title: Exploring health facilities' experiences in implementing the free health-care policy (FHCP) in Nepal: how did organizational factors influence the implementation of the user-fee abolition policy?
abstract: BACKGROUND
  This article presents an Asian experience of abolishing health-care user fees: Nepal's universal free health-care policy, implemented in 2008. Based on doctoral fieldwork between August 2008 and April 2009, the paper analyses primary-care facilities' and central and district health systems' experiences with the policy. It makes a unique contribution to existing evidence because it explicitly applies organizational theory within a carefully designed, rigorous, multiple case-study analysis to deepen our understanding of the organizational and 'people' factors in the successful removal of user fees.
  
  
  METHODS
  The cases were two pairs of primary-care facilities in one district, paired for comparison of the facilities' experiences with the policy in relation to its effects on health care utilization. Data collection methods included document reviews; key informant interviews at district and central levels; in-depth, semi-structured interviews and group interviews at case facilities. (Data on indicators of utilization and quality changes over time were also collected and will be published separately). Using key elements of Nadler and Tushman's 'Organizational Congruence' model, a degree-of-fit analysis tested the study's initial propositions and yielded generalizations for contexts in and outside Nepal.
  
  
  RESULTS
  The study found that Nepal's key implementation challenges were similar to Africa's: insufficient or delayed inputs of drugs and compensation; insufficient workforce and the resulting reduced quality of services that hampered facilities' relationships with their clients and health providers' attitudes. However, the Nepalese case facilities with (1) good intra- and inter-facility relationships, (2) adequate staffing, (3) well-oriented providers and (4) previously trained, better-informed and skilled health management committees experienced higher utilization and better-quality indicators over time.
  
  
  CONCLUSIONS
  Through its detailed analysis of Nepal's experience in removing user fees, the study highlights the importance of addressing the 'people' and 'organizational' factors in health-policy development and implementation.
authors: UNICEF, Amman, Jordan and msato@unicef.org.
authors: Midori
authors: M
authors: Sato
authors: Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors: Lucy
authors: L
authors: Gilson
mesh_terms: D001291:Attitude of Health Personnel; D006268:Health Facilities; D006284:Health Plan Implementation / Q000379:methods*; D006291:Health Policy / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D009390:Nepal; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011050:Policy Making; D011320:Primary Health Care; D019472:Universal Health Insurance
keywords: Nepal; organizational factors; policy analysis; user-fee removal