Nepal is in early stage of federalization where the country has been restructured under three tiers of government respectively federal government, seven provincial governments and 753 local governments. Power and responsibilities have been identified and delegated accordingly to the three tiers of government. Where does health sector find itself in this structure, specially in terms of policy formulation and implementation. Let’s talk about it.

After federalization in Nepal, health is one of the most decentralized sectors where responsibilities of basic health services exclusively fall under the function of local government. As country gradually institutionalizes federalism, there have been serious concerns about difficulties, challenges and problems in the health sector at federal, provincial and local level.

Let’s begin with positive note before talking about challenges. There are some cheerful pictures when we look at country’s progress in the health sector in terms of policy and legal instruments. Health service has been acknowledged as fundamental rights of citizen in the constitution including safe sexual and reproductive rights and child rights. Referring to this progress, a speaker during Public Health Conference organised in Kathmandu on 10 October 2020 noted, “Health policies are gradually being translated into action. It was reflected in the reduction of maternal mortality ratio, infant mortality rate, under five mortality and stunting. There is also increased coverage of maternal and child health services. The major factors were proper implementation of health polices”

Despite some achievements, there are several gaps in health policy implementation in the country. Federalism is meant to reduce the gap not to widen it. As mentioned by the speakers in the conference, lack of technical capacity at local level is something urgent to address to accelerate health system strengthening process. Since local levels are autonomous to formulate policies to be implemented under their jurisdiction, they need capacity building support from provincial and federal governments.

On the other, lack of cooperation from provincial and federal government has been surfaced as another gap. There has been a perception that federal government formulates policies and leaves them to be implemented by the local levels but ‘do not provide support system and guidance’ that are necessary to implement such policies.

Putting emphasis on the cooperation among three tire of government, a panellist in Nepal Public Health Conference said, “there is lack of coordination among federal, provincial and local government that has created hurdle in implementing the health policy at local level.”

As other speakers too highlighted in the conference, insufficient human resources, resistance of available human resource to change, lack of locally-tailored program, absence of robust monitoring and evaluation systems and limited space for research innovation and development are other challenges that have been creating barriers to translate health policies into action.

Experts have suggested two major steps to overcome these gaps. First is related to leadership and financial structure and second is related to support system for local government. The federal ministries should issue policies and guidelines that can be practically implemented. If such policies are a bit ambitious, then federal government should offer supplementary provisions to enable local government to implement the policies be it human resource, capacity building or something else. At the same time, it should not be forgotten that local level tailored program and culture of lateral and downward accountability should be maintained at all level.

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