1. No category

Initiative for stocktaking about
Quality Management
in Nepali health care system
Martin Vitzithum
Adviser Health Care and Hospital Management
Health Research and Social Development Forum (HERD)
05.04.2015
Introduction
 Acknowledgements
 Model to describe health system
 Dimensions of quality management
 Professional licensing
 Policy(ies) / documents
 Clinical Standards
 Interim Findings
 Next steps

Introduction
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Many and versatile initiatives around “quality in
healthcare” started or ongoing.
Focus primarily on public health and maternal / newborn
health.
Overall system approach not visible.
No central steering structure visible.
Objective of the initiative is to get an overview about all
activities in overall system and to propose an approach for
further development of systemwide quality management
This interim report is the first attempt and has surely to be
improved.
Acknowledgements
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Thanks to all partners giving information to our
external consultant.
Special thanks to NSI for comprehensive support of the
initiative.
Very special thanks to NSI for developing “eReference
Manual”
Model to describe health system
Governance, Policy
5
teaching
hospitals
14 (?)
medical
colleges
72 District, 10
Zonal, 5 Regional, 5
Central hospitals
360 (?) private
hospitals
n PHCC, HP, SHP
n private practices,
medical clinics
I/NGOs
n Pharmacies, others
Pharmaceutical
producers
PUBLIC SECTOR PRIVATE SECTOR
Dimensions of quality initiatives
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Stakeholders: Government / EDPs / I-NGOs/ civil
society / private institutions / academic Institutions
Initiatives: communities / working groups / policies /
strategies, …
Products: Standards (MSS by NSI), Guidelines, SOPs,
information systems, eReference manual (NSI), PBMS /
HFQI / IS (GIZ)
●
Legislation: draft / indorsed / agreed
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Independent institutions: professional licensing
Concrete stakeholders on quality
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Health 4 Life (establishing quality improvement system,
starting with MCH, also working in 14 districts focused
at below district level)
NHSSP (working with 2 district hospitals on quality
system)
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NSI (focusing on rural hospital quality)
●
WHO (tb clarified)
●
GIZ (focusing on reproductive health, health insurance
/ hospital management, harm reduction)
Professional licensing
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Nepal Medical Council (doctors)
Nepal Nursing Council (nursing staff)
Nepal Health Professional Council (HA, CMA, Lab
asst/tech, x-ray, physio, public health)
Nepal Pharmacy Council (pharmacist, pharmacy asst)
All professional councils established by act, governed by
regulations.
Licensing of health facilities?
Licensing of health facilities
Type of facility
Ownership
Legislative framework
Registration
Licensing body
Public facilities (sub-health post, health post, district hospital)
MoHP
N.A.
N.A.
N.A.
MoHP/Hospital Development Board
Development Board Act,
Hospital’s own regulation
N.A.
N.A.
NGO run hospitals/ Community hospital
Respective NGOs
Association Registration Act
District Administration Office
(Ministry of Home Affairs)
MoHP
Cooperative hospital
Respective cooperatives
Cooperative Act
Department of Cooperatives
(Ministry of Agriculture and
Cooperatives)
MoHP
Army hospital
Ministry of Defence (MoD)
Army Act
N.A.
N.A.
Police hospital
Ministry of Home Affairs (MoHA)
Police Act
N.A.
N.A.
Hospital for Civil Servants
Ministry of General Administration (MoGA)
Civil Servant Service Act
N.A.
N.A.
Public medical colleges
Ministry of Education (MoE)/respective
university
Act of concerned university
N.A.
Nepal Medical Council
Private (for profit?) hospitals
Private company
Company Act/Private Firm Registration Act
Office of company registrar
(Ministry of Industry)
MoHP
Private medical colleges
Private company
Company Act/ Act of affiliated university
Office of company registrar
(Ministry of Industry)
Nepal Medical Council
Specific Act
N.A.
N.A.
Semi-autonomous facilities (regional, zonal and central
hospitals)
Medical Universities/Academies/Centre
Strategic Management
Vision
Health policy
Mission
NHSP
Objectives
NHSP IP
Strategies
“Doing the right things”
Leadership, ownership, responsibilities
Actions
“Doing the things right”
Management, Trainings
Trainings in hospital management
Vision
Health policy
Mission
NHSP
Objectives
NHSP IP
Strategies
MISSING
“Doing the right things”
Leadership, ownership, responsibilities
Actions
“Doing the things right”
Management, Trainings
Documents about Vision
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National Health Policy 1991 and New Health Policy
Revised on 2014, naming “quality” 21 times, consisting
of:
–
(M) Second Long term Health Plan 1997-2017
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(M) 3 Years Plan Health & Nutrition 2010/11-2012/13
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(M) 3 Year Plan Health & Population 2006/07-2009/10
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(M) Quality Health Service Policy 2007
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(M) Health Care Technology 2005
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(O) Nepal Health Sector Programme - Implementation Plan 2004-2009
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(O) Nepal Health Sector Programme - Implementation Plan 2010-2015
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(S) Nepal Strategic Plan for Human Resource for Health 2003-2017
–
(S) Nepal Strategic Plan for Human Resource for Health 2011/12-2014/15
Documents about Mission
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Health Care Technology Policy 2006
Policy on Quality Health Service improvement system
Implementing Guideline 2009
National Safe Motherhood and Newborn Health –
Long Term Plan 2006-2017 FHD
Documents about Objectives
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Nepal Health Sector Programme - Implementation Plan
2010-2015
Documents about Strategies
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Hospital Development Board Act 2010
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National Neonatal Health Strategy 2004 FHD
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Drug act (Draft)
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Health Institutions Operations & Regulations Act (Draft,
includes quality relevant documents, by GIZ)
Documents about Actions
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Basic Needs for operation of Primary Health Center in 1994
Basic Needs for operation of Sub health post in 1994
Monitoring quality of care in Maternity Service 2004
Health Institution Minor Infrastructure Development
Implementation Guideline 2008
Ama Suraksha Program Operating Manual 2008 second revised
by FHD in 2012
Performance based Management System Implementation
Guideline 2008 by Management Division
Performance based Management System Implementation
Guideline 2010 (for District Health Office / District Public Health
Office purpose) by Management Division
More documents about Actions
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Social Audit Operating Guideline 2013
Maternal and Newborn care – Quality Improvement
tools for service Delivery and SBA Inservice Training
July 2009
Health Service Program Integrated Supervision
Operation Guideline 2011
National Medical Standard for Reproductive Health
Vol. III Maternal and Neonatal care by FHD
Docs about Actions - Clinical standards 1
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Guideline for establishment and upgrade of Health
Institution (MOHP) (BS 2013)
Minimum Service Standards for District Hospitals
(MOHP draft / NSI)
Operating Theatre Technique and Management (NHTC)
Ambulance Service, Operational Policy (MOHP)
Infection Prevention Reference Manual (NHTC)
National Medical Standard Vol 1 (FHD)
National Medical Standard Vol 2 (FHD)
National Medical Standard Vol 3 (FHD)
Docs about Actions - Clinical standards 2
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Maternal and Newborn Care QI tools for SBA Service
Delivery and Inservice Training (NHTC) July 2009
FP QI Tools for Service Delivery (NHTC) July 2012
QI Tools for Comprehensive Reproductive Health
Service Delivery (NHTC) July 2014
IMCI Manual (CHD)
Good Pharmacy Practice (GPP) (Nepal Pharmacy
Council draft)
Hospital pharmacy directives (MOHP) 2013
Standard Treatment Protocols for Health Posts and
Sub-Health Posts (PHCRD)
Docs about Actions - Clinical standards 3
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Leprosy Control Program Operating Manual (LCD)
TB General Manual (Third edition 2012) (NTP)
Snakebite Management Guidebook (EDCD)
Rabies Guidebook (EDCD)
National Malaria Treatment Protocol (EDCD)
Guidelines for Management of Dengue Fever (EDCD)
STI guidelines (NCASC)
National Guidelines (4th edition) PMTCT (NCASC)
VCT Guidelines (NCASC)
Guidelines on Emergency Preparedness and Disaster
Management for Hospitals (EDCD, 2002)
Interim findings 1
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Lots of documents defining vision, mission and actions.
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Definition of objectives and strategies?
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No system wide approach.
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Legal and implementation framework is missing.
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No common understanding of quality management /
improvement / assurance / patient safety.
Interim findings 2
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Lack of health institution management leads to failure
of implementation of quality management.
Role of MoHP as a regulator?
Different responsibilities under different units /
ministries for different level of hospitals (District, Zonal,
Regional, Central, Teaching…), harmonization?
Next steps
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Distribution of this document.
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Feedback on document.
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Completion of compilation of data.
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Conceptualizing of sector wide quality strategy, maybe
using model for strategic management…
Strategic Management of Quality
Vision
Mission
Objectives
Strategies
“Doing the right things”
Leadership, ownership, responsibilities
Actions
“Doing the things right”
Management, Trainings
Please give feedback!
[email protected]
Thank you!
Martin Vitzithum
Adviser Health Care and Hospital Management
Health Research and Social Development Forum (HERD)
05.04.2015