EXECUTIVE SUMMARY

Introduction

This report covers the sixth cycle of the Nepal Multiple Indicator Surveillance (NMIS), a process that began in Nepal in 1994. The on-going NMIS process comprises repeated cycles of data collection, analysis, interpretation, and communication of results to stimulate action. Each cycle focuses on a set of priority issues for the health, well-being and rights population of Nepal, especially women and children. A steering group from the National Planning Commission, Central Bureau of Statistics and relevant line ministries agrees the focus of each cycle, while the Technical Group develops and agrees the cycle plan and instruments of data collection for each cycle, and plays a key role in interpreting NMIS results and ensuring their use.

The five cycles of NMIS that have taken place so far are: Cycle 1 on Health and Nutrition and cycle 2 on Primary Education in 1995; cycle 3 on Diarrhoea, Water and Sanitation and cycle 4 on early childhood feeding, nutrition and development in 1996; and cycle 5 on Care during Pregnancy and Delivery in spring 1997.

The first five cycles of the NMIS demonstrate problems with delivery of public services in Nepal. Access to services is very limited in some parts of the country and the quality of services that are available is often poor. Yet effective provision of key public services is recognised as important for development. Central planning of services, with little reference to local conditions and no reference to the population being 'served', usually has not worked well. New ideas of partnership with civil society as part of good governance are now gaining wide acceptance. Ideally, public services should be responsive to the needs and wishes of the population, who should have a say in their planning and delivery. This new paradigm means asking the population about their views and experience of present services, and about their suggestions and preferences for services in the future. The limited available budget is a further reason for ensuring that money is spent on services that are acceptable to the intended users and likely to be effective, on the basis of evidence. This implies that planning of services should be based on evidence of impact, coverage and costs. Gathering adequate information about these factors has to include asking the population for whom the services are intended. This is the basis for Service Delivery Surveys; asking the population in a given area about their use, experience and perceptions of services. Such surveys have been carried out in a number of countries, using the method of Sentinel Community Surveillance.

This sixth cycle of the NMIS is a Service Delivery Survey. It focuses particularly on the delivery of government health and agriculture services. These services were chosen as essential basic services in a country whose population are mainly subsistence farmers. Less detailed information about other public services is also collected and the survey also provides information about perceptions and functions of District Administrations and Village Development Committees.

Methods

The NMIS employs Sentinel Community Surveillance (SCS). Features of this method include: the focus of each cycle on a small group of issues; the combination of quantitative and qualitative data from the same communities in a mesoanalysis; data analysis and risk analysis to produce results in a form useful for planning; revisiting of the same sites, making estimation of impact of interventions easier.

In cycle six, 18,770 households were visited. Information was available from 18,580 (99%) households. Only 188 (1%) households had no one at home at the time of the visit and only two households refused to provide information.

108,899 people were included in the survey. The mean average family size is 7.4, and median 6.0. The instruments used in cycle 6 include a household questionnaire, focus group guides on health and agriculture service, key informant interviews with DDC chairman, DDCs, LDO, DHO, community key informants, and health and agriculture facility institutional reviews.

The Epi Info software package was used for data entry and analysis. The sample sizes in districts are not proportional to the populations of the districts; weights calculated to take this into account were applied when producing national level indicators.

Results and risk analysis

Type of house was used as an indicator of economic status. More than a third (39%) of houses are kachchi, a third (32%)are pakki and a quarter (27%)are mixed. Half of the household heads are literate (able to read and write a simple letter).

Health Services

Only 12% of households reported one or more contacts with government health services in the last month. But nearly a quarter (24%) of households used non-government health services in the last month; a few used both government and non-government services. Nine out of ten users of non-government health services used private clinics and a third used traditional healers. The most common government health facility used was the health post (48%), with a quarter (25%) using sub health posts and 22% using district hospitals. The reported reasons for using the service are similar for government and non-government health services.

Households in urban areas are less likely to have used government health facilities in the last month, reflecting greater access to private clinics and other alternatives. And households of higher economic status (pakki houses) are less likely to use government health services, whether in urban or rural areas. Households in communities where the nearest government health facility is less than two hours journey away are more likely to have used the service in the last month.

For nearly all visits (93%) to government health services it is reported that a health worker was available. But this is not so for medicines. The commonest alternative source of medicines is the drug shop (80% of cases).

Only 7% of people visiting government health facilities report waiting 2 hours or more. This underestimates the tendency to limit visits to known times of availability and abortive visits when no health worker is seen at all.

All users of government health facilities report paying a small registration fee; about a sixth (17%) report paying for medicines, on average 48 NRS. Many more have to pay for the medicines that are unavailable in the government facility and that they have to buy outside.

The commonest perceived problems with the government health services are lack of medicines (59%), poor condition of the facilities (40%) and bad attitude of the staff (35%). Households would like to see more medicines (57%), more equipment (35%), more staff (34%) and a better attitude of staff (28%) in government health facilities.

More than two thirds of households report willingness to pay for improved government health services, on average 10 NRs for each visit to a facility. Households in urban sites are willing to pay more than those in rural sites. Those households who used government health facilities in the last month are one and a half times more likely to be willing to pay for improved services than households who did not use these facilities in the last month.

Agriculture and livestock services

The occupation of the household head is reported as 'farmer' (including peasant farmers) in two thirds (66%) of the households. In urban areas, less than a quarter of household heads are reported to be farmers. Three quarters of households (76%) report holding some land (owned or rented). A fifth of households holding any land hold less than 5 ropani. The mean land holding is 14 ropani (18 ropani among those holding any land). Households with any land were asked when they last had a visit from an agriculture or livestock extension worker.

One in ten households with land recall having visited the agriculture/livestock centre for their area at some time.

Households in pakki houses are rather more likely to have been visited by a government extension worker (5% have been visited) than those in other types of houses, but they are less likely to have been visited by a non-government extension worker. There is some evidence that households in communities served by fully staffed agriculture/livestock centres are more likely to be visited by an extension worker. Households in communities within 2 hours of the nearest centre are nearly three times more likely to have visited the centre and twice as likely to have been visited by a JT/JTA than those in communities more remote from the centre.

Of the small number of people reporting contact with agriculture/livestock services, over half paid nothing. Of those who paid something, the mean payment is 95 NRs. Most payments are for materials but a quarter are for advice, which should be given without charge.

Households have a low opinion of government agriculture and livestock services.

Households ever visited by an extension worker have a much higher opinion of the service (they are 10 times more likely to rate the service as good). Main problems noted with the services are lack of visits (47%), lack of chemicals and drugs (33%), centres too distant (28%) and bad attitude of staff (24%). Suggestions for improvement relate to these same issues.

Nearly half of households report willingness to pay for better agriculture services, between 10 and 14 NRs for a visit and advice, depending on the sort of advice. Households who have ever been visited and who hold more land are more likely to be willing to pay.

Only a few households holding land (13%) report applying for a loan for agriculture or livestock purposes. Most of those who applied for a loan reported being successful (86%). This suggests that households only formally apply for loans when they are fairly sure of being successful. Loans from government banks account for more than half (52%), with a third (37%) from private merchants. The success rate for applications to government banks is 81%, compared with 94% for application to private merchants. People in pakki houses are less likely to apply for loans. Households who recall being visited by an extension worker are more likely to have applied for an agricultural loan.

Households reported on the sources and availability of a range of farming inputs. Most are said to be available and the commonest source for all items is commercial shops.

Governance and local government

The commonest reported source of household information about local government services is neighbours (7!%), followed by radio (35) and the VDC (15%). Households were asked about access to and opinions of a range of basic services. Access varied from 31% (electricity) to 99% (education) and the proportion regarding the service as good varied from 5% (sanitation and roads) to 39% (electricity). These poor opinions of basic services are shared by the DDC chairman and Local Development officers who gave their views. These officials are even more critical of the quality of services than the households. Chairmen of both VDCs and DDCs gave lack of resources as an important difficulty in providing services. Other difficulties mentioned included lack of finance (at VDC level) and poor service from line agencies (at DDC level).

Households and VDC chairmen have some agreement about the role of VDCs, both rating 'construction work' as an important activity. But more than a quarter of households think VDCs do 'nothing'. Asked what VDCs should do, almost no households mentioned collection of taxes. This could be an important problem for VDCs who need taxes to fund activities that households would like them to do, including road building and other construction work. Most households reported helping the VDC, mostly through voluntary construction work (85%).

VDC chairmen are evenly split on whether their priorities are reflected in DDC decisions. Many of them want more involvement of VDCs in DDC decision-making and some want DDC members to spend more time visiting communities and VDCs. Nearly a quarter of VDC chairmen complain they receive no support from the DDC. Both VDCs and DDCs rate financial support as the most important form of support they receive, from the DDC or from central government. No VDCs and only 10% of DDCs think they receive really helpful support from the DDC or central government. Both VDCs and DDCs want more support than they presently receive in a number of areas, particularly financial support (VDCs) and project support (DDCs).

Asked about coordinating different services, over half of DDC chairmen and only 16% of VDC chairmen rate this as difficult. This probably reflects their different responsibilities for coordinating services.

VDC chairmen rate knowing the needs of the people as their most important information requirement for planning (43%) and also rate highly the need for technical advice (43%). These same chairmen report their most important information sources for planning to be community meetings (60%), key informants (54%) and 'self' (49%). None reported formal information systems or surveys as sources. LDOs at district level report their sources of data for planning to include VDCs (81%), key informants (59%) and district departments (41%). This suggests an unmet need for good data sources, including the views of the population, for the purposes of planning at both VDC and DDC levels.

 


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