Review of health planning &budgeting from province to local level in federal system of Nepal.

1. Practical Skill Development
on
Review of current health service planning in Nepal from province to local level
(PSD work was carried out in partial fulfillment of PSD 525 Public Health Service
Management)
Submitted to:
Dr. Dipendra Kumar Yadav
School of Health and Allied Sciences
Faculty of Health Sciences
Pokhara University, Kaski, Nepal
Submitted by:
Group: A
Jeny Shrestha (Roll N.18700002)
Mohammad Aslam Sheikh (Roll N.18700003)
Nabin Prasad Chaudhary (Roll N.18700004)
Selina Siwakoti (Roll N.18690006)
(2019)

2. i
Acknowledgement
Our heartiest gratitude goes to subject teachers Dr. Dipendra Kumar Yadav for their continuous
inspiration, valuable guidance and suggestions. Their valuable support and guidance has helped
us to complete our task successfully without hesitation. We would like to express our hearty
thanks to Dr. Damru Prasad Paneru, Director of School of Health and Allied Sciences (SHAS)
for providing us the opportunity to conduct Practical Skill Development (PSD) for enhancing our
skills in practical setting.
We sincerely acknowledge the contribution of Mr. Chirajivi Adhikari, Program Coordinator of
MPH, for his kind cooperation and guidance and support throughout the program.
We would like to express special thanks to entire team of Provincial Health Directorate team for
providing valuable time, information, and thereby supporting us to conduct our task feasibly.
Our sincere thank goes to the seniors and classmates who provided supportive feedback and
impressive comments during the study and documentation. Lastly, we would like to express our
sincere thanks to all those who were directly and indirectly involved in the entire process of our
practical skill development.
Group A

3. ii
Contents
Acknowledgement ........................................................................................................................... i
CHAPTER 1: INTRODUCTION:.................................................................................................. 1
1.1 Background: .......................................................................................................................... 1
1.2Rationale of the study:............................................................................................................ 2
CHAPTER 2: OBJECTIVE:........................................................................................................... 2
2.1 General Objective:................................................................................................................. 3
2.2 Specific Objectives:............................................................................................................... 3
CHAPTER 3: METHODOLOGY .................................................................................................. 3
3.1 Study area:............................................................................................................................. 3
3.2 Study duration:...................................................................................................................... 3
3.3 Technique and tools used for Review of System:................................................................. 3
CHAPTER 4: RESULTS & FINDINGS ........................................................................................ 4
4.1 At Local Level:...................................................................................................................... 4
Health planning and budgeting Structure in local level:............................................................. 5
Revenue and consulting committee: ........................................................................................... 5
Resource estimation and budget ceiling allocation committee................................................... 6
Program planning and budgeting Committee: ............................................................................ 6
4.2 At Provincial Level: .............................................................................................................. 6
Health planning and budgeting from federal to provincial level: ............................................... 8
Organogram of Provincial Health Directorate: ........................................................................... 9
Planning and Budgeting Process and Time Frame: .................................................................. 10
CHAPTER 5: STRENGHTS AND CHELLENGES.................................................................... 11
5.1 Strengths:............................................................................................................................. 11
5.2 Challenges:..................................................................................................................... 11

4. iii
5.2.1 At Province Level: ........................................................................................................... 11
5.2.2 At Local Level............................................................................................................ 11
6. CONCLUSION AND RECOMMENDATIONS: .................................................................... 13
6.1 Conclusions:........................................................................................................................ 13
7. REFERENCES: ........................................................................................................................ 15

5. 1
CHAPTER I: INTRODUCTION:
1.1 Background:
Nepal’s new Constitution envisions three tiers of Governments in Nepal, when previously there
was just one. Central or Federal Government based in Kathmandu, the capital, 7 Provincial
Governments and Local Governments. In between Provinces and Local governments, we also
have 77 districts and in each district, there is a District Coordination Committee (DCC), which
has less power than Local Governments and just tries to coordinate activities of several local
governments within it. Based in Kathmandu mainly Singh durbar, it is the main Government in
Nepal. Its functions are laid down in the Constitution but their chief responsibilities among many
others are national defense and conducting foreign relations. At Federal Government, MOHP is
leading government ministry for health.
The seven provinces of Nepal were formed on 20 September 2015 in accordance with Schedule
4 of the Constitution of Nepal. Each district (77) has local units. Nepal consists of 6 metropolitan
Cities, 11 Sub-Metropolitan Cities, 276 Municipalities and 460 Rural Municipalities. These 753
local units are known as the local level in Nepal which are considered as the implementing unit
of government. A total of 6,743 wards are formed under these 753 local levels. The Constitution
of Nepal 2015 (Schedule 8) gives 22 powers to these local levels. Besides these single powers,
there are 15 such concurrent powers that can be implemented by all three level of state, i.e.,
federation, province, and local levels, in the principles of coordination, cooperation, and
coexistence.The current system of seven provinces replaced an earlier system where Nepal was
divided into 14 Administrative Zones which were grouped into five Development Regions. The
provinces of Nepal are governing by provincial governments, which form the second layer of
government, between the federal government and the local government. Provision of Provincial
Governor in each province, which perform the managerial functions such as program planning,
organizing, coordinating, recording & reporting and budgeting
Planning is predetermining future. It is the process of setting goals and choosing the actions to
achieve these goals. It attempts to define the future path of the organization. Effective planning
ability is a necessary tool for manager to determine what is to be done and how it is to be done.
Planning in health system are long term, short term, annual and ad-hoc planning.

6. 2
In provincial and local health system, annual and ad-hoc planning are in practice but long term
and short term planning was found inadequate. Theoretically planning should take in bottom-up
approach for effective implementation, in Gandaki Province and at local level health system
planning approach is bottom up, however programs and plans were being imposed from center
to province and local government. However, micro planning was being done in province and
local level.
The bottom-up plan has been practiced regarding budget planning in the province and local level.
Only two grants: conditional and equalization (Non-Conditional) disbursed through federal
government are in operation; however the resource generated from the local government is also
being used at the local level. The issue of health sector prioritization is a concern across all three
levels of government and different grants including the special and complementary grants.
1.2. Rationale of the study:
The government of Nepal has adopted the new federal system and experiencing the different
strategies to govern the federal, provincial and local government system which is very new
concept. So, Changing different structure, organogram, staffing pattern, role and responsibility
and the planning and budgeting system may be differ in each level of government system, that’s
why. After election ( federal, provincial and local), there is necessary and important to enhance
the capacity of local elected bodies on health planning and budgeting and raise advocacy on
budget for health from unconditional budget annually on the basis of evidence.
The main aim of the study was to understand the planning and budgeting process in federal
context especially from provincial to local and role of federal government to develop the
technical capacity and address the challenges and issue of health in federal system.

7. 3
1.3. Objective:
1.3.1. General Objective:
 To review the current health system planning from province to local level in Nepal.
1.3.2. Specific Objectives:
 To explore about the health program planning system in federal and local level
 To Explore about the health budget planning system in federal and local level
 To identify the challenges of implementing the health system planning in federal system
of Nepal
CHAPTER II: METHODOLOGY
The main aim of the study was to review the current health system planning from province to
local level in Nepal and explore the health management system in province and local level from
perspective of health program planning and budgeting. Methodology contain following aspects:
2.1 Study area:
1. In Province Level: Health Directorate, Gandaki Province
2. In Local Level: Pokhara Metropolitan city, Kaski
2.2 Study duration:
The duration of this field practice was 3 days (From 21, 22 and 23 April 2019).
2.3 Technique and tools used for Review of System:
 Rapport building through the phone call with focal person of RHD to confirm the date for
visiting the RHD to collect the required information regarding the Health Planning
system in federal.
 Interaction
 Meeting - formal and informal

8. 4
CHAPTER III: RESULTS & FINDINGS
3.1. At Local Level:
 There is the system of top-down and bottom up approach for program planning and
budget planning. Top down approach is using for conditional health program planning
and budgeting and bottom up approach is using for unconditional budget planning for
health in metropolitan city
 There are 33 wards in Pokhara Metropolitan city and 41 service outlets (1 Hospital, 2
PHCs, 1 Urban Health Promotion Centre, 2 Ayurvedic Dispensary, 16 Urban Health
Clinics and 19 Health Posts) which is providing health services to 4, 79, 000 population.
 There is 88 PHC-ORC, 112 immunization clinics and 654 FCHVs
 Monitoring of FCHVs by Metropolitan City at every 6 months
 At every 3rd day of month, the monthly meeting of in-charge of health facilities was
conducting, review of progress report was done, and the information was reported in
HMIS 9.3.

9. 5
Health planning and budgeting Structure in local level:
Ministry of Finance
Resources allocation
National Planning Communication (NPC)
Final recommendation for budgetary allocation
EDPS/Donor agencies
Resources allocation
Line agencies/Ministry
Recommendation for budget
(MOHP, MOE, MoFAGA),
MoPIT, MWCSC, DoHS
Ministry of federal affair and
general administration,
ministry of education, ministry
of physical infrastructure and
transport, Ministry of women,
children and senior citizen,
Ministry of water supply and
sewage
Ministry of forest and
environment
(Multi-lateral/Bi-lateral
agencies,
I/NGOs)
District Coordination
Committee
Municipality/Rural Municipality
Assembly/Council (Prioritize,
coordination, fund allocation and
approval
Need collection, Ward
health planning and
prioritization workshop
Basic Health facilities
(PHCC, HP, UHC, CHU)
PHC/ORC, FCHVs)
NGOs /CBOs, Child club,
youth clubs and INGOs.
Agriculture, livestock,
education sectors
Source: MOHP, federal government of Nepal

10. 6
Revenue and consulting committee:
1. Rural/Municipality vice-chair person/deputy-chief - Coordinator
2. Rural/Municipality executive officer - Member
3. Allocated 2 respected member including 1 female by Municipality - Member
4. Local Federation of Nepalese chambers of commerce and industry chief or
representative - 2 Member
5. Rural/Municipality revenue- section officer - Secretary member
Resource estimation and budget ceiling allocation committee:
1. Rural/Municipality chairperson/Mayor - Coordinator
2. Rural/Municipality deputy-chairperson/deputy-Mayor - Member
3. Representative member(female, dalit and municipal member) allocated
by rural/municipality chairperson/Mayor - 3 members
4. Rural/Municipality Planning section chief - Member
Program planning and budgeting Committee:
1. Rural/Municipality chairperson/Mayor - Coordinator
2. Sector wide officer or representatives 6 members - Members
Rural/Municipality executive officer - Secretary
Member
3.2 At Provincial Level:
 There is 11 Districts under the Gandaki province and each district have health offices
under the province, which technically support to local level health facilities.
 Provincial Assembly/Council do Prioritization, coordination for fund resource
allocation and forward for review and approval of health program and budget to
health directorate.

11. 7
 Health directorate review and approve the health budget and program planning and
finally forward to Ministry of Social Development (MoSD) for approval of provincial
program and budget.
 MoSD forward it to the concerned ministry of federal government and final Federal
government/National Planning Communication (NPC) Final recommendate for
budgetary allocation

12. 8
Health planning and budgeting from federal to provincial level:
Source: MOHP, federal government of Nepal
Ministry of Finance
Resources allocation
National Planning Communication (NPC)
Final recommendation for budgetary allocation
Ministry of federal affair and
general administration,
ministry of education, ministry
of physical infrastructure and
transport, Ministry of women,
children and senior citizen,
Ministry of water supply and
sewage
Ministry of forest and
environment
EDPS/Donor agencies
Resources allocation
Line agencies/Ministry
Recommendation for budget
(MOHP, MOE, MoFAGA),
MoPIT, MWCSC, DoHS(Multi-lateral/Bi-lateral
agencies,
I/NGOs)
Ministry of social
development-7
Multi-lateral and Bi-
lateral agencies, I/NGOs,
Agriculture, livestock,
education
Provincial Health
Directorate-7
FederalgovernmentProvincialgovernment
Health Office
Provincial Assembly/Council
(Prioritization, coordination,
fund allocation, and approval

13. 9
Organogram of Provincial Health Directorate:
Provincial Health Directorate
Director (11th
)
Planning, Monitoring and
Regulation Section
Sr.PHA(9/10th
)-1
Sr.PHO (7/8th)
-1
Demographer/Statistic
officer (7/8th
)-1
Statistic assistant (5/6th
)-1
Curative Service and
Disease Control Section
Sr.PHA (9/10th
)-1
Medical officer (8th
)-1
Health education,
information and
communication section
Sr. Health education
administrator (9/10th
)-1
Health education officer
(7/8th
)-1
Administration Section
Joint Secretary (9/10th
)-1
Section Officer (7/8th
)-1
Account officer (7/8th
)-1
Na.Su. (5/6th
)-1
Accountant (5/6th
)-1
Light vehicle driver-2
Office assistant-4
Ayurveda and Alternative
Medicine Section
Sr. Ayurveda specialist
(9/10th
)-1
Kabiraj (5/6/7th
)-1
Program, Coordination
and Population
Management Section
Sr.PHA (9/10th
)-1
Sr.PHO (7/8TH
)-1
Demographer/statistic
officer (7/8th)-1
Health assistant (5/6/7th
)-2
Nursing Service
Management Section
Sr. Nursing Administrator
(9/10th
)-1
Sr. Nursing Officer
(7/8th
)-1
Training division
Logistic and procurement
division
MOHP, Provincial health directorate

14. 10
Planning and Budgeting Process and Time Frame:
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15. 11
CHAPTER IV: STRENGHTS AND CHELLENGES
4.1 Strengths:
Nepal has moved from unitary system with a three-level federal system of government. As
federalism accelerates, the national health system can also speed up its own decentralization
process, reduce disparities in access, and improve health outcomes. The turn towards
federalism creates several potential opportunities for the national healthcare system. This is
because decision-making has been devolved to the federal, provincial and local governments,
and so they can make decisions that are more representative of their localized health needs.
Newly elected bodies can involve directly during planning and budgeting in local level based
on evidence.
Direct responsible for the allocation of budget and planning as per local need and health
problem.
Development of concept and practice of good governance on planning and budgeting of
health program and activity with full participation of local community and stakeholders.
4.2. Challenges:
4.2.1 At Province Level:
 The major challenge during the transition phase is to ensure that there are
uninterrupted supplies of medical commodities and services. This requires scaling up
the ability of local bodies to manage drug procurement and general logistics and
adequate human and other resource in local healthcare centers.
 Less power of authority to provincial government than local government and it has
just responsibilities to provide technical support to local level and coordination
between provincial government and local government.
4.2.2. At Local Level:
 Issues like infrastructure development and human resource development need to be
directed towards developing competent human resource through trainings and capacity
building activities.

16. 12
 Budget disbursement is a major challenge because now it is harder to allocate and
disburse budget in a timely manner to multiple layered and widely dispersed local
authorities.
 Delay in decision making, programme implementation, planning and resource allocation
could be an issue with lack of prior experience and expertise.
 Successful implementation of the Act needs to be rigorously supported with planning,
technical assistance and better clarity between the local agencies and the central
government
 Timely and effective monitoring and evaluation of several fragmented local authorities
and agencies is another major challenge under the new federal context.

17. 13
CHAPTER V: CONCLUSION AND RECOMMENDATIONS:
5.1 Conclusions:
The country is administratively divided into 753 local government units, seven provincial
governments and a central government. The federal government redistributed the decision
making power and resources among the central, provincial and local governments in all sectors
including health. Health system in Nepal is functioning under new governance with Ministry of
Health and Population (MoHP) at the central level, Ministry of Social Development at the
provincial level and health section or health department under the local level governments. The
provincial governance contributes and facilitate to local level governance for planning and
effective utilization of resources.
There is inadequate capacity among province and local level governments in health sector
planning and it can be improved by empowering local decision makers to invest in health,
engaging them in making healthy public policies and promoting accountability towards health in
addition to devolution of authority and resources. Planning for management of drugs and
supplies, adequate management and implementation of health program and activities also
required at these levels. Effective coordination and communication channels need to be there
between different levels of governments for ensuring the provision of basic health services,
increasing population coverage in health insurance and other social security measures, and in
providing quality and equitable health services. Involvement of stakeholders and other sectors in
health system planning at local level government need to strengthen.
Role sharing between different levels of government is still a problematic and should be clearly
identified with proper distribution of power and financial autonomy. While there should be check
and balance from the center, this should however not derail the functioning of health system of
province and local level.
5.2 Recommendation:
5.2.1. Provincial government:
 National coordination needed between federal, provincial and local, more coordination
and cooperation needed to provincial health directorate due to new structure.

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 Clarify on job description of every Sections and Division under the Organogram of health
institutions
 Orientation and capacity building to newly elected bodies and health staffs on current
health planning and budgeting.
 Implementation of plan and activities on timely.
5.2.2. Local government:
 Adequate Budget Supply and proper allocation
 Proper Prioritization of Health activities
 Orientation and Capacity building to newly elected body on appropriate health planning
and budgeting
 Adequate collaboration and coordination between different sector and tiers of
government
 Adequate infrastructure and human resource management at local level.
Skill Learning and Development:
 Skill development on exploring the information in detail through the interactions
 Knowledge development (Cognitive Skill) on the process of health planning and
budgeting system in province and local level.
 Learning on the organizational structure and staffing pattern of provincial health
directorate and health division under the metropolitan city of kaski

19. 15
REFERENCES:
1. Local level planning and budget Drafting guidelines-2074
2. Nagarpalika Kaarya bibhaajan Niyamaawali-2074

20. 16
ANNEXES:
Annex I: Organogram and staffing of provincial health directorate:

21. 17
Photographs: