INTRODUCTION
The Constitution of Nepal put forwarded health as a fundamental right of the people, and ensures universal health coverage. The three tiers of governments who are responsible to make the health services available to all the citizens of Nepal. Nepal National Health Policy, 2014 has been introduced to promote, preserve, improve and rehabilitate the health of the people by preserving the earlier achievement appropriately addressing the existing and newly emerging challenges and by optimally mobilizing all necessary resources through a publicly accountable efficient management. Similarly, Nepal Health Sector Strategy (2015- 2020) has emphasized the equitable distribution of human resources in health as well as overall HR development.
In past years, significant achievements have been made in health sector. In this perspective, efficient and effective management of human capital is increasingly becoming very important to materialize the vision of health policy and constitution on the top. Being a building block of the health system, Human Resource in Health (HRH) has to be documented, distributed, developed, retained and projected well for sustainable, through the use of information and communication technology. Thus, reliable data on the health workforce is a prerequisite for evidence informed policy making and decisions.
In present scenario, federal context in health sector facilitation role played by Ministry of Health and Population comprises delivering promotional, preventive, diagnostic, curative and palliative health care services, and other health system related functions such as policy and planning, human resource development and mobilization, financing and financial management including monitoring and evaluation. Though institutional structure of health system is developed but part of HR management remained under consideration. Hence, new laws and regulations will elaborate the overall management of HRH including norms for distribution complying with federal structure.
Human resources required for almost all levels of health care are being produced within the country by the health sector regulatory bodies such as Nepal Medical Council, Nursing Council, Health Professional Council, Ayurvedic Council, Nepal Pharmacy Council and Nepal Health Research Council. There are three Department under the MoHP, i.e. Department of Health Services (DoHS), Department of Ayurveda (DoA) and Department of Drug Administration (DDA).
Management Information System (MIS) within the health sector includes Health Management Information System (HMIS), Logistic Management Information System (LMIS), Financial Management Information System (FMIS), Health Infrastructure Information System (HIIS), Planning and Management of Assets in Health Care System (PLAMAHS), Human Resource Information System (HuRIS), Training Information Management System (IIMS), Ayurveda Reporting System (ARS) and Drug Information Network (DIN). These all are sources of information and are partially computer based. Health Facilities Survey provides information on HR situation in general, but ad- hoc in nature. HuRIS is operating in the MoHP but underutilized.
The Ministry of Health’s decentralization policy and directives focused on the handover of health facilities to health management committee and maintain harmonize relations with other health development partners (not- for – profit non-governmental organization, private for- profit organization and mission/faith organization) in all 77 districts of the country. National Health Workforce Registry, initiated by Ministry of Health and Population (MoHP) is in under operation. Nepal’s intervention in health sector aimed to collect, mange, disseminate and use HR information in Health to satisfy information need for HR planning, management, supervision and monitoring to advance Universal Health Coverage.
This need assessment study also aims to observe the WHO recommended customized form of software ‘Health Resources Information System (iHRIS) and provide its feedback for its customization in context of Nepal. Getting the right health worker in the right place at the right time is the key to improving health outcomes. iHRIS is free and open-source software for managing health workforce information. This information system helps countries to address health workforce shortages and solve other challenges across the health sector. Thus, operationalization of developed system is primary work later additional features are needed as follows to facilitate management as well as to move towards automation.
OBJECTIVES:
The general objective of this assessment is to explore current and future needs of information for HR management system and recommend feasible and viable IT based solutions for HR data management, processing, simplification and automation. The specific objectives are as below:
To audit Human Resource Information Management Systems developed and rolled out in the past and examine their relevancy and compatibility in the federal context
To assess end user’s requirement and find the solutions for establishing HRM information system at all three tiers of the government complying with rules and regulation for the staffs.
To find solutions for HR data sharing among public, private and NGO sectors.
To design structural framework for development of integrated software system, data management system and roadmap for rolling out.
To adopt e Health vision regards to inter-operability with HF and Service Registries.
To identify existing HR-Software in practice across the health sector.
To suggest/ recommend solution for the use of technology for HR management.
FINDINGS:
1 The findings are outlined from the literature review covering national provisions, international declarations and national commitments; national health plan and policies; acts rules and regulations related to HRH as well as from the audit/review of existing HRH and other information systems used at federal level, provincial level and local level public health institutions.
2 The Constitution of Nepal guarantees the access to basic health services as a fundamental right of every citizen. The three tiers of governments (federal, provincial and local) are responsible to make health services available for all the citizens of Nepal. The Constitution has articulated about the combined and distinctive responsibilities of the three tiers of governments to implement the health plans and policies.
3 The National Health Policy 2019 has precisely declared that the HRH information covering all health workforces and the health facilities for all level will be maintained and updated in an IT-friendly scientific database system.
4 Nepal Health Sector Strategy 2015-2020 (NHSS) is the primary instrument to guide the health sector until 2020. This strategy paper has emphasized for reasonable distribution of human resources in health.
5 The National provisions and global initiatives that influences on HRH policies and plans are: Millennium Development Goals (MDGs), Sustainable Development Goals (SDGs) the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel, Global Strategy on Human Resources for Health: Workforce 2030, National Health Policy 2014, Civil Service Act, Health Services Act, Employee Adjustment Act, Strategic Plan for Human Resources for Health, the Nepal Health Sector Programme, Good Governance Act 2008, the Three Year Plan (2016/17– 2018/19).
6 Human Resource in Health (HRH), a building block of the health system, has to be developed, documented, distributed, retained, motivated, skilled, and well projected for sustainable health care delivery through the use of modern information and communication technology. Thus, reliable data on the health workforce is a prerequisite for policy making and implementation.
7 The five of the councils, namely: The Nepal Medical Council, Nepal Nursing Council, Health Professional Council, Ayurvedic Medicine Council, and Nepal Pharmacy Council are responsible for regularizing the health workforce.
8 The Department of Health Services (DoHS), Department of Ayurveda (DoA) and Department of Drug Administration (DDA) of MoHP are responsible for formulating programs as per policy and plans, implementation, management of the allocated human and financial resources, accountability, and monitoring and evaluation.
9 The Management Information Systems (MIS) being practiced within MoHP are: Health Management Information System (HMIS), Logistic Management Information System (LMIS), Financial Management Information System (FMIS), Health Infrastructure Information System (HIIS), Planning and Management of Assets in Health Care System (PLAMAHS), Human Resource Information System (HuRIS), Training Information Management System (TIMS), Ayurveda Reporting System (ARS) and Drug Information Network (DIN). Recently, the Health Workforce Registry (iHRIS) is introduced for the five Health Councils. Most of the information systems are weak and underutilized. The information systems are not interlinked or e-shared among themselves.
10 At federal level, findings are outlined from the observation and review of human resource, training, health management and other information systems operated by the MoHP and its’ subordinate divisions and departments. Similarly, at federal level, the HR information management system of all five health councils, personnel information system (PIS) of Ministry of Federal Affairs and General Administration (MoFAGA), the information management system of Civil Hospital and Nepal Ayurvedic Hospital assessed and findings drawn. As well as, at provincial and local levels, the HR information management system of Ministry of Social Development (MoSD), Provincial Health Directorate of all seven provinces and the selected District Health Offices / District Public Health Offices, Provincial Health Training Centre, Provincial Drug Store, Vector Borne Diseases Research and Training Centre, Ayurvedic Aushadhalaya and Municipalities observed, reviewed and findings are outlined.
11 e-HuRDIS started in 1994 and made operational from 2008. Originally this system was housed in DOHS and has now been moved to Health Coordination Division of MOHP with a new name of Human Resource Information Centre (HuRIC)/ e-HuRDIS. HuRDIS was built in Access, however now running under Database & Version of Oracle 10G; Software Type: Web Based Internal Server; Software Platform: ASP .NET #C; Hardware Used: XEON 4 CPUS – 2.7 GHz 4 GB RAM. This system was initially designed to manage information on HR situation of each health facility including public, private and NGO sector in the country but during the implementation, it narrowed down only to manage official records of the employees of the MoHP. This system generated report was mandatory for HRH related decision making in the past years, but at present, it is more or less, dumped as the HRH data are rarely updated and system is also not supporting for digital HR information management. Hence, e-HuRDIS, the digital system, is now being roll-backed to both-paper and database based system. The digital data handshaking mechanism with PIS is also not functioning due to the back-logs at HuRIC and inactive MoU between MoHP and PIS.
12 Out of five health councils, Nepal Medical Council, Nepal Nursing Council and Nepal Health Professional Council have online web based software to register the health workforce. Whereas, other two Nepal Pharmacy Council and Nepal Ayurvedic Council have manual system to register health workforce.
13 The technology used by some of the councils are outdated and some are planning to upgrade. The variance in the use of the software platform and database would create complexity while linking the software with various entities and organizations.
14 The Civil Hospital is only one organization that uses desktop based system ‘Delphi 5’, this is the most outdated system among all the reviewed system.
15 The web base system used by PIS is keeping all the records of staff of Government of Nepal. Also given access to the data for various government offices. Linking the application with PIS will be a very efficient for upgraded eHuRDIS. However, PIS is using a very old version of PHP (v5.2) which also requires further update.
16 Department of Health Services is using the open source platform DHIS2 which is built in Java, DoHS is also using the same platform for most of their application. DoHS is also using open source Database, postgreSQL. Use of the open source platform has made the HIMS very successful which reduces the cost of the renewal. HIMS is using programming language Java (v1.8) which also requires update as Java latest version is Java SE 14 (v1.14)
17 Most of the organizations are using a web based application. The councils are using php based web application built on Yii 2 framework, laravel and core php using mysql database. The online registration with online payment system with the payment gateway is also implemented in the application. The upgrade is required for NNC as the php version is 5.2 where as other councils are using updated version. NNC is using a desktop based system developed in VB6 and SQL Server 2000. Even the system is fully functional, it is too old, therefore requires upgradation.
18 Some of the organizations like PIS, MoHP, Civil Hospital, NNC, NHTC are using commercialized database system Oracle and Microsoft SQL Server. They are not updating the database to the latest version of the software due to the cost and dependency with the vendor. The organization can mobilize the cost to the software feature additions, updates, and yearly maintenance rather than paying for the commercial database.
19 Most of the organizations are hosting their web based application in DoIT, the DoIT server downs specially when the user excesses the data from various sources and the user volume or request is very high. They are also using their own server for maintaining backup but there is no automatic regular backup system.
20 In comparison with the e-information system, HIMS is found one of the better system that uses a robust platform and open source technology. The PIS is using an outdated platform, however, it is fully functional and have given limited access to the data for various organizations. Among the councils, NMC has the records in their online system built in php 7.1 with laravel framework where they already have all the workforce along with the backlogs.
21 The core HRH functional areas are identified as HR deployment, HRH policy production/planning/forecasting, maintenance/retention, training and development, allied HRH functions and post retirement HRH management. The sketched log-frame in chapter 3.2 explains in detail about the HRH functions, data/information need and data sources. The data management mechanism or access control needs to be developed in line with the assigned functions, role and responsibility of the employee.
22 Health Workforce Registry (iHRIS) has been installed in 5 Health Councils and has recently been customized to use initially in the Councils. It needs to be further customized/developed, trained, tested/piloted and then can be used in Nepalese context.
23 The existing institutional capacity including expertise in related field and IT structure needs to be enhanced to support for the online/real-time HRH information management. MoHP should address this issue on time.
24 The WHO classification of health workers has not been harmonized across all the data bases, that is: Health Councils, HuRIC, TIMS, HMIS, PIS, Hospital Management Information System. This harmonization resolves the global comparability issues, our data and information will be useable internationally and can be compared among other similar nations.
25 Sustainability of the system is a very critical issue. It has caused a huge loss of efforts, data and resources. The current fate of old e-HuRDIS is the bad lesson of sustainability of information system of MOHP. Most of the databases and IT infrastructures are running without or with limited ad hoc AMC. They don’t have regular, reliable maintenance system in place. Frequent change of guards and operators, insufficient funding, poor structures, less priority, neglected area and absence of Public-Private Partnership are threat to the system sustainability.
26 Funding Provision: Current fragmented information systems can be developed into a national integrated and comprehensive system only with a provision of basket funding to the comprehensive information system rather than hand picking of a sub-component by a specific donor.
27 The HRH functions (n=44) and the required data need for informed decisions is thoroughly projected in the chapter 3.2, that must be considered during the database redesign phase.
28 However, the study team explored and identified some issues and challenges across the HRH information system like Policy, Plan and Strategy Issue; issues regarding Communication among Healthcare Systems; Data Capturing at Source; Data Back Logs and Updating; Biometrics Links; Data Security and Safety; Data Handshake Challenge; challenges in Information Utilization and Sustainability issues.
29 The identified needs are: There is a greater need to strive for wider data-handshake, need of web based online platform rather than desktop based system, the iHRIS is yet be fully customized as per the Nepalese health system, the recovery of lost data both at e-HuRDIS and at iHRIS is a challenging need, national harmonization of health workforce categories and professions with WHO category (latest ISCO revision), inputting of backlogs and paper data into database, and update of pending information, need of Infrastructure (computer, network, IT environment) and Operation Staff, Need of levelling of all software, language, database, versions, architecture, platform, documentation, manual for the operation, Need for Orientation on the power of database (advocacy), Outsourcing for sustainability and to move from independent to interdependent database are other pertinent needs.
RECOMMENDATIONS:
The recommendations are categorized in four major segments—for Policy- Federal, Overall-Operational, and Provincial-Local and regarding IT and database, that are outlined in detail in chapter VI of this report.
Major recommendations are:
1. Design, develop and test a comprehensive information interface,
2. Implement a data handshake module to link with the integrated HRH information system either designing a new system or upgrading the existing e-HuRDIS for the real-time data sharing
3. Outsource for the system development, literacy, operation and maintenance support until and unless the institutional capacity of the MoHP is enhanced,
4. Establish a reliable online IT environment and data updating mechanism for real-time HRH data management,
5. Create mandatory provisions for vertical/horizontal reporting,
6. Digitize all backlogs of e-HURDIS and at councils,
7. Enhance capacity of Managers and Executives so as to utilization of HR information,
8. Harmonize national classification of health workers with the WHO for the comparative analysis of health service within the similar nations and internationally,
9. Make mandatory provision of online e-attendance registration for better health service delivery and its linkage with proposed interface,
10. Develop secured/robust database system with mirroring at multiple locations in consultation with DoIT,
11. Enhance the institutional capacity at each level,
12. Create conducive environment for functional data handshaking mechanism within public health sector and beyond,
13. Convert existing system into a HRH information powerhouse so that it works as National HRH Information Interface,
14. Improve the quality level of IT structure/ IT environment, specially of computer and internet facility at local level,
15. Establish link among the database and software systems used in health sector in Nepal,
16. Insist to use opensource platform for database for cost effective and sustainable management,
17. iHRIS should be first tested in councils and further customized based on the feedback so that the system can be adapted and made fully functional.
