Int Health 2015; 7: 228–238 doi:10.1093/inthealth/ihv020 Advance Access publication 15 April 2015

REVIEW

Strengthening state/non-state service delivery partnerships in the health sector in Nepal Baburam Marasinia, Chandrakala Chaulagai (Oli)a,* and Judy Taylora,b,c a

Policy, Planning, and International Cooperation Division, Ministry of Health and Population, Kathmandu, Nepal; b James Cook University, School of Medicine and Dentistry, Australia; cCentre for Regional Engagement, University of South Australia, Australia

Received 2 May 2014; revised 1 December 2014; accepted 12 December 2014 State/non-state partnerships in the health sector are of crucial importance in Nepal where partnerships between the Ministry of Health and Population (MoHP) and external actors have been fundamental to Nepal making progress in meeting millennium development goals. However, partnerships need to be strengthened. To gather information about partnerships we searched MoHP partnership evaluations as well as PubMed Central, EBSCOhost, OVIDSP, PROQUEST, Science Direct, and MedLine. We found 11 MoHP documents and 167 papers about state/non-state partnerships. Using the inclusion criteria we examined three MoHP policy documents/evaluations and 16 papers to extract information about partners, partnership health area focus, partner contributions, partnership outcomes, and partnership functioning themes. Themes about partnership functioning include the need to strengthen clarity of roles and responsibilities, strengthen leadership, as well as to ensure integration of partnership achievements systemically within the health sector. There were limitations in this review. In the academic literature there were no studies where the state/nonstate partnership itself was evaluated. The focus was on the health outcomes and the partnership processes and functioning received little attention. To improve partnerships there is a serious need for research that evaluates the effectiveness of the partnership and the relationships between the partnership and the health outcomes achieved. Keywords: Health reform, Nepal, Policy, Public private partnership, State non-state partnership

Introduction The Government of Nepal is committed to improving the health of all its citizens, particularly women, children, the poor and the marginalized populations, and to achieving its millennium development goals (MDGs). It has made significant progress. Nepal won the 2009 Global Alliance for Vaccines and Immunization Award for its success in reaching MDG 4 (child survival) and the 2010 MDG 5 (maternal health) award for reducing maternal death.1 Between 2000 and 2010 Nepal’s neonatal mortality rate fell by 3.6% per year.2 Immunization coverage for children aged below 12 months increased to 96% in 2011 from 82% in 2010.3 Partnerships between the Ministry of Health and Population (MoHP) and non-state actors, external development partners (EDPs), bilateral and multilateral donors, international non-governmental organisations (INGOs), non-governmental organisations (NGOs) and private sector organizations have played a significant role in each of these health improvements. It is against this backdrop that the Government of Nepal seeks to implement a policy framework in which to operate state/non-state partnerships.4 This paper reports on a literature review to source academic literature

and policy documents about what might strengthen state/non state partnerships in the health sector in Nepal.

Rationale for state/non-state partnerships in the health sector State/non-state partnerships or public private partnerships (PPPs) are terms used interchangeably in Nepal to refer to collaborations between the MoHP and all its partners for the purpose of achieving ‘similar goals, certain objectives and common interests effectively and equitably’.5 The generic term PPP refers to a Ministry partnership with for-profit oriented private sector agencies as well as with not-for profit entities such as NGOs and INGOs. There are many examples of effective partnerships in Nepal and some of the innovations in partnerships could well be transferred to other low resource settings internationally. However, there has been no overall policy framework or strategy, limited monitoring, evaluation and review and some lack of clarity among stakeholders about what state/non-state partnerships actually means.4,6

© The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].

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*Corresponding author: Tel: +977 984 124 6287; E-mail: [email protected]

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countries there is less on state/non-state partnerships in resource poor countries where the health budget is dependent on contributions from EDPs. It is against this backdrop that the Government of Nepal seeks to implement a policy framework in which to operate state/non-state partnerships.

Methods We used the PRISMA 200913 checklist to guide us in the literature review. First we defined what we meant by state/non-state partners. State agencies referred to the government agencies MoHP, Department of Health Services (DoHS) and state controlled national centres and district offices. Non-state partners included multilateral and bilateral donors, INGOs, NGOs and private sector agencies. We searched both the ‘grey literature’ which consisted primarily of MoHP policy documents and the academic international peer reviewed literature. We extracted from the MoHP Policy Planning and International Cooperation section 11 MoHP policy documents and strategic and implementation plans referring to state/nonstate health sector partnerships. We searched EDPs’ web sites for partnership reports, for example, Nepal Health Sector Support Program, World Bank, the German Development Bank KfW and the Department for International Development UK. We searched INGO and NGO web sites, for example the Nepal Red Cross and the Nepal Netra Joyti Sangh, who we knew to be influential operating partners in the health sector. One MoHP policy document and two MoHP sponsored evaluations were included in the review in that they met the selection criteria which were: detail of specific partnerships; partners names identified; partner contributions identified; the area of health in focus identified; health outcomes associated with the partnership identified; and had information about partnership themes.1,6,14 The second source of information was peer-reviewed literature, published in English, about state/non-state partnerships in Nepal’s health sector. We used the key search term ‘Nepal’ and combined this with ‘public private partnerships’, or ‘state/non-state partnerships’, and ‘health’, or ‘health outcomes’. Databases searched included PubMed Central, EBSCOhost, OVIDSP, PROQUEST, Science Direct, and MedLine. This search yielded 158 eligible documents. In addition, we searched key journals including Health Policy and Planning, Global Health Action, and International Health, and this search yielded nine documents, 167 in all. We chose these journals to review because of the likelihood of retrieving articles about health sector partnerships in Nepal. All 167 records were screened to remove duplicates and those that were not about Nepal or public private partnerships in the health sector. A total of 49 papers were extracted and analysed independently to see if they met the inclusion criteria: an explicit reference to a type of health service delivery in Nepal; health service delivery was conducted through a partnership process; the names of the partners were specified and their contribution; the partners included a government partner such as the Ministry of Health and Population; and the paper included some themes about the partnership process. Sixteen academic papers met the inclusion criteria and we independently critically reviewed these to extract information about partners, partnership health area focus, partner contributions, partnership outcomes, and partnership themes (see Table 1). Three MoHP documents were analysed and data extracted in the same way (see Table 2). There were 19 studies included in total.

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The current plethora of PPPs or state/non-state health sector partnerships in Nepal must be understood in the context of the development of modern medicine and health services in Nepal, both of which are relatively recent. Significant progress in establishing modern health services has only been achieved since the 1950s. Prior to this, state provision of hospitals and dispensaries was very limited and the majority of citizens lacked access to even basic health services.7 The introduction of democracy in Nepal in 1991 proved highly significant in the development of the nation’s health services. The government reintroduced modern medicine and institutionalized the Ayurvedic system of medicine through the Health Act Nepal 1991. The Ayurvedic system of medicine is a generic term for traditional medicine in Nepal. A planned health development process commenced with more public health institutions established to increase access to basic health care. In 1991 the Government of Nepal made explicit the need for partnerships with both for profit and not-for-profit organizations and mainstream economic liberalization supported this approach.7 The move to encourage partnerships was because Nepal had difficulty in securing sufficient resources in the public sector to discharge the fundamental functions necessary to maintain the health of its citizens.5 This has not changed significantly. Despite an increase in the public funds allocated to health, the supply of public health care remains insufficient to address the needs and demands of the nation.6 Funding and programmatic partnerships with EDPs, NGOs and INGOs are critical to addressing the full range of Nepal’s health needs including access to safe water supplies, sanitation, and adequate nutrition. Recent data from the Nepal National Health Accounts suggests that in 2013/14 the Government contributes 66.2% and EDPs 33.8% of the public health budget of NPR 30.43 billion8 (US$31 billion) Nepal’s difficulty in securing health sector resources is ameliorated in part by the availability of international funds to address global health concerns, particularly the control of communicable diseases.9 Significant financial resources from global agencies and resource rich countries have supported efforts in Nepal to meet millennium goals to improve maternal, child and neonatal health; to decrease TB, HIV and malaria; and to decrease poverty. While additional financial resources are critical, WHO acknowledges the need to work in partnership with resource poor countries in order to improve health. The Partners for Health in South-East Asia Conference in 2011, sponsored by the WHO Regional Office for South East Asia,10 was devoted to improving partnership processes in the health sectors of low resource countries. However, partnership working in Nepal is significantly affected by the context of political instability.11 With the popular People’s Movement of April 2006 came a period of transition that led to an Interim Constitution, the electing of a Constituent Assembly, and the intention to establish a Federal Republic. The Interim Constitution established the right of all Nepalese citizens to primary health care services, including maternal health, the right to a clean environment, access to education, and a means of livelihood in a social and political environment free from discrimination and institutionalized inequality.1 It must also be noted that the post democracy period has been one of continuous political instability with parliamentary elections conducted in 1992, 1994, 1999 and 2008 without a single parliament running its full term.12 While there is a wealth of literature about the processes of inter-sectoral and community partnerships in resource rich

Citation

Partners

Barker Ministry of Health and et al.32 Population (MoHP); Department of Health Services (DoHS); Department for International Development (DFID); Nepal Health Sector Support Programme (NHSSP) Bhandari MoHP; DoHS; DFID; et al.33 NHSSP; Private practitioners

Partnership operating arrangements

Partnership health area focus

Partnership contributions from state and non-state partners

Results associated with partnership

5 year agreement

Maternal and child health

Frequent change of key Joint planning for maternal government staff; Complex and child health between bureaucratic systems; the government and major Political instability external partners; Implementation of minimum package of services; Skilled birth attendants; Improved blood transfusion policies

5 year agreement

Maternal and child health

Donor financial support; Technical assistance; Joint policy development; Joint planning; Staff training; Building capacity; Improving monitoring systems and use of process indicators; Research and evaluation Donor financial support; Technical assistance; Joint planning; Research and evaluation assistance

Clapham Government of Nepal Agreement Blood transfusion et al.20 between MoHP service for (GoN); Nepal Red Cross and NRCS emergency Society (NRCS); Nepal obstetric care Safer Motherhood Project (NSMP) (DFID funded); Blood Transfusion Service Centre (BTSC) Dawson Pneumonia MoHP; John Snow Inc.; Agreement et al.22 treatment in FCHV; WHO; UNICEF; between MoHP children USAID and Integrated Management of Childhood Illness Program

Edgar BIR Government Hospital; Not available et al.15 Royal Perth Hospital; AusAid; McComb Foundation

Donor financial support; Technical assistance; Capacity building; Research and evaluation

Donor financial support; Technical assistance; Planning; Evaluation; Monitoring of treatment by FCHV; Research and evaluation

Education for the Donor financial support; treatment of burns Education and training for Nepalese staff

Partnership functioning themes

MoHP needs to build on Skilled birth attendants at partnerships between delivery; Improved FCHV at community level abortion services; Female and engage better with community health the private sector volunteers (FCHV); Joint planning with central DoHS officers; Improved cooperation between agencies Substantial improvements in Lack of GoN partnership policy framework; Lack of quality and management clarity of roles and of blood transfusion responsibilities at central services; Effective working level; Lack of staff and partnership between the technical capacity at NRCS, the community, and central level the local hospital Substantial improvements in the recognition of childhood pneumonia and appropriate treatment given by the FCHV

Multidisciplinary education programme in Nepal with exchange visits. Improved burn patient management at the Bir Government Hospital

Strong and sustained leadership from the MoHP and donor partners facilitated the start-up of this programme and kept it on track; Support now from a larger group of partners is essential Need for sound cross cultural preparation for the non Nepali team members; Local assessment of the partnership strengths and limitations was essential

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Table 1. Data synthesis of state/non-state partnership academic literature

GoN; Nepal Vitamin A Program (NVAP); USAID; Helen Keller International; FCHV; Nepalese NGO (TAG)

Not available

Vitamin A distribution Donor financial support; programme Technical assistance; Capacity building

Grundy34

MoHP; Global Alliance for Vaccines and Immunisation (GAVI)

Public private global health agreement

Evaluation of country coordination mechanisms for implementation of immunisation programmes

Donor financial support; Technical assistance; Coordination; Joint planning

Gurung MoHP; Nepal Family et al.23 Health Program II; USAID; JSI Research Training Institute

Not available

Health sector strengthening (governance) partnership

Donor financial support; Training for Health Facility Management Committees (HFOMCs)

Hurtig GoN National et al.21 Tuberculosis Centre (NTC); Nuffield Institute for Health; Private practitioners; Four NGOs Karki District Public Health et al.35 Office (DPHO); Three NGOs; Patan Hospital; Private medical clinic

Not available

Tuberculosis registration and direct observed treatment short course (DOTS) linkage project Tuberculosis control through involvement with private practitioners and NGOs Provision of TB treatment and identification services in Lalitpur Nepal

Memorandum of Understanding with DPHO; Informal agreements

Newell GoN, Nepal National et al.17 Tuberculosis Program, (NTBP); DFID, UK; Three NGOs; Private medical practitioners

Not available

Pradhan et al.2

Working groups

MoHP; Family Health Division; Universities; External Development Partners (EDPs)

National Neonatal Health Strategy (NNHS)

The NVAP is a highly successful, high-dose vitamin A distribution program with sustained high coverage rates and low cost Governance by country coordination mechanism (committee)

Capacity building of HFOMCs; Increased community engagement in governance; Improved mobilization of local resources; More accountability Four NGOs were providing Donor financial support; well-functioning DOTS Technical support to NGO centres DOTS centres; Drug distribution; Research and evaluation

Donor financial support; Collaboration to provide services through treatment centres

Donor financial support; Technical support; Joint planning; Training; Evaluation; Joint service delivery

Donor financial support; Technical taskforce; University research; Joint planning

Treating TB patients through a state/non state partnership increased notification, improved treatment outcomes and had a low cost Partnerships resulted in increased TB case notification of sputum-positive patients in the study area and high treatment success rates

Lack of staff and technical capacity at government central level to support and institutionalise the program; FCHV are key to program success and are trained by the TAG Evaluation showed that country coordination mechanism assisted information sharing; Less joint evaluation or technical support coordination The success of the good governance initiative required institutionalisation in the government health sector systems Partnerships with private practitioners for TB treatment proved difficult; Role and responsibilities of partners have to be well defined Partnership challenges were the engagement of private practitioners and leadership

Combining the different strengths of private practitioners, nongovernmental organizations, and the public sector improved service delivery The MoHP provided A national newborn-specific leadership for newborn strategy developed and survival strategy at a high implemented that resulted level and was effective in in advances in newborn partner co-ordination survival

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Continued

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232 Table 1. Continued Partners

Partnership operating arrangements

Partnership health area focus

Partnership contributions from state and non-state partners

Raja District Health Services/ et al.24 FCHV; DFID; Livelihoods Education Development Society (LEADS)

Social franchise

Provision of mental health services in Districts

Rana Family Health Division; et al.19 UNICEF; DFID; Columbia University; NHSSP

Not available

Rath MoHP; UNICEF; DFID; et al.16 NHSSP

Seven year agreement; Sub contracts

Women’s Right to Life and Health Project to provide emergency obstetric care in Districts The NSMP for access to emergency obstetric care

The partnership acts as a Donor financial support; Community-based mental ‘push’ for government to Provision of Mental health and development set up more mental health Health and Development model used to provide services (MHD) service model; services in districts; Training supervision Capacity building with health facilities integrate the model into activities of the existing providers and communities Improvement over 4 years in Partnership was crucial for Donor financial support; the availability, quality, joint planning, providing Technical advice; Joint and utilization of resources, and planning; Service emergency obstetric care coordination required to delivery; Infrastructure reduce maternal mortality provision; Research

Trägård MoHP; Global Fund et al.25 Principle Recipients (NGOs)

Country Coordinating Committee; MoHP has agreement with Principle Recipient NGO

Initiatives to fight AIDs, TB and malaria

Donor financial support; Equipment; Training; Technical advice; Joint planning; Service delivery; Research

Results associated with partnership

The NSMP increased access to midwifery and obstetric services. It also influenced policy development in the Ministry and helped to strengthen health sector

Global Fund financing; Joint The Global Fund planning; strengthened the TB, Implementation; Malaria and HIV Research programmes; Early diagnosis and treatment of malaria and TB have been successfully decentralized to all levels of health care

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Citation

Partnership functioning themes

Project experience of contracting NGOs for training and service provision to the public sector helped develop local policy thinking about working collaboratively with non-state providers Implementation through Principle Recipient NGOS demands new arrangements are complementary to the public health system; Stewardship lies with the public health system

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Table 2. Ministry of Health and Population Public Private Partnership literature synthesis Citation

Partners

Partnership operating arrangements

RTI International: Ministry of Health and Population14

Contracting out Ministry of Health and Population (MoHP); Human Development and Community Services (HDCS); Lamjung Integrated Community Health Centre (LICHC)

Ministry of Health and Population, WHO6

Eye Health Social franchising. MoHP; Nepal Netra Joyti Main partners NNJS, Sangh,(NNJS); Nepal Eye BPEF and Nepal Eye Hospital, (NEH); Tilaganaga Program. Eleven eye Eye Center; B.P. Koirala; hospitals being Lions Center for operated under Opthalmatic Studies; B.P. NNJS as social Eye Foundation. (BPEF) franchises Nepal Red Cross (NRC)

Ministry of Health and Population, NHSSP1

Review of partnerships in the health sector in Nepal (District Hospital management focus)

District Hospital management contracted out to NGO or local communities

Partnership health area focus Management of the Lamjung District Community Hospital

District hospital health service delivery

Results associated with Partnership functioning partnerships themes Contract ambiguities; Service delivery has MoHP financial MoHP poor monitoring improved contributions; HDCS capacity; Poor quality, significantly since financial contributions; coverage, pricing, and the partnership Management and incentives for commenced, strong service delivery by performance governance, and HDCS; Capacity arrangements sound staffing development HDCS; arrangements MoHP oversight Lack of specific policy, Eye health services MoHP financial strategy and guidelines improved contributions; Policy on what is expected in significantly; High coordination through the partnership; Limited level of specialised Apex Body for Eye involvement of service delivery; Health (ABEH); Technical stakeholders (MoHP) in Production of lenses support, training and planning and evaluation supervision provided to of eye health program hospitals by NNJS (franchisor) (non-state) Contracting out results Partnerships limited by MoHP funding; NGO/ in improved service inadequate policy; Weak community funding delivery, state sector; Poorly from fees, donations, management defined performance and donor agencies; access, and training. indicators NGO/community provides staffing, management and service delivery

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Results This section reports the results of the academic literature search (Table 1) and the MoHP literature (Table 2) using the headings from the literature synthesis.

health6 and district hospital management.1,4 The health areas written about in MoHP literature did not overlap with the academic literature.

Partnership functions Types of partners

Partnership modalities or arrangements through which the partnership is conducted From the MoHP perspective different types of partnership and contracting arrangements are in place in Nepal’s health sector. They include community management arrangements for health facilities, direct service provision, facility management, and lease contracts as well as Built, Own, Operate and Transfer arrangements, joint ventures, and performance based payment schemes. Some of these arrangements are complex and include more than one type of partnership.6 The operation of the Lamjung Community District Hospital is an example of contracting-out the management of a hospital to improve service delivery; The Human Development and Community Services, a faith-based national NGO, manages the hospital while the MoHP owns the facility, is responsible for all agreed-upon fiscal requirements, and oversight.14 Another type of arrangement is the performance-based contracting arrangement that operates for the provision of comprehensive emergency obstetric care.16 The current arrangements include memoranda of understanding between a district health office (DHO) in Nepal and a service provider that might be a medical college, an INGO, or a private doctor in line with the Government procurement rule. Funding for services is negotiated between the DHO and the service provider. The academic literature about partnerships mentions agreements, memoranda of understanding, contracting out, contracting in, social franchises, working groups, and informal arrangements as partnership modalities. Six papers did not include information about the structure through which the partnership is conducted.

Partnership health area focus Half the peer-reviewed literature consisted of papers about partnerships in maternal and health (six papers) and TB control (four papers). There was one paper about partnerships in each of the following areas, health system strengthening, immunisation, vitamin A distribution, burns treatment training, mental health and pneumonia treatment. The MoHP literature gave information about health sector public private partnerships overall1 as well as specific reference to public private partnerships in eye

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Results associated with partnerships The significant health improvements for Nepal’s citizens that are associated with state and non-state partners working together are noted both in the MoHP reports and in three academic papers.16,17,19 One paper outlines the different strengths of partners and how they combine to effect overall improvements in health service delivery.17 The MoHP reports that non-state actors, working in partnership with the MoHP, have ensured better access to services, offered safety nets for targeted groups, increased the number of beneficiaries, improved the supply and availability of necessary services, improved infrastructure and facilities and eased pressure on the public sector health care facilities.6 In addition, partnerships have helped build stronger government policy responses to diseases, helped place key issues on the national agenda, and provided services in areas where, because of cultural values and practices, it was difficult for the Ministry to do. The academic literature indicates some very positive health improvements involving state/non-state partnerships in TB control,17 vitamin A deficiency prevention,18 the Women’s Right to Life and Health Project19 and newborn health.2 In 1994 the Nepalese government, in conjunction with DFID and WHO, initiated the Safe Motherhood Program followed by the introduction of emergency obstetric care services, the presence of skilled attendants at birth, and an enhanced public awareness of safe motherhood issues.19 This program is associated with some strong improvements in neonatal and maternal health. The MoHP acknowledges these positive health improvements in all of these areas and the improvements in district hospital management, and in eye health.

Partnership themes The themes from the literature about partnership contextual issues and processes are in much greater depth from the MoHP publications than the academic literature. From the MoHP planning perspective state/non-state partnerships for service delivery have grown haphazardly in response to needs or recognized problems, or through the initiatives of donor agencies, and each partnering opportunity is usually handled as unique. While this provides a degree of flexibility to ensure that needs are met appropriately, it also means that partnerships are time consuming to negotiate and monitor.

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From the MoHP literature we found that the MoHP has diverse partnerships with a wide range of partners, global multilateral donors, bilateral donors, Nepal Health Sector Support Program (NHSSP), INGOs, NGOs, private sector organisations, and citizens groups. From the academic literature we found that global multilateral organisations such as Global Alliance for Vaccines and Immunization, and bilateral organisations, such as the Department for International Development (DFID) are very significant. There were also reports of short-term partnerships for example, the Royal Perth Hospital in Western Australia for burns management training.15

From the academic literature we found that all partnerships involved financial contributions to the MoHP from multilateral or bilateral donors. Technical assistance, joint planning and coordination, training and capacity building and research and evaluation were contributions in almost all partnerships. The MoHP partnership evaluation reports on management of District Hospitals and in eye health show financial contributions from the MoHP and donors to the partnership, joint planning and policy making, with the MoHP having oversight of the partnership.

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Understanding roles and responsibilities of partnerships

Leadership The MoHP reports suggest that the fragility in leadership sometimes apparent in partnership initiatives is due to frequent changes of staff, uncertainty in government budget allocations in the longer term, and an uncertain policy context.6 One paper reports extensively on the issues with state/non state partnership leadership.17 Where strong leadership was apparent partners were able to believe the partnership could work. A commitment for working together and a respect for the importance of expressing all partners’ ideas and fears were conveyed through positive leadership. In addition, the fragility of the public health sector makes strong leadership from within the sector difficult. Partnership sustainability issues Six academic papers refer to the vulnerability of partnership outcomes in health service delivery improvements because of the difficulty to integrate changes in weak government systems.17,18,22–25 Weak government systems come about because of changes of staff, the complexity of the bureaucracy, the unstable political environment and the lack of staff capacity. Non-state partners identify the insecurity caused by the government’s standard one-year funding commitment as a problem.20 Partners also note the time lag in funds dispersal that occurs at the beginning of Nepal’s fiscal year.6 The fiscal year of the MoHP and those of EDPs and are not aligned and there are numbers of factors that influence the Nepal health sector’s budget including the extent of commitment from EDPs.

Discussion The responsibilities facing the MoHP in health sector reform to implement this new state/non-state partnership policy are considerable. The MoHP must increase the current level of service delivery while sensitively negotiating with partners to introduce a regulatory framework and performance monitoring system. Once officially approved the Technical Working Group responsible for working with the MoHP in producing the state/non state partnership policy will assist in implementation. Considering the information available from the literature review some areas where partnership strengthening might be possible are clear.

Clarifying partner roles and responsibilities and improving working relationships It is likely that government staff and non-state partners have disparate and potentially conflicting understandings of what state/ non-state partnership means in general and in specific instances. The lack of a state/non-state partnership policy means that there are no overarching guidelines to draw on. In addition, partnership arrangements are usually drawn up specific to each situation. Standardizing partnership arrangements and clarifying appropriate models for service delivery within the overall policy framework will greatly assist in strengthening partnerships. In standardizing partnerships a set of operational models for each type of partnership is necessary. Within the model, the goal and outcomes of the partnership should be made explicit along with the roles and responsibilities of partners and the funding arrangements. Each partnership type should have a set of outcome indicators. Flexibility should be maintained but within an overall policy framework.

MoHP moving from a ‘silent partner’ to an active facilitator and strong leader The introduction of a state/non-state partnership policy in the health sector highlights MoHP’s role in partnership development allowing it to move from a ‘silent partner’ to an active facilitator and strong leader.4 There are several reasons why the MoHP should assume leadership. First, MoHP leadership will assist in institutionalising the improvements partnerships have brought about. Second, if the MoHP is aware of partnership objectives and activities then sector-wide planning is much more effective. However, there are challenges in taking on this more active role. First, government staff do not always know about all of the health related activities of the for-profit sector, INGO and NGO partners as there are so many of them.26 There will need to be a process of knowledge sharing and improved communication. Second, there has not always been acknowledgement of the different roles and responsibilities of the state and non-state actors in partnerships and where they overlap. Communication between state and non-state partners has not always been open and misunderstandings about respective roles have arisen.6,17 In addition, partners have been operating for some time without protocols or guidelines and the introduction of new regulations and review processes might be considered to be intrusive. Extensive use of the key partner technical working group that helped the MoHP develop the new state/non-state partnership policy is essential if all partners are to embrace a more regulated environment. Currently, district health officers have the oversight of state/ non-state partnerships in their work role but there is no written protocol to guide their activities. The introduction of the new PPP policy will overcome this, and provide much needed clarity, but staff will need to take a proactive role in facilitating partnerships. Given that there are likely to be almost 1000 NGO and INGO partners are already involved in health this is a considerable task on top of an already busy workload. To become an active facilitator and strong partnership leader will require meaningful incentives and a high level of staff motivation. There are some situations where the state is weak and completely without capacity to lead or even initiate partnerships. In Nepal, this occurred in the provision of a mental health package

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The term used to describe this in the MoHP partnership literature is ‘conceptual understanding’ and the reviews of state/non-state partnerships undertaken by the MoHP use this term ‘weak conceptual understanding’ extensively.6,12,20 ‘Weak conceptual understanding’ refers to a lack of awareness at central and district levels of the goals and objectives of partnerships and the roles and responsibilities of the partners, and a lack of capacity to work together, largely reflecting the incremental and haphazard manner in which the partnerships developed. Three papers in the academic literature refer to a lack of clarity of roles and responsibilities of government staff and partners responsibilities including a lack of trust in each others capacity.16,20,21 The evaluation of the Nepal Red Cross blood transfusion service in comprehensive emergency obstetric care pointed to problems resulting from the lack of legal frameworks and central MoHP support.20

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to children during a period of armed conflict in the country. The service was provided by a Nepal based NGO and funded through international donors.27

self-sufficient so that they are able to take responsibility for implementing the partnership policy. This is consistent with how Khul defines the outcome of capacity building of health sector staff in low resource countries.31

Access and equity in service delivery

Capacity building to enable partnership policy implementation The issue of ‘capacity building’ is important in Nepal, even though there is considerable debate about its meaning in the international literature.30 In the context of the implementation of the state/ non-state partnership policy, it is necessary that both MoHP and DoHS staff and representatives from EDPs, INGOs and NGOs negotiate desired partnership outcomes and the roles and responsibilities of partners. There are important contextual factors that act as enablers and one of these is a trusting environment in which clear communication between partners can occur. Another requirement is that relevant government staff have the technical and managerial capability to design, implement, manage, and monitor partnership arrangements, as well as to regulate the non-state sector.4 Having capacity in this regard is likely to lead to government staff becoming motivated, independent and

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Limitations of the literature review The bulk of the peer reviewed material reported on a type of health intervention or program, with outcomes included but with limited analysis of the partnership modality and with rarely any attempt to relate partnership outcomes to the nature of the partnership. Only qualitative data about partnerships could be obtained. As the papers were not all reporting on studies assessing quality of the information was impossible. Where partnership themes were mentioned in the academic literature the writing was from the perspective on the non state partner. The material from the MoHP is much more indicative of partnership themes but clearly from the perspective of the MoHP. The discussion in this paper attempts to integrate state and non-state actors’ views about partnership strengthening.

Conclusions In any resource poor country there is very real pressure to reduce mortality and morbidity and improve the health outcomes of citizens’ most in need. To achieve this, interventions are chosen which have been shown to be most effective and efficient given the context in which they are to be applied. Health outcomes data resulting from these interventions provides vital information. However, this is not the full story. An analysis of the effectiveness of the partnerships involved and the types of staff or volunteers that deliver the interventions provides a fuller picture. The dynamics of the health system that supports the intervention and the role of government leadership and commitment together with the level of community involvement are also important. Nepal’s constitution, budget, and the Nepal Health Sector Plan II (2010– 2015) all give priority to state/non-state partnerships. If these partnerships are to flourish then there must be a solid evidencebase of what processes work and which ones are less successful in conducting these partnerships. This is especially the case in Nepal where there has been such significant progress in achieving health improvements. There is still an extraordinarily weak evidence base to support (or challenge) the ways in which the interventions are being implemented and the partnerships which are supporting the interventions.9,28,29 Nepal is at the forefront of an opportunity to provide information about health sector strengthening, negotiating partnerships with the private for-profit sector, INGOs, NGOs and external development partners, aligning outcomes with partnership types, and assessing the extent of integrated planning. If this opportunity is to be realized there will need to be an effective partnership monitoring system so that key outcomes and processes are identified. There will also need to be a robust set of base-line data on partnership functioning so that changes over time can be measured. If the Government of Nepal monitors the implementation of the new PPP policy, and makes public this information, then it may prove instructive for other resource poor countries that are experimenting with different styles of partnerships and funding modalities.

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One of the problems related to health services provided by INGOs in response to emerging local needs is that there might be inadequate service coverage. Some excellent specialized service systems of care, such as eye health,6 are available in some districts in Nepal but not in others. Often it is the more remote and mountainous regions that are not covered. In some instances services provided by INGOs and NGOs are running parallel to the public system and services are not well integrated. On occasion there are difficulties in making referrals from the district health care system to the specialist system resulting in access and equity disparities.6 Implementing a state/non-state partnership framework has the potential to act as a lever to stimulate the development of a more integrated health planning and service delivery system. The issue of disease specific vertical planning and service delivery, and the planning problems that can be associated with it, are debated in international health development literature.28,29 Vertical approaches to planning and service delivery use systems that are specific to a particular disease while horizontal approaches work through existing health-system structures. Nepal has a complex mix of both vertical and horizontal planning and service delivery systems. Some programmes, including maternal and child health, vitamin A distribution, treatment for childhood pneumonia and immunization are strongly embedded in government systems. In the eye care system and for some diseases, TB and HIV for example, vertical planning and service delivery are the accepted mode of delivery. The problem with vertical planning and delivery is that when there are multiple organisations delivering different disease-specific initiatives at the district or community level, then problems of integration, overloading of staff, and overlapping regimes might occur.29 The strengths of horizontal planning and delivery are that capacity is built and changes have a greater chance of being institutionalised. The introduction of a state/non-state partnership policy promises to provide a useful first step in bringing potential partners together with government to open dialogue on a collective way forward.

International Health

Authors’ disclaimer: The opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Ministry of Health and Population in Nepal, the Australian Department of Foreign Affairs and Trade, or the Australian Volunteers for International Development (AVID) program. Authors’ contributions: BM, CC, and JT conceived of the study and the paper. CC and JT conducted the literature review. CC and JT conducted analysis and interpreted the data and JT drafted the manuscript. BM and CC critically revised the manuscript and all authors agreed to the final version and are guarantors of the paper. Acknowledgements: The generous assistance of the Nepal Health Sector Support Program (NHSSP) in the preparation of this paper is acknowledged.

Competing interests: None declared.

13 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) http://www.prisma-statement.org 14 RTI International, MoHP. Management of the Lamjung District Community Hospital. Research Triangle Park NC: RTI International; 2010. 15 Edgar D, Tonkin C, Baker T et al. A partnership in burns care education – Nepal and Australia. Ann Burns Fire Disasters 2005;XVIII:173–6. 16 Rath AD, Basnett I, Cole M et al. Improving emergency obstetric care in a context of very high maternal mortality: The Nepal Safer Motherhood Project 1997–2004. Reprod Health Matters 2007;15: 72–80. 17 Newell JN, Pande SB, Baral SC et al. Leadership, management and technical lessons learnt from a successful public-private partnership for TB control in Nepal. Int J Tuberc Lung Dis 2005;9:1013–7. 18 Fielder JL. The Nepal national vitamin A program: Prototype to emulate or donor enclave. Health Policy Plann 2000;15:145–56.

Ethical approval: Not required.

19 Rana TG, Chataut BD, Shakya G et al. Strengthening emergency obstetric care in Nepal: The Women’s Right to Life and Health Project (WRLHP). IJGO 2007;98:271–7.

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Funding: This work was supported by the Australian Volunteers for International Development program funded by the Australian Department of Foreign Affairs and Trade (to JT).

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