementation of LHGSP related plan and programmes shall be done within the limits of concerned LB's approved annual plan. The HMC, HFs and LBs shall implement the plan, programme and activities. But, HMC shall decide implement such activities even through the local NGOs and community organizations. Cost sharing and participatory approach should be given priority while implementing the projects. The social mobilisation agencies at the local level may support the process. Local Governance and Community Development Programme (LGCDP) of MoLD at local level may support especially for social mobilisation and co-financing for local level health activities. DHO/DPHO and concerned subject-wise offices and TA partners shall provide technical support to the implementing agencies. The technical committee at the district and centre as well support providing technical guidance to DHO/DPHO, HFs and HMCs. MoHP, MoLD, TA partners and the technical committees will support implementing agencies coordinate among the stakeholders to implement their plan successfully.

3.4 Steering Structure


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To support in the implementation of LHGSP various institutional arrangements are made to establish in the centre and local level.

3.4.1 National level Committees

Considering the smooth functioning of this guideline and implementation of LHGSP the following committees shall be established at the centre.

a) Steering Committee

(1) Chief, Policy, Planning and International Cooperation Division, MoHP: Coordinator (2) Chief, Human and Financial Resource Division, MoHP: Joint Coordinator (3) Representative, National Planning Commission: Member (4) Representative, Local Governance Division, MoLD: Member (5) Representative, Ministry of Finance: Member (6) Chief, Management Division, Department of Health Services: Member (7) Team Leader, HSRSP: Member (8) Coordinator, External Development Partner’s Forum: Member (9) Coordinator, Health Sector Reform, MoHP: Member Secretary

The Member Secretary in consultation with the Coordinator shall call the meeting of Steering Committee. The steering committee shall meet at least once in two months and be responsible for the followings:

• Policy formulation and strategy development

• Approval of annual work-plan and budgeting

• Vertical and horizontal coordination

• Advocacy and lobbying for the successful implementation of LHGSP

• Networking and linkage development

• Support LBs and concernd stakeholders in implementing LHGSP

• Feed back to monitoring committee

• Others

b) TA Coordination Team (1) Coordinator, Health Sector Reform Section, MoHP Coordinator (2) Representative, USAID/NFHP-II Member (3) Representative, HSSP/GTZ Member (4) Representative, HSRSP Member (5) Representative, RPHC Division/DoHS Member Secretary

This team may invite other agencies as member who is expected to contribute the programme. The Team will meet at least once a month. The Member Secretary in consultation with the Coordinator shall call the meeting of TA Coordination Team.

3.4.2 Local Level

a) District Focal Unit

The DHO/DPHO shall assign one of its' appropriate section/unit as a focal Unit (FU) and

one of the senior staff as Focal person (FP) for LHGSP implementation. The FP shall

functions its duties in close cooperation and coordination with DDC the Programme Officer


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(PO) who looks after the social development sector. DHO/DPHO in coordination with DDC

will take overall responsibility of LHGSP implementation

b) District Technical Team

A five member Technical Team (TT) lead by the Chief of DHO/DPHO will facilitate the LHGSP implementation process including supervision, monitoring and project evaluation at local level. Team composition shall be as follows:

(1) Chief of DHO/DPHO: Coordinator (2) Representative (1) from among the institutions or experts

in health; as domitated by DDC: Member (3) FP, LHGSP: Member (4) Representative, TA Partners: Member (5) PO, SDU, DDC: Member Secretary

The Team may invite in its meeting, the experts and representatives from civil socity as and when needed. The Member Secretary in consultation with the Coordinator shall call meeting with agendas.

Specific responsibilities of TT are as follows:

a) Facilitate the programme execution process including implementation level decisions,

b) Provide technical and managerial support to HFs and HMCs in the for the successful progarmme implementation,

c) Supervision, monitoring and evaluation of the programme activities.

c) Local Health Management Committee (HMC)

The local Health Management Committees are formed as accordance with the existing policies including this implementation guideline. DHO/DPHO shall follow the same process and policy during the course of LHGSP implementation. The structure of the local HMC is given in Annex 6.

3.5 Human Resource Management

All the posts existing in the health facilities at the time of commencement of this guideline shall be deemed to be in existence under this guideline and class adjustment shall be made accordingly. However, the existing staff of the health facilities would have an option to continue their job with DDC or move other way. Thus the existing staff sent by the centre shall continue their service in the piloted HFs under the management and supervision of DHO/DPHO. But, once the position is vacant, it will be handed over to DDC where MoHP should not send its staff. Such vacant positions shall be fulfilled by DDC either recruiting new staff or hire service in contractual basis. Based on the policies and provisions made in the framework the staff recruitment process for LHGSP shall be as follows:

a) Fulfillment of the vacant positions: The posts falling vacant in the local health institutions shall be fulfilled by open competition. The required minimum qualification shall be as prescribed by the MoHP.

b) Staff recruitment committee: For the selection of appropriate candidates in the vacant positions there shall be a staff recruitment committee to recommend DDC


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the successful candidates. Such a committee shall be as prevailed in the DDC or they can form a new committee for this purpose. However, the DDC would invite representative from the concerned HMC and DHO/DPHO in the recruitment committee meeting.

c) Appointment: As per the recommendation of staff recruitment committee, the Chief of DHO/DPHO shall appoint the candidate. The job description of the staff shall be made available along with the appointment letter. The remuneration, benefits and terms of service of the employee shall be as decided by the DDC.

d) Transfer: MoHP with consent of the concerned DDC may transfer the staff

recruited by the centre. But, the DHO/DPHO in consultation with concerned DDC shall transfer the staff recruited locally.

e) Reward and punishments: i) under the recommendation of DHO/DPHO the

concern DDC may make necessary reward system as per the prevalining rules and regulations; ii) remuneration, allowance and benefits of the staff shall be as per the staff of the concernd DDC. MoHP provides salary and other cost associated with mobilization of staff, as a block grant to DDC, including their fringe benefits, but such grant shall limit to the sanctioned positions prevailed at the commencement of this guideline.

f) Work performance evaluation: The procedures of evaluating the work

performance of the employee shall follow the existing practices of concerned DDC, based on the Local Self-Governance Regulation, 2056 (1999).

3.6 Coordination and Synergy Effect

The LBs shall develop coordination mechanism and establish vertical (MoHP, MoLD, DoHS, RHD, EDPs) and horizontal (DDC, Municipality, VDC, HFs, HMCs, I/NGOs, sector-wide agencies and service seekers) linkages among the key stakeholders and service seekers. Concerned DDCs shall lead the process and be responsible for developing such mechanism. Such mechanism shall focus in mobilizing the human, physical and financial resources among the stakeholders and develop synergy effect. More specifically, DDC shall prioritize coordinated efforts in promoting local health governance and effective service delivery while making periodic and annual plan.


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10. Role and Responsibility of Stakeholders

11. Central Level Government Agencies

a) Ministry of Health and Population (MoHP)

• Take lead the programme at the central level to support implementation at local

level, provide policy guidance and facilitate implementation process, coordinate with stakeholders at the national/central level and give overall direction to the activities that take place at the implementation districts.

• Develop a formula in collaboration with MoLD, NPC and MoF and provide health grant to programme districts to help address local health needs.

• As outlined in the Local Self-governance Act-1999, MoHP will devolve and delegate necessary power and resources to the appropriate level institutions.

• Collaborate with and encourage and involve more TA programmes to strengthen implementation process and increase the pilot districts.

• Monitor and evaluate results from different perspectives: quality, quantity, access and coverage of the health services. These will be monitored based on the pre-identified performance indicators on periodic basis.

• Organize and facilitate Participatory Experience Sharing Exercise (PESE) on periodic basis involving key officials from the pilot districts.

• Lead the process and play pro-active role in replicating/scaling up of successful schemes, and use lessons as inputs for policy improvements.

• Reflect the contribution of partners in National Health Accounts.

• Support documentation process and disseminate information and knowledge with the support of TA programmes.

b) Ministry of Local Development (MoLD)

• Nominate a senior officer as a representative to participate in the LHGSP’s Steering

Committee and other related events.

• Provide necessary policy and other supports, and coordinate with the local bodies, as required, for successful implementation of the LHGSP.

• Help replicating/scaling up of successful schemes and use lessons as inputs for policy improvements.

• In accordance with the LGCDP Guidelines allocate certain amount of grants to the health sector for the direct benefit to women, children, senior citizens and marginal groups of people.

• Help strengthening collaboration and creating synergy with the Local Governance and Community Development Programme (LGCDP) at local level.

• Help in harmonizing and implementing the decisions made by the Decentralization Implementation and Monitoring Committee (DIMC) related to health and population.

c) Department of Health Services (DoHS)

• Support MoHP and MoLD for LHGSP implementation.

• Monitoring and evaluation of the programme.

• Progress reporting and documentation.

• Support DHO/DPHO, LBs, HFs and HMCs in implementing LHGSP.

• Replicate the success cases and lesson learnt.


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12. Regional and Local Level Agencies

a) Regional Health Directorate (RHD) • Monitoring and evaluation of the programme.

• Progress reporting and documentation.

• Support DHO/DPHO, LBs, HFs and HMCs in implementing LHGSP.

• Replicate the success cases and lesson learnt within the region.

b) District Development Committee • Take leadership and facilitate the periodic and annual planning process and support

VDCs and Municipalities in implementing the plans,

• Allocate at least 1 percent amount of LHGSP fund transferred in DDF, as a contribution of DDC to LHGSP,

• Fund release to VDCs and Municipalities,

• Mobilize government line agencies and other stakeholders in planning, monitoring and evaluation (quality assurance) of LHGSP,

• Vertical and horizontal coordination,

• Document experiences and learning and share with the stakeholders though workshop, seminars and dissemination sessions,

• Play pro-active role in replicating /scaling up of successful schemes, and use lessons as inputs for policy improvements at the district level,

• Prepare strategies for sustaining the programme on its own management control in the long-run.

c) District Public/Health Office

• Play catalytic role in implementing the LHGSP internalizing its concepts, principles

and approaches.

• Technical, managerial and logistics support to the health facilities,

• Coordinate between the benefiting VDC/Municipalities for effective implementation of the LHGSP,

• Mobilize HFs, FCHV, I/NGOs, development partners and community people in planning, implementation, supervision, monitoring and evaluation of LHGSP,

• Develop district health periodic and annual plan in coordination with LBs,

• Support and facilitate LBs to incorporate the health plans in the village, municipal and district periodic and annual plans,

• Assign FU and a focal person to support implement the LHGSP,

• Take ownership of the LHGSP implementation,

• Support HMC for their capacity enhancement, organize orientation programme and training to HMC/UC, and follow timely monitoring and supervision,

• Receive financial and technical progress reports from HMCs/health facilities and report it to DDC, MoHP and other agencies as required,

• Support HMC/UC in organizing Social Auditing events and publications of their success stories,

• Carry out action research/output assessment especially on resource mobilization and service delivery,

• Incorporate the success of LHGSP in the progress reports following the supervision, monitoring and review of the project activities,

• Support HMC management as per their request to success the project,


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d) Municipality/VDC • Take leadership and coordinate the stakeholders in developing periodic and annual

plans,

• Support HMCs/health facilities in developing annual plan of action and its implementation,

• Release fund to the health facility/HMCC and other implementing agencies and take necessary actions to ensure transparency and effective use of fund delivered to them,

• Support, coordinate, facilitate and take ownership of the overall process of LHGSP implementation,

• Document experiences and learning and share with the stakeholders through workers, seminars and dissemination sessions,

• Provide necessary information though periodic reports,

• Prepare strategies for sustain the programme on its own management control in the long run.

e) Local Health Management Committees • Make implementation level decisions,

• Planning and management of LHGSP,

• Vertical and horizontal coordination and linkage establishment,

• Support DDC and DHO/DPHO in the part of human resource mobilization including staff recruitment,

• Implement, manage to implement the LHGSP activities,

• Monitoring, supervision and evaluation of the LHGSP activities and report to the concerned authorities,

• Take ownership of the progarmme,

• Other works as per prevailing rules and regulations,

4.3 Technical Support Agencies

a) GTZ/HSSP and USAID/NFHP-II GTZ/HSSP will provide technical support for Kalali and Doti and USAID/NFHP-II will provide technical support for Surkhet and Dang districts. Role and responsibility of these TA partners shall be as follows:

• Provide technical support to develop guidelines, manuals and conduct orientation to

officials at different level (centre to village level). MoHP take the lead and the TA partners support and participate in the process.

• Establish functional network and work in collaboration with the partners at different levels.

• Support Steering Committee to design and conduct assessment by external consultant and document findings, prepare case studies, experiences and learning in collaboration with DDCs, VDCs and Municipalities, and health facilities at local level and with HSRSP, MoHP and its departments at the central level.

• Provide need- based technical and other support for the full period of time to at least two districts.

• Provide support for periodic field and exposure visits to key officials involved in designing and implementing the pilot programme as per their rule and guidelines.

• Specifically, provide the following support to programme districts: o Process facilitation at local level (support to develop systems and

procedures as necessary, and so on) o Technical support - capacity building, local planning, reporting, monitoring,

review and so on.


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o Data collection, interpretation, analysis and documentation of local innovations, experiences and best practices.

• Facilitate learning at horizontal (between communities/districts/regions) and vertical levels (between communities, districts, regions and central level).

• Other support, as needed and agreed upon.

b) Other Interested TA Programmes • Support areas of their comparative advantage and strengths focused at local level.

• Collaborate to contribute to pilot programmes creating synergy, bridging resource gaps.

• Other support, as needed and agreed upon. The TA partners will provide technical support in overall process of programme execution including the following activities:

i. Capacity development strategic plan: The LBs will develop capacity development strategic plan to own the devolved functions as mentioned above. The strategic plan should address the issues of human, physical and financial resources, institutional arrangements, coordination and networking system and service demand and its delivery mechanism.

ii. Health Profile: Each of the programme implementing VDCs/Municipalities shall

prepare their health profile. Such profile will serve as benchmark for the programme and support in measuring the minimum indicators (Annex 1) set by this guideline. The bench mark will serve in finding programme impact at the end of the progarmme period. Health profile shall be prepared mobilizing the human resources available in the VDC/Municipality. The FCHV and the CO, local NGO members could be the potential personnel to carry out this activity. Concerned VDC/Municipality remunerates the service of such personnel based on the local rates. HH survey form is given in Annex 3.

iii. Organization and Management (O&M) Survey: Each of the health facilities in the

project areas will carry out O & M survey in coordination with the concerned VDC and Municipality. O & M survey shall be carried out mobilizing the human resources available in the VDC/Municipality. The FCHV and the CO, local NGO members could be the potential personnel to carry out this activity. Concerned VDC/Municipality remunerates the service of such personnel based on the local rates. O & M survey shall be a quick assessment and generate information and make recommendations on the organogram, physical facilities, human resources, local needs, annual budget and potential financial resources, liabilities and management of the HFs. O & M survey report and recommendations shall be approved by the concerned VDC and Municipality and shall come into force. The VDC/Municipality shall provide a copy of O & M Survey Report to concerned DDC and DHO/DPHO.


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13. Resource Mobilization3

14. LHGSP Account

There shall be a LHGSP operating account in each of the VDCs and Municipalities. This operating account shall be operated as per the existing practices of concerned VDC/Municipality. Following amount shall be deposited in these accounts:

(1) Earmarked grant for LHGSP, (2) Block grant supported by MoLD for health sector, (3) Fund allocated by the concerned DDC for the health sector, (4) Fund allocated by the concerned Municipality and VDC for the health sector, (5) Other sources of income,

15. Fund Flow

a) LDO of DDC receive budget authorization from the centre, b) Fund release from DTCO to DDF account c) Fund flow from DDF to Municipality/VDC operating account after receiving fund

release recommendation from DHO/DPHO d) Budget release to HMC/plan implementing agencies' account.

DDC upon the request of concerned VDC/Municipality and recommendation of DHO/DPHO will release budget in the trimester basis. Budget request format is given in Annex 5. The financial report formats shall be as prescribed by LBFAR. The implementation contract shall be made between HMC/implementing agency and respective Municipality/VDC based on the approved plan. The LBs may use the implementation contract formats that are used in their regular projects. Installment and payment procedures shall be as defined in the implementation contract.

16. Local Contribution

The following contributions are expected at the local level, for the execution of LHGSP:

• DDC - minimum 1% of the total block grant supported by MoHP for LHGSP

• VDC/Municipality - minimum 2% of the total project cost under LHGSP, However, this provision should not be binding for the cost associated with projects other than the physical infrastructure development.

17. Financial Auditing

• Internal audit: by the internal audit section of DDC

• Final audit: as per the GoN system

• TA partners shall be authorized if they demand for process audit up to the limit of fund they supported.

3 This guigeline shall be applicable for the budget deliverd in Fiscal Year 2009/2010 for this

programme.


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18. Monitoring, Evaluation and Reporting

19. Monitoring

The concerned stakeholders especially the DDC/Municipality and DHO/DPHO at the district shall develop annual monitoring plan. MoHP in consultation with MoLD shall facilitate the process of monitoring LHGSP activities providing the monitoring tools and techniques if demanded by the district. However, monitoring of this programme shall be based on Local Self Governance Act, 1999 and the existing practices of MoHP. But in case of the absence of elected representatives the LBs may develop alternative arrangements. Also, MoHP, MoLD, DoHS, Central level Monitoring Committee, National Steering Committee for Local Health Governance System, Regional Health Directorate and TA partners shall perform regular monitoring of LHGSP. A trimester, bi-annual and annual review of LHGSP related activities should be done at district level. Quality assurance is one of the major parts of LHGSP implementation that can be ensured through process, output and outcome monitoring including case studies. Support of TA partners would be crucial for such initiatives.

20. Social Audit

The HFs has to undergo at least one annual social audit and public hearing at the local level. The concerned LBs may link it with the social mobilization process in function. The implementing agencies including HMCs, FCHV, UCs, COs and local NGOs will be oriented on the subject and will be equipped with handouts/tools to carryout social audits. Operational Guideline for social audit in health sector, 2009 devolved by DoHS can be used for this purpose.

21. Reporting System

22. Progress Reports:

The reporting and documentation system shall match the existing practices of MoHP and MoLD at the centre and concerned DDC, Municipality and DHO/DPHO at the local level. The Health Management Information System (HMIS) framework shall be applied while reporting the activities of LHGSP. The process of reporting shall be as follows:

a) HMC/implementing agency: as mentioned in the implementation contract. b) DHO/DPHO and local HFs shall report LHGSP as per their existing reporting

system. MoHP if needed will develop and introduce additional formats to report in line with HMIS. The progress, success and issues relating to LHGSP shall be discussed in the review meetings organized by MoHP and MoLD at the centre and DDC at the district level, Municipality at the municipal level and VDC at the village level. DHO/DPHO will report the progress of LHGSP to the concerned DDC and MoHP. DDC shall submit the report to MoLD. The concernd TA partners shall get progress reports through MoHP and MoLD. The progress reports shall also cover the findings and matters of social/public audits and public hearings. MoHP, MoLD and EDPs shall incorporate the progress of LHGSP in their annual progress reports.

23. Programme Completion Report:

At the end of the programme period the DHO/DPHO in each of the piloted districts in coordination and cooperation with concerned DDC, Municipality and VDCs will develop the programme completion report. Such report shall cover the programme background, implementation process, key strategies and activities, decision making and resource mobilization, programme outputs and the lessons learnts. DHO/DPHO can mobilize the


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HFs and HMCs and may seek support from DDC and external agencies in developing the report. TA partners especially the GTZ and USAID will provide technical assistance for this purpose. The DHO/DPHO through DDC/Municipality shall submit the report to MoHP, MoLD, DoHS, RHD and the TA partners at centre. DDC/Municipality shall document the programme completion report and make available at the District/Municipal Information and Communication Centre (D/MIDC).

24. Action Research

MoHP in coordination with MoLD and support of TA partners carry out result action research especially on the part of devolved functions, resource mobilization and service delivery. More specifically, the action research will follow to assess the status of minimum indicators as defined in this guideline. DHO/DPHO at the local level will take responsibility in supporting this process. The learning and the success cases of piloting LHGSP shall be replicated in other districts and HFs. MoHP in cooperation and cooperation with MoLD, MoF and TA partners explore the opportunity of generating additional resources for scaling-up the piloting process and its replication. Lesson learnts and the success cases of the programme will be desimetated at the national and international level.

25. Programme Evaluation

The service functions supported through LHGSP shall undergo an independent evaluation study by the end of the programme. MoHP, MoLD and TA partners shall make arrangements to support concerned LBs for the independent evaluation of LHGSP. The evaluation team shall fix the evaluation process, tools and the result of LHGSP based on the minimum indicators identified by this guideline.


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26. Amendment on Guideline The MoHP under the recommendation of Steering Committee may perform required changes on the points and sub-points of this Implementation Guideline without affecting its central theme. Accordingly, the Steering Committee may amend the Annexes of this Guideline and the clauses of the Memorandum of Understanding signed between MoHP, MoLD, TA partners and concerned DDC and DHO/DPHOs, on March 17, 2010.

Documents

Implementation Guidelines Main text English Sept.2010nfhp.jsi.com/Docs/LHGSP_ImplementationGuidelines.pdfSN Selection Indicators Score Scoring formula 1 Remoteness 20 Average travelling