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Improving health outcomes in Nagaland

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Mike Naylor Pooja Singh Prabal Vikram Singh Ruhi Saith Tom Newton-Lewis

This project is one of the components of the World Bank-supported Nagaland Multi-Sectoral Health Project. In Nagaland, the community has been involved in the management of service delivery in a number of sectors, including health, since the passage of the ‘Communitisation of Public Institutions and Services Act, 2002.’ Following a situational analysis, our team proposed a two-pronged strategy to build on the existing platform of community participation, involving holistic capacity building of the committees along with the implementation of a results-based financing (RBF) framework, where the provision of a discretionary fund is tied to the achievement of certain target indicators. This ensures spending efficiency and the incentive structure also promotes interaction between the different tiers of the health system.

A detailed strategy has been provided to the World Bank and the Government of Nagaland, implementation of which would be expected to strengthen the health system, enhance the capability of community based health committees, and improve health outcomes. We provided preliminary support towards capacity building of the implementation team and selected committees in the pre-pilot phase of the project.

Challenges

Drawing on the strong community ties and social capital that characterise the 16 different tribal groups that live in Nagaland, an institutional framework has been developed by the state government to involve the community in the improvement of public service delivery. The ‘Communitisation of Public Institutions and Services Act, 2002’, an act unique to the state, gives local community members (not necessarily part of the elected governance structure) resources as well as responsibilities. Three Ts are involved: the local community is trusted, it is trained to undertake the new responsibilities, and government resources (as well as power) are transferred to the local community to allow them to manage delivery. The act imposes responsibility on the government to provide to such committees critical supervisory and supportive assistance.

Implementation has, however, faced a number of challenges. Capacity building of the committees by government has been limited, with the result that committees are not aware of their rights and responsibilities. Funding provided to the health committees is irregular and often inadequate. Motivation levels are low, as committee members are regularly of the opinion that their participation will not make a difference.

This project aims to strengthen community involvement and the functioning of the health committees thereby improving the delivery of services and health outcomes.

Our approach

In proposing a strategy to strengthen communitisation, our approach has been that of proposing implementation through existing government structures, thereby also strengthening them, and promoting sustainability.

In order to base the strategy on sound evidence, we first undertook a situational analysis together with a local partner ‘Entrepreneur’s Associates’. Field work was undertaken across four districts of Nagaland (Phek, Kiphire, Tuensang, and Dimapur), as well at the state level in Kohima. Focus group discussions and in-depth interviews were undertaken with a range of stakeholders, including community members who were and were not part of the health committees, health staff (of facilities as well as front line), and other government functionaries.

Based on a review of existing literature as well as the field work, a broad two-pronged strategy to build on the existing platform of community participation, involving the following, was proposed:

  • Capacity building – We proposed a broader strengthening of capacity (than just training for provision of skills) using material including audio-visual aids in local languages. In addition to sustainability, capacity building would have to involve reiterative sessions and not just be directed to committee members but also health system functionaries to support committees as well as the wider community. The capacity building is suggested for strengthening communitisation as well as implementing results-based financing. We suggested provision by an external organisation but delivered through the government systems. 
  • Results based financing – This would involve the provision of a discretionary fund to the committees, tied to the achieving of certain targets.

Key features are:

  1. Ensuring that existing government systems are used for the fund flow as well as reporting and monitoring
  2. Extensive support to build capacities to achieve targets, as well as the ability to plan and spend the incentive funds received
  3. The use of indicators to stimulate a greater focus on:
    1. preventative and promotive care
    2. management of facilities, not just monitoring
    3. targeting important gaps identified with regard to health status and health indicators in Nagaland
    4. targeting important components in the areas of maternal, newborn, and child health along the continuum of care
    5. offering a balanced score-card in terms of ease/difficulty of achievement
    6. promoting advocacy by committees (for government provision) to ensure that the targets are met, are in control of the committees to achieve, and are relevant to the roles performed by that tier of the health system
    7. strengthening coordination and oversight between differed tiers
    8. promoting inter-sectoral convergence of health with nutrition and WASH

We also developed a Programme Implementation Manual with necessary details and formats to serve as a guide during the implementation. The Terms of Reference for the capacity building and counter-verification agency have also been prepared.

Outcomes

The strategies proposed in this project are expected to strengthen community involvement in the management and delivery of health services.

It would be expected that:

  • Health committees will be able to develop action plans, achieve targets set out in the results-based financing strategy, and responsibly spend the incentive funds they receive.
  • Advocacy by the committees pressuring government to ensure they undertake their responsibilities will increase.
  • Monitoring and evaluation capacities of government functionaries and systems will improve.
  • Links between the tiers of the health system (village, sub-centre, and primary health centre) and the supervisory role of the higher tiers will also be strengthened, due to the manner in which the RBF is set up.

Therefore, by strengthening community involvement in service delivery, our strategy will also strengthen other aspects of the health system.