Impact Of Federalisation On Healthcare


Nepal has been on a journey of transformation in recent years, wherein the country shifted to a federal system that changed how governance and other services are done. This immense transition has transformed the entire system of health care, provided numerous benefits while posed various drawbacks. Pioneering research being carried out in the Bagmati, Karnali, and Lumbini regions, as well as Kathmandu, contributes much to understanding the complex dynamics between federalisation and healthcare.

The initial results from this research conducted by the Health Systems Research Initiative indicate a positive tendency towards developing Nepal’s health system. In the last decades, the country has seen continual development, and this matches the positive trend since federalisation. But in the midst of this positivity, there are serious challenges that require consideration, which makes it an effective study for policymakers as well as stakeholders. One of the main issues highlighted in the research is confusion among different levels of government about their responsibilities. Governance is critical, and the lack of a clearly understood ‘division of labour’ can impair integrated healthcare services. The research team welcomes the idea of legislation being considered for better clarity and seeks greater transparency as well as efficiency in governance structures within the health system. Inadequate planning and the prevalence of temporary positions within the health workforce are identified as challenges.

Good healthcare depends on a trained and motivated workforce. The study righteously recommends reconsidering staff adjustment procedures, improving hiring transparency, and establishing a complete information system aimed at efficient workforce management. The procurement of medical products and technologies is very important for the effective implementation of health services. The study indicates that local procurement requires simplified control to prevent cases of over- and under-storage. The critical elements of legislation to clarify roles, strengthen data management, and involve experts for quality controls must be taken in order to secure a resilient medical procurement system.

The study brings attention to challenges in healthcare financing, with local governments struggling to fully utilise their budgets. Timely release of funds, along with training for elected representatives on health budgeting, can bridge these gaps and ensure a more efficient allocation of resources.

A glaring challenge lies in the fragmentation of health information systems. To enhance data-driven decision-making, the interoperability of software systems and the implementation of a nationwide electronic patient record system are essential. In service delivery, political influences must be replaced with evidence-informed decisions and community engagement for inclusive services.

The research team reaffirms the appeal of a participatory and collaborative approach among government levels, healthcare providers, and local communities. By adhering to the needs raised in this study and implementing policy suggestions, Nepal can facilitate a resilient, inclusive health system.

The next decade is pivotal for Nepal's health system, and the Health Sector Strategic Plan 2022–30 presents an opportune moment for decisive action. The research team urges policymakers to heed the findings of this study, considering it a compass guiding us towards a healthcare landscape that is both robust and equitable.

The project is a research collaboration between researchers from Nepal and the UK that received funding through the HSRI. Since 2020, a research team co-led by Professor Simon Rushton of the University of Sheffield, UK, as well as Professor Julie Balen from Canterbury Christ Church University, has begun to study federalism’s impact on the Nepali health system.

Their collaborative efforts bring an international perspective to the study, enriching it with diverse insights and expertise. The exchange of knowledge between the academic communities in Nepal and the UK fosters a holistic understanding of the complex interplay between federalization and healthcare dynamics.

The current research investigates the heterogeneous effects of federalisation on health care. It analyses the complex interdependencies of governance structures, human resources development trends, procurement practices, budgetary allocation, and data management. In this regard, the insights that derive from their study are not simply observational but set in stone as a policy guideline and intervention.

The lack of clarity in the division of roles among different government levels emerges as a critical concern. The study recognises the necessity for an explicit 'division of labour' within the healthcare governance structure. It proposes legislative measures to define roles and responsibilities, fostering transparency and efficiency. By addressing this foundational issue, Nepal can establish a governance framework that ensures the seamless operation of healthcare services.

Inadequate planning and the prevalence of temporary positions within the health workforce represent additional challenges identified by the research. A resilient healthcare system hinges on a skilled and motivated workforce. The study advocates for revisiting staff adjustment processes, enhancing hiring transparency, and establishing a comprehensive data system for effective workforce management. These measures aim to address workforce-related bottlenecks and contribute to the overall improvement of healthcare services.

Efficient procurement of medical products and technologies emerges as a cornerstone of a successful health system. The study emphasises the need for streamlined oversight in local procurement to avoid issues of over- and under-stocking. Legislative measures are recommended to clarify roles, strengthen data management, and engage experts for quality checks in the medical procurement process. This strategic approach ensures the resilience of the medical procurement system, contributing to the overall effectiveness of healthcare delivery.

Addressing financial challenges is crucial for sustaining and enhancing healthcare services. The study sheds light on the struggle of local governments to fully utilise their healthcare budgets. Timely release of funds and targeted training for elected representatives on health budgeting are proposed as measures to bridge these gaps. These interventions aim to ensure a more efficient allocation of resources, thereby maximising the impact of healthcare budgets at the local level.

The fragmentation of health information systems poses a significant challenge to data-driven decision-making. The study advocates for the interoperability of software systems and the implementation of a nationwide electronic patient record system. These technological interventions are crucial for enhancing the accessibility and usability of health data. By replacing political influences with evidence-informed decisions and promoting community engagement in service delivery, Nepal can move towards a more inclusive and responsive healthcare system. As the study underscores the importance of collaboration, it calls for inclusive dialogue and joint efforts between government levels, healthcare professionals, and local communities.

(Bhusal is a journalist at The Rising Nepal)

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