Health System Governance Under Federalism in Nepal: Early Experiences and Emerging Challenges
Shophika Regmi, Sushil Baral, Krishna Hort
International Journal of Health Policy and Management · 2020 · DOI: 10.34172/ijhpm.2020.07
Countries: Nepal
What Was Studied
A qualitative study using key informant interviews and document analysis to examine how Nepal's transition to federalism has affected health system governance, coordination between government levels, and health service delivery in the early years of implementation (2017-2019).
What They Found
Three critical challenges emerged: (1) Ambiguity in roles — the constitution devolved health to local governments but implementing legislation lagged, creating confusion about who is responsible for what; (2) Capacity gaps — many local governments lacked health planning and management expertise; (3) Coordination failures — provincial governments struggled to play their intended intermediary role. Positive findings included local governments' enthusiasm and some innovative local health initiatives. Drug procurement was particularly problematic, with supply chain disruptions during the transition.
What This Means for Nepal
This study highlights that Nepal's health federalism is a work in progress. Priority actions: (1) Fast-track implementing legislation that clearly delineates health responsibilities across government levels; (2) Invest heavily in local government health management capacity through training and technical support; (3) Establish formal coordination mechanisms between federal, provincial, and local levels; (4) Create a unified drug procurement system to prevent supply chain disruptions. These governance foundations must be strengthened before other health reforms can succeed.
Contextualisation
This is one of the few rigorous studies examining how Nepal's 2015 federal transition has affected health system governance. Essential reading for understanding the current governance challenges that affect every other health policy domain.