Studying the effect of federalization on Nepal’s health system: from participatory action research to producing policy briefs’
Authors: van Teijlingen, E., Wasti, S. and Simkhada, P.
Conference: 21 st BNAC Nepal Study Days
Dates: 13-14 May 2024
Abstract:Background The introduction of federalism in Nepal with the new 2015 Constitution resulted in decentralization of its health system. The old unitary system is now divided into one federal, seven provincial and 753 local governments, each with its own sphere of authority and responsibility. The choice to move to a federal system was made to help accommodate the diversity of interests across Nepal, with the new provincial governments having the flexibility to enact (health) policies that reflect local preferences and priorities. However, undertaking such a wide-ranging transformation of government is not without its challenges. Here, we explore the federalisation of Nepal’s health system through first-hand experiences and perceptions of stakeholders who are directly involved in, and/or impacted by, this change.
Our team conducted an interdisciplinary, mixed-methods, longitudinal study across three provinces (Bagmati, Karnali, Lumbini), representing hilly, mountainous and terai regions of Nepal, as well as the capital, Kathmandu. Qualitative data were collected at intervals, between 2020 and 2024, from all three levels of government. We conducted 243 in-depth interviews and 32 Participatory Policy Analysis workshops with health and political leaders, administrators and implementers, as well as community-based health volunteers. Data analysis was iterative and inductive, drawing on the World Health Organization (WHO) health systems six building blocks framework and principles of systems theory (“systems thinking”).
Results Federalisation of the health system was described as complex and “both an opportunity and a challenge”, suggesting that how it is implemented may be more important than what the intended design of the (federal) system was. Federalism was also portrayed as dynamic, ongoing, and an incomplete process, with uneven progress in different geographical locations, governance levels and health system building blocks. While many structural aspects of the system were federalised, some cultural or human elements of the previous system remained outdated and unchanged, in particular interim legislation, and people’s mindsets and behaviours. The latter was especially prominent at national level, where many struggled to let go of the old unitary system, with repercussions at provincial and local levels. Stakeholders also reported that federalisation had a somewhat mixed impact on the health system, with the emergence of both positive and negative (unintended) consequences. The most noted positive improvements were in the decision-making autonomy of local government, though not in its spending capacity, and in access to health services, though not in service quality. We found that the federal system also significantly contributed to the control and management of COVID-19, allowing for more localized responses and tailored interventions. Yet new challenges also arose; particularly the unclear power and authority of provinces, and the absence of well-functioning mechanisms for coordination and cooperation within and between the different levels of government and between health and non-health sectors. While perhaps not an entirely new problem, this lack of inter-connectedness was said to prevent adequate monitoring, feedback and learning from successes and failures – all key elements for health system improvement. In addition, local-level individual and institutional capacity building, especially in health leadership and management, was still lacking. Conclusion While building new federal structures is important, challenging the status quo through strategic “unlearning and undoing” of old tendencies is also essential, as this creates spaces for new approaches that are more in line with federalism. This requires attention to emotional and political spheres, and not just structural or technical ones. With almost a decade since the promulgation of the new constitution, many aspects of the Nepal's health system have now federalised, bringing decision making, resources and the delivery of services closer to the people, yet the process remains challenging and incomplete. Importantly, at the same time as federalism Nepal also dealt a pandemic, as well as the everyday stresses and challenges of a resource limited setting. It is difficult to disentangle the effects of the pandemic from those of federalisation. The health system is also part of a broader, complex, and interdependent set of socio-political, economic, legal, and cultural systems. Unlocking the full potential of federalism will require working together towards politically difficult decisions, as well as stopping, continuing, and starting a range of concrete actions in the short, medium and long term. Our policy briefs were delivered to the relevant health minister and his civil servants
Source: Manual