Health Facility Operation and Management Committees (HFOMCs) and Their Significance in Local Health Governance in Nepal

Introduction

Nepal has undergone a significant governance transformation in its governance structure, transitioning from a unitary to a three-level federal system with the federal, provincial, and local government, offering new possibilities for development, especially in healthcare.  The division of legislative and executive powers for these three levels of government offers potential to address disparities in access and enhance overall health outcomes. Specially, devolution of power to decision making to local level has provided ample opportunities to the local level to have a nuanced understanding of health challenges, set priorities and seek effective solutions.

Health Facility Operation and Management Committee (HFOMC) is a legitimate body formed locally at each health facility and supposed to govern all the affairs of local health facilities. The Health Facility Operation and Management Committee– A reference guideline for local level outlines the composition of the committees, their responsibilities, and the overarching goal of delivering effective health services while ensuring accountability and transparency in daily management functions from health facilities. However, formation of HFOMC as per the guideline and their effective operationalization has remained a challenge since the country was federalized. At HERD International, we are engaged in strengthening the local health system and building resilience capacity through ReBUILD For Resilience project. As part of our interventions, we are working in partnership with Kapilvastu Municipality to strengthen the HFOMCs. This blog presents our approaches and the learnings.

Composition and the role of HFOMC:

Guiding Principles

One essential aspect of the healthcare decentralization process is the formation and functioning of HFOMC. The efficacy of a Health Facility relies greatly on the good management, diligent monitoring, and thorough supervision conducted by the HFOMC. Acknowledging the crucial role of community engagement in supervising local health facilities and services, and adhering to the guidelines outlined in the Local Self-Governance Act of 1999, the Ministry of Health and Population (MOHP) has handed over the administration of health facilities to local levels as part of the decentralization policy. Under this provision, HFOMCs are tasked with overseeing all aspects of local health facilities. After the federalism and the Local Government Operation Act, 2074, the responsibility of health activities has come to the local government, the role of the HFOMCs and elected representatives has increased even more.  

Committee Composition

The HFOMC, established locally at each health facility, is designed to be inclusive in its structure. According to the guidelines, the mayor of the municipality serves as the patron, ward chairperson as the chairperson and HF In-charge as member secretary of the committee. Beside them, the seven members’ committee comprises elected female ward representative, local headmaster, ward secretary, representative of the business community and representative of FCHV from the ward. The elected female representatives serve as the vice-chair of the committee (elected male if ward chair is female). Additionally, three members are nominated as invitee members, which includes one representatives from adolescents, elderly & disable and ethnic and Dalit community.

Roles and responsibilities

The HFOMC is responsible for overseeing all aspects of a health facility to ensure its smooth operation and improve local people’s access to healthcare services. The formation and functioning of the HFOMC, the understanding of its members regarding their roles and responsibilities, and the extent to which they fulfill them is crucial for ensuring the smooth operation of health facility. The functions of the HFOMC as outlined in the guidelines include:

• Ensure the availability of physical infrastructure, medicines, health personnel and health equipment in health institutions,
• Ensure the protection and regular maintenance of physical assets of health institutions,
• Carry out necessary coordination activities and to ensure the quality of service flow,
• Take the initiative to create a local health plan based on evidence.
• Strengthen local health governance and ensure social accountability of the health facility through social audit, financial audit and public hearing of the health facility.
• Ensure the access of health services to the local communities deprived of health services.
• Communicate and coordinate with the health section of the respective local levels in the matters related to the operation and management of health institutions.
• Formulate the necessary policies, plans and programs related to the progress and development of the Health Facility and implement them effectively.
• Set the annual targets for health facility and review of the implementation and achievement of annual programs conducted by health facility.

Current status of operation and challenges

Empowering local governments to allocate resources based on community requirements can result in more efficient and targeted healthcare services. Despite the roles and responsibilities assigned to the HFOMC regarding health facility management, a majority of the committee members have inadequately fulfilled their duties. There have been instances where committee members were unaware of their roles and responsibilities, despite the orientation resulting in ineffective functioning. Community participation is a vital component of the local healthcare system to identify the local needs. But their participation in the planning, implementation, and monitoring of health activities within the facility has been minimal. The ward chairs, who serve as the committee chairperson, hold financial authority at the ward level but rarely engage with health facilities to address their issues. The relationship between chairperson and the committee’s member secretary (ward chair and health facility in-charge) significantly influences resource allocation for health facilities via the HFOMC, as well as the committee’s overall effectiveness. The main reasons for not having regular meetings included a lack of identified need to meet monthly as they felt there were no issues to discuss, busy schedules of members especially ward chair; and meetings not being called by the health facility in-charge who had the secretarial responsibility to call the meetings. There is a lack of concerns from other members of the HFOMC regarding irregularity of the meeting and reluctance of the chair and secretary to hold meeting. This lack of attendance and engagement of the HFOMC members hindered the effective implementation of health initiatives and opportunities for community participation in decision-making.  

The activeness of the HFOMC relies on the priority accorded by the ward chair to the health facility and delegating other committee members to oversee health facilities and monitor their activities. Mostly, the HFOMC members visit the health facilities if the committee meeting is called rather than for quality assurance, supervision, and support. Despite the date for the meeting is fixed by the health facilities, the meeting is held on the convenient date of the HF In-charge and the ward chair.  The committee is inclusive and endeavors to bring forth issues from the respective community they represent for discussion. However, it is predominantly the member secretary of the committee, i.e., the Health Facility In-charge, who forwards the discussion agendas.

Even though committee meetings are irregular, HFOMC members meet at health facilities during certain events, such as the follow-up sessions for Health Post Minimum Service Standard assessments, social audits (if planned by municipality). During these gatherings, they collaborate to prepare action plans addressing the deficiencies identified during the assessments, aimed at improving healthcare provision at the facilities. The action plans are formulated through discussions among the members, reaching a consensus within the committee with the assistance of facilitators. Some of the health facilities with funds in the HFOMC account organize regular meetings to strategize the allocation of resources to address facility needs based on the action plan. However, at most of health facilities, the subsequent follow-up on these action plans during upcoming committee meetings appears to be lacking at the majority of health facilities. Some of the health facilities practices the meeting of HFOMC during Annual Work Plan and Budget to plan the needs of the health facility and recommend ward committee to prioritize those needs during the budgeting. But most of the health facilities neither have the meeting before the annual planning and budgeting nor the ward has meeting with HF to discuss about their needs.

Moreover, there were instances key stakeholders, who played a significant role in decision making at ward level did not prioritize healthcare in their planning and budgeting, instead focused on physical infrastructure and other visible developments. This lack of attention and accountability towards crucial sectors from the ward had a direct impact on the quality of healthcare services delivered to the community. The inactiveness of the committee can be attributed to inadequate monitoring, guidance, and directives from key stakeholders within the municipality, such as the mayor, CAO, and the health section.

Way forward

The transition to a federal system of governance in Nepal offers immense potential for the national healthcare system. Decentralization allows decision-making authority to be vested in the hands of those who are closest to the communities they serve. This enables better alignment with local health needs. However, challenges persist in fully operationalizing the HFOMC at all levels as most of the health facilities don’t have the regular committee meetings and actions. In-charges of the health facility has the crucial role to regularize the HFOMC meeting as they are the member secretary of the committee who call the meeting.  Including HFOMC meetings as one of the evaluation criteria for ranking health facilities during annual health reviews and providing merit point on the performance appraisal of HF In-charge is essential, urging health facilities to conduct regular HFOMC meetings. Consistent follow-up from the health section, including Chief Administrative Officer, is also necessary to ensure the routine occurrence of these meetings. Elected officials, particularly the mayor and the deputy mayor should seek commitment from the ward chairs for regularity of the meeting. Additionally, the consistency of HFOMC meetings should be integrated as evaluation criteria for each ward. Mayor, as a patron of the committee, should conduct frequent monitoring to ensure meeting regularity. In addition, increasing awareness among committee members particularly the ward chair, ensuring active participation, and prioritizing budget to the healthcare sector is crucial to optimize the benefit of federalism.