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Federalism is a system of government in which the same area is controlled by two levels of government; a national division and smaller subdivisions.

Nepal had a unitary form of government in place until 2015, when it transitioned to a federal democratic republic. This shifted the power from the central government to seven new provincial governments - and below them, to 753 local governments.

The primary responsibility for running the health system was shifted to the 7 new provinces, each working with their respective local governments, to help the system better meet localised health needs. However, the coordination of transitioning the new health system structure in the midst of a pandemic has had its challenges. 

Dr Julie Balen, a Lecturer in Global Health and Dr Simon Rushton, a Senior Lecturer in the Department of Politics and International Relations, at the University of 91ֱ�� are leading a collaborative project on the impact of the shift to federalism on Nepal’s health system.

Funded by the Health Systems Research Initiative (HSRI), a collaboration between the Medical Research Council (MRC), the Economic and Social Research Council (ESRC), the Wellcome Trust, and the Foreign, Commonwealth and Development Office (FCDO), the team is investigating how the healthcare system is coping with new political and structural changes whilst also faced with managing the pandemic.

Throughout the duration of the research, they will report their findings directly to the local, provincial and federal governments, allowing immediate changes to be considered.

Despite launching the project at the beginning of the pandemic, the team have successfully carried out valuable participatory research as a result of previously established partnerships and a strong team of postdoctoral researchers in Nepal. 

We are talking to those who are on the frontline of delivering healthcare, such as nurses delivering maternal health services, rather than just looking at the national level picture.

Professor Simon Rushton

Senior Lecturer in the Department of Politics and International Relations at the University of 91ֱ��

The team continues to conduct interviews, focus groups and participatory workshops with Nepalis working in the health system to understand their perspectives on this huge reform process and identify both the challenges and benefits it is creating for their own working lives. 

This research provides new insights into how federalism has had an impact on health system elements such as service delivery, the availability of medicines, and human resources.

We are not approaching this kind of work as experts. The experts are people in Nepal who are living through these changes every day. They are going to work in the pandemic under the new federalism changes and manage to deliver their services under challenging conditions.

Dr Julie Balen

Lecturer in Global Health at the University of 91ֱ��

Commonly, research on big health system changes relies on the analysis of policy levels and data. However, this team is taking a context-led approach by focusing on varied stakeholder experiences and involving a multidisciplinary team. This combination will provide a deeper understanding of the ongoing complexities of federalism in Nepal and its impact on healthcare.

In the next phase of research, the project hopes to look at how financial aspects of health system reform are impacting service delivery in more detail. This raises questions not only about how much Nepal spends on healthcare but also about barriers to that funding being effectively delivered and put to use.

The team co-develops recommendations for healthcare policy and practice throughout Nepal’s COVID and post-COVID era.

“Often, what makes the real difference is not national level policy making, but changing how a system functions on a micro level.” says Professor Simon Rushton.

Written by Alina Moore, Research Communications Coordinator