COVID-19 as a challenge to Nepal’s newly federalised health system: capacities, responsibilities, and mindsets.

Abstract

Objective: The aim of this study is to explore how Nepal’s newly federalized health system responded to the COVID-19 pandemic, using this as a basis for drawing wider lessons for health policymakers in Nepal. Method: An exploratory qualitative method was used, involving Key Informant Interviews with 145 health system stakeholders from diverse locations and all three levels of government. The resulting transcripts were thematically analysed using NVIVO software. Finding: We found significant differences in perceptions between the local and higher levels of government. At the local level, major themes identified included: i) a good ability to enact an initial response based on locally-available resources and capacities; ii) a consequent raising of the profile of health amongst local governments; iii) a feeling that they had not received the necessary support from higher levels of government. At the higher levels of government, we found: i) doubts about the capabilities of local governments to manage a health crisis; and ii) uncertainty about the roles and responsibilities of Provincial governments. Discussion: The newly-federalized health system understandably struggled to function effectively during the pandemic. However, this was not only the result of resource deficiencies or bureaucratic weaknesses. The performance of the system was also in part undermined by the continuation of a centralized mindset, especially amongst high ranking policy makers and senior officials, which was at odds with the theoretically devolved nature of decision-making under the federalized system. Conclusion: The study shows that, even outside the exceptional circumstances of the pandemic, there is a need for a change in mindset amongst Federal-level policymakers, from a command and control mentality towards supporting and empowering the lower levels in order to deliver a robust and functional federal health system.