Health system actors' participation in primary health care in Nepal

• Main Author: Karki, Jiban Kumar
• Other Authors: Jones, Graham ; Lee, Andrew C. K. ; Johnson, Maxine ; Simkhada, Padam ; Chhetri, Muni Raj
• Published: University of Sheffield 2016
• Subjects: 610
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.700873

Background: Nepal was an early adopter of World Health Organization's (WHO) Primary Health Care (PHC) approach with Community Participation (CP) for delivery of basic health care service. These approaches have formed the mainstay of efforts related to provision of health care services in Nepal. However, it has struggled with its implementation because of developmental challenges, poverty, civil war and geography. Hence, it becomes important to seek to understand the dynamics around CP and PHC and how these relate to broader development challenges in the country. The main aim of this research is to understand how various Health System Actors participate in PHC in Nepal and what its implications are in PHC Methods: In order to understand CP in PHC a qualitative case study method was undertaken. Forty-one semi-structured interviews, four focus group discussions (FGD) and observation were conducted with 26 groups of grass root level and district level health systems actors in two Village Development Committees (VDC) of Sindhupalchok district of Nepal in 2014. This study examined how these actors understand PHC and CP, how they participate in it and what motivates or hinders them to participate in PHC. The results are based on data collected from interviews, FGDs, observation and the field notes. Results: There was very low understanding about PHC and CP among actors in these VDCs. Often, CP for these actors was a 'tokenistic participation' which was limited to material contribution, voluntary labour and financial donation in PHC infrastructure development and maintenance. Participation in Health Facility Management Committees and Female Community Health Volunteer were the only mechanisms of CP in PHC, which rarely represented community views. Existing traditional health system was not taken into account. Decisions were imposed top down without considering local context, practices and without involvement of local actors. The main motivations for CP amongst participants were material benefit, social recognition and religious merits whereas geography, opportunity cost, lack of awareness and socio-cultural discrimination, were barriers to participation. Discussions/Conclusions: PHC with CP needs to be contextualized to accommodate, learn and benefit from the existing traditional health system. Similarly, a stronger policy measure is needed to minimize if not to eradicate the discrimination against gender, caste, ethnicity and poverty to increase CP in PHC. In the current socio political situation, geography and current status of infrastructural development in Nepal, neither the government nor the nongovernmental / private sector alone are able to address the increased health care need. Therefore, a wider broad partnership based PHC with CP is recommended as a way forward to ensure basic health care service in Nepal. This has been even more important where reconstruction of the health system is underway after the devastating 2015 earthquake, for the community to feel ownership of local health system.