Overcoming the challenges facing Nepal’s health system during federalisation: an analysis of health system building blocks

Abstract

Introduction Nepal’s move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal’s health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal’s health system as it adapts to federalisation. Methods This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders’ practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. Results Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. Conclusion Our findings suggest that since federalisation, Nepal’s health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

Enhancing Performance of Health Assistants through Technical and Vocational Education and Training for Better Healthcare Access

“…These contributions effectively address immediate health needs, prevent illnesses, and promote overall community well-being, making them vital in pursuit of equitable healthcare and improved public health outcomes (Adhikari et al, 2022). Despite challenging geographical diversity and limited healthcare infrastructures, health assistant program initiatives strive to achieve fundamental right of the people, including marginalized communities' access to quality healthcare in Nepal (Wasti et al, 2023a).…”

“…Compounding these challenges is a persistent shortage of healthcare professionals, including doctors, nurses, and midwives, especially in underserved areas, resulting in compromised healthcare delivery and limited access to essential treatment (Tamata & Mohammadnezhad, 2022). These deficiencies collectively contribute to existing gaps in healthcare services, leaving sizable population without adequate medical care, thus underscoring the urgency of comprehensive strategies to address these pressing healthcare challenges in Nepal (Wasti et al, 2023b).…”

Participatory policy analysis in health policy and systems research: reflections from a study in Nepal

“…Federalism in Nepal has been a result of political grass-root reaction against the long-standing centralized system, and it has not progressed through a systematic evolutionary process nor have its mechanisms been guided by any research [25]. The process therefore is facing several challenges, including a lack of cooperation and overlap/confusion in the functions and responsibilities among the three government levels; service delivery interruptions; and problems with resource mobilization, financial autonomy, effective participatory planning, budgeting and implementation at the local level [25][26][27].…”