Nepal under federalism: what next for the health sector?
The Nepal Constitution states that basic healthcare is a fundamental right of every citizen. This obligation is further reflected in Nepal’s commitment to the Sustainable Development Goal of good health and well-being. Yet, many Nepalese continue to face barriers in accessing health services due to poverty, socio-cultural discrimination, and living in remote and hard-to-reach areas. These barriers are multi-faceted and are further encumbered by health policies that fall short in ensuring no-one is left behind.
For a health system to function properly, i.e. for people to be able to access affordable quality health services, the right policies and procedures need to be in place at both central and local level government.
Nepal is facing a particularly challenging period as it transitions towards federalism; a process whereby powers and responsibilities have been devolved from the federal (central) level to the provincial and local levels. This is a momentous change for a small country like Nepal, which now has 761 government structures; the federal government, seven provincial governments and 753 local governments.
As the roles and responsibilities of each government level are defined, policies are being reviewed and updated, including those in the health sector.
Creating policies that reach the hard to reach
The UKAid-funded Nepal Health Sector Programme (NHSSP) is providing technical assistance to the Ministry of Health and Population (MoHP) to develop policies and strategies that are evidence-based, respond to the changing political context, and ensure everyone - including the poor and underserved - has access to basic health services.
To realise this, an enabling policy and legal framework is essential. As Nepal’s health policies were developed under a unitary government system, they remain mostly relevant at the federal level. Few policies can be applied to local levels of government that now bear the responsibility to deliver basic health services. In light of federalism, NHSSP technical advisors supported the MoHP to review all policies in the health sector.
Most health policies focus on governance and delivery of healthcare services. Aspects that are considered the “building blocks” of the health system, such as infrastructure, equipment, pharmaceuticals and laboratories, are not consistently addressed. Policies pay limited attention to equity and multi-sectoral approaches, which are key components of the Nepal Health Sector Strategy (NHSS) 2015 – 2020, and are vital to ensuring universal health coverage.
In partnership with the MoHP, NHSSP’s review of 22 health policies provided a crucial opportunity to develop a consolidated national framework that would guide provincial and local governments to develop their health policies.
As part of the review, various recommendations were made to support the development of Nepal’s health policies and legal framework, including:
- A law to govern the overall management of the health system should be developed, that spells out access to health services as a fundamental right of every Nepali citizen as provisioned in the Constitution of Nepal.
- A national health policy, which prioritises equal access to healthcare for all, needs to be established at the federal level. With people at the centre of this policy, it should cover aspects such as governance, information, financing, service delivery, human resources, and medicines and technology. It should provide policy guidance, and be aligned with the new roles and responsibilities of all levels of government. Policies should also consider priority areas identified in the constitution, such as the provision of basic health care, emergency health care, health insurance, immunisation, maternal health care and access to clean drinking water. NHSSP is part of the Technical Working Group, supporting the MoHP to develop the 2018 National Health Policy, in line with these recommendations.
- Provincial and local governments now have the authority to draft their own laws. As functions of each level of government are reviewed, NHSSP has been providing support to the restructure of government bodies. Standard operating procedures and guidelines that support all government levels to fulfil their roles need to be developed, and policy provisions are essential to guide the management of critical service delivery areas that have now been devolved to provincial and local government. This includes the provision of blood transfusion services, procurement of medicines and equipment, and supply chain management. To date, NHSSP has supported the MoHP in developing guidelines for the health sector’s annual work plan and budgeting process, programme implementation guidelines and minimum service standards for hospitals.
The review also showed that many policies acknowledge the importance of multi-sectoral partnerships in the health sector. None of the existing policies currently provide clear directions for this. NHSSP is supporting the MoHP to develop approaches and guidelines for effective partnership with the private sector and sectors beyond health. The programme hopes to see the growth of a transparent and coherent partnership approach with the private sector, and for increased accountability within the private sector.
In all of these priority areas, NHSSP technical advisors will continue to provide strategic technical advice to the MoHP, to develop all relevant policies, legal frameworks, standards, protocols and guidelines, to support Nepal to achieve universal health coverage. In 2019, the programme will be working with the ministry to develop various guidelines including those for Health Facility Operation and Management Committees, for the implementation of Nepal’s Basic Health Services Package, for establishing and upgrading health facilities, and for development of standard treatment protocols for basic health services.
Finally, because the analysis found that the implementation of health policies is not regularly reviewed, NHSSP will work with the MoHP as well as provincial and local governments to develop a culture of periodic review of health policy implementation. In doing so, the programme hopes that measures are taken to correct and update policies, making them more robust and relevant to Nepal’s changing context.