Skip to 0 minutes and 11 secondsKRISHNA HORT: In this video, we're going to explore in a bit more depth the issues of district health management, and in particular, the way the district works between the national level and the community level. And to assist us with that, I've invited two colleagues, Dr. Krishna Paudel from Nepal and Dr. Mwawi Mwale from Malawi to talk to us about their own experiences in their different countries. I might begin with Dr. Paudel and ask him to tell us briefly a bit about the context and situation of district health systems in Nepal.

Skip to 0 minutes and 48 secondsKRISHNA PRASAD PAUDEL: Thank you, Kris. In Nepal, we do have a central government, a federal government, followed by a provincial government, and districts, as well as the local governments also. So there's a three tier system in governance. And overall, the health program in a particular district is run by a district health management system. A district health office is the office which looks after the overall health program in their district, and it includes holistic approach-- preventive, promotive, as well as curative services.

Skip to 1 minute and 20 secondsKRISHNA HORT: Well, I can see that the district has quite a broad remit of role and function. What do you see as some of the challenges that district health managers face?

Skip to 1 minute and 31 secondsKRISHNA PRASAD PAUDEL: So a district health manager is sort of like, he is loaded with...

Skip to 1 minute and 37 secondsapart from the regular day to day administrative work, he has to look after the clinical work also in most of the districts, if he's from clinical background. Some of the districts do have a public health person who are solely dedicated, but most of the districts do have doctors as managers, and they have to look after both curative as well as preventive/promotive part. There are a lot of programs -- health programs -- from the national health program they have to be run smoothly. And he's also responsible for regularly feeding the data to the centre for each program divisions for different programs.

Skip to 2 minutes and 11 secondsKRISHNA HORT: What are the challenges that managers of these systems face?

Skip to 2 minutes and 14 secondsKRISHNA PRASAD PAUDEL: Because of the difficult geography, and also, not all the districts in Nepal are readily accessible, the district manager has got a big challenge of maintaining regular human resource in all the health facilities throughout all 12 months. Some of the districts are challenging in terms of weather, like the, you know, continuous snowfall and all. So it's challenge. And there are certain, like, unplanned... you know, catastrophes do happen, like landslide and flood. It's also another challenge to maintain the regular service in the health facility. And having a trained human resource, which are not always available in all districts.

Skip to 2 minutes and 56 secondsIt depends-- districts with good access do have a better human resource profile, while those in the remote places do have a challenging human resource profile.

Skip to 3 minutes and 6 secondsSame thing with the commodities: drug supply, and maintaining that logistic is also another challenge.

Skip to 3 minutes and 13 secondsKRISHNA HORT: So plenty of challenges. But are there also opportunities? Perhaps you'd like to tell us a little bit about your own experience.

Skip to 3 minutes and 19 secondsKRISHNA PRASAD PAUDEL: Yeah. He is a leader in the district, the district health manager is in a very good position to serve best in his district, his or her district, and he gets a lot of support from the communities once he has got programs for their support and community participation is very good in the districts.

Skip to 3 minutes and 39 secondsKRISHNA HORT: Right.

Skip to 3 minutes and 40 secondsKRISHNA PRASAD PAUDEL: So we just need to convince them about the program and all. And there are good opportunities. Some sort of flexibility in the budget, but not much. So whatever flexibility with money that can be properly utilised. And maybe we can convince the centre for further budget if you need as part of their plans, and you can do some innovative plans also in the districts. I wanted to share something about hepatitis B in one of the remote districts. They are like the remote districts bordering with Tibet in the Tibet province of China. They have got high incidence of hepatitis B, and we wanted to have a separate immunisation program for the newborns.

Skip to 4 minutes and 18 secondsKRISHNA HORT: Okay.

Skip to 4 minutes and 19 secondsKRISHNA PRASAD PAUDEL: At birth, immunise them with the hepatitis B immunoglobulin and hepatitis B.

Skip to 4 minutes and 23 secondsKRISHNA HORT: So you can develop an initiative that's specific to your own local needs, but you do need to get national level support.

Skip to 4 minutes and 29 secondsKRISHNA PRASAD PAUDEL: Yeah, exactly.

Skip to 4 minutes and 31 secondsKRISHNA HORT: Well, thank you Dr. Paudel. We might now pass on to Dr. Mwale. I guess you don't have too much problem with snowfall and glaciers, but no doubt you face other problems.

Skip to 4 minutes and 43 secondsMWAWI MWALE: Well, we don't have that kind of problem, Kris. I'm from Malawi and that's in Africa-- the warm heart of Africa. And in Malawi, we've got a population of about 18 million with 28 districts. Now, in those 28 districts, each has a district health management team, and they basically translate the central government health policy to the community through curative, preventive, and all other modes of setting up within the communities.

Skip to 5 minutes and 25 secondsKRISHNA HORT: And what challenges to do these district health management teams face in carrying out their role?

Skip to 5 minutes and 32 secondsMWAWI MWALE: Well, the district health management teams face quite a number of challenges on both ends. They have to, like I said, they have to basically implement all the government policies when it comes to health. And on the central level side, you will expect a lot of influence, some political twisting here and there. And also, when you're looking at logistics of some of the things which are centrally managed, you will have difficulties getting those things in at the right time.

Skip to 6 minutes and 6 secondsKRISHNA HORT: Right.

Skip to 6 minutes and 7 secondsMWAWI MWALE: Yeah. And then on the other side, you'd have challenges of transportation, your facilities-- making sure that your facilities have got all the equipment they need, your personnel-- making sure that you've got the right people at the right places, and even getting your information. Because if you don't have the right resources at times, you'll also have problems being able to make the correct decisions on the next steps.

Skip to 6 minutes and 39 secondsKRISHNA HORT: So plenty of challenges, but perhaps some opportunities as well?

Skip to 6 minutes and 42 secondsMWAWI MWALE: Where there's a challenge, most of the times you will get the opportunity to become innovative about your different programs. I'll give you an example. We had this low turnout for antenatal care. The expectant mothers, there were hardly many who were coming to the hospitals, and there were so many reasons why they were not coming. And we decided in one of the districts to say, "When you come to the hospital and if you come with your partner, you get to jump the queue." Because some of the times they didn't want to come to the hospital because they said there's always so many people.

Skip to 7 minutes and 23 secondsBut once we said that, now you had them coming with a partner, which also gave us the opportunity to do proper couple counselling and any other couple management which would be required-- made it very possible than sending the wife back and saying, "Oh, when can you come back with your husband or your partner?" So we were able to tackle several things by just changing one or two things and just looking at what the community needs and what they'd be willing to take up.

Skip to 7 minutes and 58 secondsKRISHNA HORT: Thank you very much, Dr. Mwale and Dr. Paudel. So you can see here that while these are two very different countries, there are a number of things in common that the district health management has to face, in particular the issues around resources. They also have the same role in terms of translating national policy to local level. But it's good to see, too, that both our visitors were able to tell us about opportunities and initiatives that they were able to develop to respond to local health needs, and this is something we'll explore further.

District health systems: challenges and opportunities

Health staff with management roles at district level can often find themselves burdened with expectations to meet targets set at national level, but without the autonomy or resources to mount strategies to achieve these targets. One way to address this is through devolution of power and resources to the district level, which we will look at in the next step.

But before considering this, how can planners and policy makers at national level consider the needs and capacity of district staff in their planning processes? Reflect on this as we consider decentralisation in the next few steps.

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