Policies, Plans, and People: Foreign Aid and Health Development

2. The Health Bureaucracies:Structure and Culture

2 The Health Bureaucracies: Structure and Culture Understanding the Integrated Health Program requires a look at the organizations that created it: the Nepal government and the international donor agencies. Their goals, structure, and patterns of operation have determined how ICHP was planned and carried out. Cultural differences among the health bureaucracies complicate the planning process : thus, the program that has emerged reflects the interactions among the bureaucratic cultures as well as their linkages to the cultures of rural Nepal. Government Structure Since 1951, Nepal has been governed by a constitutional monarchy. Broadly speaking, Nepal's administrative bureaucracy consists of three levels, with the king and the Palace Secretariat at the top. The king is the chief figure in policy formulation. In the 1970s, all formal channels of communication converged in the Palace Secretariat, which consisted of the king's secretaries and assistants. This was the major The Dynamics of Nepal's Bureaucracy 16 THE HEALTH BUREAUCRACIES: STRUCTURE AND CULTURE policymaking institution in the government, but it had a less important role in implementing policy.* An important part of the Palace Secretariat at that time was the Janch Bhuj Kendra (the Centre for Enquiry and Investigation), which consisted mainly of handpicked bureaucrats who formulated programs under direct Palace Secretariat supervision. This body worked on special assignments, assisted by experts from relevant ministries. For example, two doctors from the Ministry of Health and an official from the Ministry of Finance were temporarily seconded for nine months to the Janch Bhuj Kendra to prepare the Long-Term Health Plan, which was released in 1975. At the second administrative level is the Central Secretariat , which consists of the ministries and departments. Although less directly involved in defining policy, the Central Secretariat gathers and provides data for the Palace Secretariat and the king, and it is directly responsible for implementing policy decisions. The district and local administrations form the third level. Nepal is divided into fourteen zones, each of them headed by a zonal commissioner for administrative purposes. The zonal commissioner is appointed by the king and reports directly to the Palace but has marginal administrative powers . The zones are further divided into districts, seventy-five in all, with each headed by a chief district officer (CDO) who works under the Home Ministry. The CDO is responsible for maintaining law and order and for coordinating all development and social welfare activities, including those pertaining to health. District officers are formally part of the national public service and are responsible to the Central Secretariat. In 1978 the expression of local interests was provided for by a four-level system of elected government councils called panchayats. In 1962, after a brief experiment with a system This account describes the government structure at the time of my research during 1978-79. Major changes in Nepal's political process, including direct election to the NationalPanchayat,have occurred since 1979, but their effects on health planning, if any, cannot yet be determined. THE HEALTH BUREAUCRACIES: STRUCTURE AND CULTURE 17 of parliamentary democracy, King Mahendra introduced a partyless political system based on village panchayats, district panchayats, zonal assemblies, and the national panchayat , Nepal's legislative body. The Council of Ministers, or cabinet, the executive organization, was appointed by the king from the national panchayat (Bhooshan 1979:39). Health policies are implemented by the Ministry of Health (one of the ministries within the Central Secretariat), headed by the Minister of Health (Fig. 1). Directly under the Minister is the Secretary of Health, who is the chief administrator of all Ministry of Health activities, and under the Secretary is the Department of Health Services, headed by the DirectorGeneral of Health Services. The Integrated Community Health Program was one of several programs administered by the Department of Health Services in 1978. While the other programs were single-purpose mass campaigns, ICHP was designed to deliver all types of health care services— curative, preventive, and promotive. According to long-term plans, by 1985 all single-purpose or vertical programs, such as the malaria and tuberculosis programs, were to be integrated into ICHP. ICHP was perceived as the support structure for primary health care, through its aid to and collaboration with the community at all levels of its operation. The central division of ICHP in Kathmandu was headed by a senior public health administrator, a medical doctor, who was directly responsible to the Director-General of Health Services. This administrator, more commonly referred to...