| Low accessibility to and sub-optimal levels of health care service have been problems at peripheral level in Nepal. In order to tackle those problems, an operations research was conducted as a pilot study of the Community Drug Program (CDP), a Bamako-Initiative approach, in a hill district (Nuwakot District) in Nepal from 1993–1995 in line with the government's new health policy. It was designed to develop prototype operational guidelines and training manuals for the forthcoming national CDP expansion, and to assess the effect of the CDP strategies (of improving accessibility to the government health services through the establishment of sub-health posts, combined with improvement in the quality of care, the provision of essential drugs, the introduction of user fees, and community participation in planning and management) on household health care seeking, utilization, and costs. With a view of increasing sustainability, the project intervention was implemented as a field simulation exercise, strictly following government's financial and administrative rules so as to permit replication by the central and local governments and communities in future. This project involved a quasi-experimentation design, with the use of non-equivalent control area. After a baseline survey was carried out, monthly assessment of the sub-health post performance and longitudinal household surveys were conducted for a 13 month period. It appears that the households were motivated to increase their use of sub-health posts and decrease their use of less accessible private pharmacies. Also, the study results suggest that less privileged ethnic groups tended to use sub-health posts, however, the sub-health post utilization rate was much lower than expected. In light of the maintained quality of cam and better accessibility, most of the patients at the sub-health posts showed positive reactions toward the services provided and toward the user fees charged at sub-health posts. By ensuring the quality mid quantity of health service delivery, four sub-health posts in the project (treatment) area appeared to contribute to a reduction in the household health expenditure proportion. However, their effects did not appear to reduce the household opportunity cost. As the utilization rates of sub-health posts were very low and the recurrent costs of the sub-health posts were much higher than the existing government health facilities, it is highly recommended that the sub-heath posts should be expanded with careful local planning with community participation and involvement in management with support from the central level ensuring quality of care and financial recovery. |
