Data collection and tools

First, the available unpublished documents and files of the meetings (agenda, presentations, and minutes) conducted by HCD with health partners for COVID-19 response from March 2020 to February 2022 were reviewed using a tool (S1 File) that was developed from the meeting evaluation checklist [13] and post-meeting assessment steps [14]. The tool assessed the meetings based on four main themes of conduction, process, participation, and follow-up actions/next steps.

Second was the information available from the responses by the health partners to the survey conducted by MoHP using a survey tool modified from the cluster coordination performance monitoring tool [15] from the Global Health Cluster (S2 File). This tool was pretested among the Provincial Health Emergency Operation Centers before it was disseminated to the health partners for response. The survey was administered from 30 May 2022 to 13 June 2022 by email to the primary focal point of each of the 82 organizations who had participated at least once in the health coordination meetings.

Third was the information available from the Focus Group Discussion (FGD) transcript conducted by HCD among focal person of two UN agencies, two donors, two INGOs and one NGO. These stakeholders were selected based on their participation in more than 50% of the last 20 health coordination meetings conducted for COVID-19 response, with documented attendance list. The FGD was conducted using an interview guideline (S1 Table) with questions to discuss on the major themes as conduction, process, participation, and way forward. The available transcript analysed is the English translation of the recorded FGD which was conducted in Nepali.

Ethical clearance

A written approval from the Ministry of Health and Population was obtained to collect and analyze these unpublished documents and files. Ethical clearance from Nepal Health Research

Council (8/2023 P) was obtained before conducting this analysis. As the methodology included

collection and analysis of secondary information, no human subjects were involved in the study. However, deidentified data were used for analysis and codes were provided to maintain anonymity of the person who had provided information (S1 Data).

Data analysis

Descriptive analysis was performed using MS Excel on the data that were available from the document review tool. The available responses on the survey tool were analysed using four categories, i.e., an overall performance score of greater than 75.0% defined to be good, 50.1%-75.0% as satisfactory, 25.1%-50.0% as unsatisfactory, and less than or equal to 25.0% as weak. This was applied to each of the six core functions and with the addition of accountability to the affected population. Thematic analysis was performed in MS Word on the available transcript of the FGD.

Anonymity of personnel and organization was maintained during analysis of data and results description. Codes were provided to the FGD participants which were used during analysis. Privacy of all the data and information is observed through a password protected data repository managed by the Health Emergency Operation Center, MoHP. This data repository is to be maintained for a period of ten years.

Results

The findings from the analysis of unpublished documents and files of the meetings conducted by health coordination division with health partners for COVID-19 response, analysis of the information available through a survey tool modified from the cluster coordination performance monitoring tool, and the analysis of the information available as transcript of a Focus Group Discussion (FGD) are as below:

Health coordination meetings’ document review

A total of 72 meetings were conducted till mid- February 2022. The frequency of the meetings varied as per the COVID-19 situation, that is from weekly, two-weekly, monthly, to as required (Fig 1). Each meeting had aproximatley 55 individual participants. On average, 43.5 minutes were spent on presentations and 11.5 minutes for discussions in a one-hour meeting. The country level coordination, planning and monitoring pillar had the longest time allocated (average of 17.2 minutes), followed by surveillance, rapid response teams, and case investigation pillar (average of 6.3 minutes).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. COVID-19 epidemic curve of Nepal and health coordination meetings, Jan 2020 to June 2022.

https://doi.org/10.1371/journal.pone.0308941.g001

All the agenda items were covered in 80.6% of the meetings while only 66.7% of the meetings had follow-up action points to review from the preceding meeting. Partners presented in 63.9% of the meetings with at least half of the invitees present in 73.6% of the meetings and at least half of the concerns addressed/recognized/acknowledged in 66.7% of the meetings. Finally, follow-up actions and next steps were fully documented at 100.0% of meeting while there were room for improvement in action point completion i.e., "who will be doing what activities and when" was only documented in 22.2% of the meetings (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Analysis of health coordination meeting documents.

https://doi.org/10.1371/journal.pone.0308941.t001

Performance monitoring of health partner coordination through survey

Out of the 82 survey recipients, responses were received from 26 (31.7%) organizations. While the response rate was low, the organizations which responded had participation rate to the meetings of more than 50.0% whereas the organizations which did not respond had participation rate to the meetings of less than 50.0% (out of the 20 meetings with information available on participants’ details).

Two subfunctions yielded good results by scoring more than 75.0% score (Table 2). First is the "Coordinating to ensure that service delivery is driven by the agreed strategic priorities" subfunction of the supporting service delivery function which covers activities related to coordination meetings like regularity, participation, partners’ decision-making power and ability to follow-up decision made, usefulness in discussing needs, gaps, and priorities, and agreement on strategic direction. Second is the "Application and adherence to existing standards and guidelines" subfunction of the planning and strategy development function which covers the activities like agreement on the technical standards and guidance by cluster members and its application by the responding organization. “Prioritization grounded in response analysis” subfunction of the informing strategic decision-making function yielded ‘Unsatisfactory’ result, i.e., 25.0%-50.0% score. This covers the activities on the response planning and prioritization, supported by joint analyses.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Analysis of the responses in the adapted cluster coordination performance monitoring tool.

https://doi.org/10.1371/journal.pone.0308941.t002

Thematic analysis of the focus group discussion

Participation

One of the participants highlighted the need for the Terms of Reference (ToR) for all the stakeholders in the health cluster coordination mechanism.

“During the beginning, health coordination was activated in a different manner from HEOC, ToR was not clear, some people even put forward their questions, another in logistics part, the information were confusing at times. Especially, during the staff turnover, many of us were unknown about our responsibility.”—Participant F

Sending of the link to the organization only and the conflicting schedules of the participants caused the missing of the meetings by some participants.

“Our participation was frequent most of the times, but then there was constraint in sending meeting link…But some of them were missed due to conflicting schedules.”—Participant L

Next steps

Participants were univocal on continuation of coordination meetings for preparedness, readiness, and response for disasters and other public health emergencies.

“Similarly, health coordination should also focus not only on disaster, but also in post- disaster, like the COVID cases have been dropping, we can also focus on discussing the other important areas of health. Since monsoon is approaching, we can also decide if we can take up the issue in health coordination or start preparing now. Also, I think regular coordination needs to be continued…. I feel like we need to bring out updated health coordination partners in a loop and update in resource mapping. We should develop a resource sharing platform and similarly, health coordination meetings can be regularized monthly. In general, health coordination mechanism needs to be in place.”—Participant G

“…Hence, this meeting should be regularized. Likewise, since monsoon is following, we

need to get prepared for the monsoon. Health coordination can look after the WASH and provincial clusters and update information…”—Participant C

“We can regularize health coordination and certain dedicated human resources should be in place. Nepal being challenged due to many aspects like climate, geography, etc., we cannot predict what comes in the way, information sharing mechanisms can be updated like via Viber group or any kind of emergency group.”—Participant F

One of the participants also highlighted the role of health coordination meetings as the platform for progress monitoring and sharing.

“…but another important work is to monitor, just to see what progress has been made and share the documents with all in a continuous process. It is also one of the critical roles of health coordination division, since it builds up the confidence for all the partners who actually are keen to work.”—Participant F

Suggestions/Recommendations

One of the participants suggested sharing experiences/expert views in the meetings and the connection with the provincial and local level to be maintained in the meeting.

“There are a lot of places where we don’t know exist, we need to seek expertise in those areas, the issues need to be addressed and existing guidelines should be easily accessible. The lessons learnt from our own experience need to be systematized in the upcoming days.”—Participant E

“Because federal ministry of health is to be responsible to coordinate in health emergency as being driven by constitution, so I think that message must be set up and due to work of, for example, health emergency response in the province and the local government are playing their part in health emergency plan or response plan. They should sanction coordination; they are willing to coordinate with ministry and related any support which

is of ministry of health and ultimately health coordination cluster… Also, I think the

connection between provincial and federal level should not be lost. We are discussing over here, but ground realities need to be addressed and solved, we need to consider those as well.”—Participant E

Participants also requested to develop and/or revise the Terms of Reference (ToR) for Health Cluster Coordination Meetings.

“Therefore, I think the ToR (Terms of Reference) of the health cluster must be reviewed in all federal, provincial and district level because we lack in the process of information flow system and the way forward can be reviewing of ToR and handover system should be improved so that we’re on the same page now onwards. Even though the sub-clusters are not formed, we should keep going with the health cluster…. One of the action points could be that we can include ToR from HEOC, and all the participants need to follow that. Agency’s responsibility needs to be clear…. I think a revised ToR is a must. We should scale up the cluster activation like, during the normal period, we can get going with the preparedness while during emergency we get the activity done.”—Participant C

“We need to identify the health partners and seek their own roles and responsibility in close coordination. Some relevant questions should be documented and addressed during or after the meeting.”—Participant G

“During the beginning of cluster meeting, there were two kinds of institutions: 1) existing health institutions and 2) other non-health institutions that diverted their funds to work during COVID. Hence, we need to define their roles and update members so that they can engage beside COVID in later days…. Likewise, we do have a defined ToR for all the leads, co-leads, members etc. in our organization, maybe similar kind of defined ToR needs to be developed which might enhance effective participation further.”—Participant J

Participants requested for one door mechanism for support and information sharing, through the health coordination meeting.

“But in context of coordination, two things seemed lacking, not only from center, but the entire system. Example, the needs/asks coming from different divisions, centers, was quite confusing. Rather than coming from multiple channels, it would have been quite easy if it carried one institutional value.”—Participant F

“…it should be improvised one door mechanism; there are different clusters, we have WASH cluster, and so many of the information were overlapping at times.”—Participant G

“…we created parallel system or multiple system, then there was struggle to share the information as quickly as possible. That was good. But I think we should have mainstreamed those multiple information systems, that created more confusion.”—Participant F

Participants suggested a mixed model for meetings with identification of focal person from each organization to reduce novelty of the meetings.

“Hence, we can switch on to mixed module so that the issues, gaps, and challenges faced in field level can also be reached directly to federal level. Along with this, the meeting time can also be maintained, and it might be more effective that way…. Even when we observe in meeting, there are almost 30/40 organizations, that might not be able to physically attend meetings during other emergencies, hence, we can also opt for mixed model, i.e., virtual and physical so that there’s limited physical presence.”—Participant J

“Periodic sharing of template and updating it needs to be done and a focal person and alternative focal person needs to be allocated for information sharing to minimize gap.

These things need to be mandated.”—Participant C

“I’ve regularly attended the HC meetings, as there are focal points in relevant clusters, cluster leads/co-leads/ any focal point need to be present. Because, we are discussing on the same topic, but not reaching conclusion.”—Participant J

“Also, individual participation would be crowded, but allocating focal person would be much helpful.”—Participant L

“We should have a defined resource and a limit to our responsibilities. Maybe, we can allocate a communication person, it is very important to have a dedicated person for information.”—Participant F

Participants also suggested developing a website for information sharing from and to the health cluster members.

“Likewise, we can opt for some innovative ideas to address the issues, this might not require a long report but rather it’ll be issue based, we can create a website for that, it’ll more be like learning by doing.”—Participant E

“It’ll be better if we could develop a website for sharing that information. Forming an interactive dashboard and linkage of all partners could be effective for future reference as well.”—Participant F