The impact of federalisation on Nepal's health system: a longitudinal analysis

Nepal is currently in the midst of a process of radical constitutional reform. After almost a decade operating under a post- conflict Interim Constitution, the highly contested political process of agreeing on a model for the country's future governance finally came to an end in late 2015, when a new Constitution was adopted by the Constituent Assembly. The 2015 Constitution heralded a complete restructuring of the country's political system, creating a Federal Republic with significant devolution of power and resources from the central government to seven newly-created Provinces, each with its own legislature. Implementation of the new Constitution has already delivered the first local elections in 20 years, which were held in late 2017.
The new Constitution brings about significant changes in the health system. Nepal's national health system has historically been unitary and centralised, with the Ministry of Health and Population providing the resources and directing health services for the entire country. The new Constitution places the responsibility for health service provision primarily with the seven new Provincial governments, with significant powers and responsibilities being further devolved to Municipalities/Rural Municipalities. All of this has put Nepal's health system in a period of rapid, and far-reaching, transformational change.
In theory, these changes have opened up the possibility for greater localism and responsiveness to communities' health needs. In practice, national health policy has not (yet) been revised to reflect the new system. Furthermore, there are fears regarding the capacity of the newly formed Provincial and Municipal governments to successfully take on their new roles, as well as doubts about the 'readiness' of the health system to adapt to the changes. How the transition to a Federal Republic unfolds within the health system, how the system itself responds to the reforms. These concerns are central to our project.
This project uses Participatory Policy Analysis (PPA) to track this immense health system reform effort in real time, drawing upon the experiences, perceptions and expertise of health system actors from across all levels of government. We will work with policymakers at the federal, provincial and municipal levels, as well as with community-level providers (primary health centre staff and the Female Community Health Volunteers who are on the frontline of delivering maternal and child health services in rural communities). The project aims to uncover the perceptions of this wide range of different stakeholders and to bring them into dialogue with one another - bridging governance and practice levels - in order to identify systemic design deficits, delivery gaps and capacity constraints in the emerging system that may be impacted by, and in turn impact upon, the reform process.
Supporting the PPA with a mixture of quantitative and in-depth qualitative work, the research team will iteratively track developments and perceptions within the health sector, across all of the health system building blocks and all levels of government, over a vital period in the creation of the new system. This will allow us to better understand the dynamic process of this transformational change. We will work with stakeholders to co-produce new knowledge of relevance to policy and practice in Nepal, but also to a variety of academic and policy audiences elsewhere.

The proposed project will track, in real time, the massive health system reform process that Nepal is undertaking as a result of the implementation of its new Constitution, and the shift to a Federal government system, with primary responsibility for health being devolved to seven new Provincial governments, and further to Municipalities and Rural Municipalities. Although the changes have the potential to bring greater localism and responsiveness in health service management and delivery, there are real concerns about the 'readiness' of the system for this change, and the capacity of Provincial and Municipal governments to deliver. Key elements of the new system are still to be determined, and national health policy has not yet been revised to reflect the new government structures.

Working in eight communities selected to represent the variety of Nepal's ecological and social-economic regions (mountain; hill; terai; urban), the proposed project will utilize Participatory Policy Analysis backed by more traditional forms of qualitative and quantitative data to track the perceptions of health systems stakeholders at all levels as the reform process unfolds. Taking a holistic approach to the health system, the project will examine all of the WHO's health system building blocks as well as investigating the complex relationships between them.

This is both a timely and highly innovative project, proposing work that has not yet been done in Nepal, and utilising methods that are at the cutting edge of the health systems research field. The project is also highly interdisciplinary, drawing on the variety of disciplinary backgrounds of the project team, and placing a strong emphasis on co-design and co-production of knowledge through continuing stakeholder engagement and a series of Participatory Policy Analysis (PPA) workshops across governance levels.

Since the project's central aims are to contribute to the major health system reform process that is just beginning in Nepal, impact is fully integrated into the project design. Relevant officials at all levels of government have already committed to supporting the proposed research (see letters of support).

A variety of forms of impact, both direct and indirect, are anticipated to occur on:

i) Policy-makers and practitioners at community, municipality, provincial and national levels.
We will work extensively in eight local communities. Iterative rounds of qualitative KIIs and Participatory Policy Analysis workshops with health system stakeholders will enable us to have an extended dialogue over the progress of the decentralisation process and the problems and opportunities arising. Municipal, Provincial and national-level workshops will bring these stakeholders into direct contact with policymakers at higher levels, allowing them to express needs and concerns and to find ways of addressing these through our Participatory Policy Analysis (PPA) approach.
We will be working in three of Nepal's seven newly created Provinces, covering each of the four major geographic divisions (Urban, Hill, Terai and Mountain regions). Iterative rounds of PPA workshops will be held in each Municipality and Province, allowing for exploration of problems and opportunities, and the co-development of recommendations for practitioners and policy audiences at all levels. Although not all Provinces will be covered (due to time and resource constraints we have selected a representative sample), the results of this project are likely to be somewhat generalisable across other non-study areas of Nepal.

At the culmination of the project, a policy briefing paper will be produced, bringing together the co-produced policy and practice recommendations from all levels of stakeholders.

ii) Partner NGO: PHASE Nepal
The project will have a positive impact on the research capacity-building efforts of our partner NGO, PHASE Nepal. The project will fund substantial new research capacity in the organization.

iii) Study communities and other communities in Nepal
Ultimately the aim of the project is to work with stakeholders to identify and seek ways to overcome problems with the reform process, as well as maximising opportunities for health system improvements to be delivered as a result of decentralisation. If successful in achieving these aims, this could have real impacts for the users of health services, maximizing the benefits from reform and minimizing the potential downsides. Overall health outcomes are poor in Nepal and the health system suffers from significant weaknesses. This project, which seeks to work with policymakers and practitioners to strengthen the health system, could therefore deliver positive impacts in the study communities, but also more widely in Nepal.