The health system in Nepal's unique federalisation experiment.

Abstract

Nepal’s introduction of its federal system in the 2015 Constitution changed the way society, including its health system, was organised. It meant that political changes and health systems changes occurred in parallel. Prof. Edwin van Teijlingen explores the impact of federalisation on Nepal’s health system as part of an interdisciplinary mixed-methods study* called ‘The Impact of Federalisation on Nepal’s Health System: A longitudinal Analysis’. First, implementing a new federal system is a slow, resource intensive process. 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. Federalisation, generally, brought decision making, resources and service delivery closer to the people, yet the process remains challenging and incomplete. Importantly, at the same time as federalism was being introduced, Nepal’s health system had to respond to COVID-19, making it 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. We found that the impact of federalisation varied across the six WHO building blocks and pre-existing conditions, e.g. wealthier regions often benefit disproportionately, exacerbating inequities in health. Our study further highlighted: (a) the importance of leadership and governance, combined with financing mechanisms; (b) insufficient planning and misalignment between central and local levels resulting in inefficiencies; (c) weak health information systems hinder the ability to measure long-term effects. Overall, unlocking the full potential of federalism will require political will and commitment at all three levels of government. • Funded by the UK Health Systems Research Initiative (Grant ref MR/T023554/1). Prof. van Teijlingen is part of the Nepal Federal Health System Team, see: https://www.nepalfederalhealthsystem.com/.