| Methodology/Approach |
Nepal's Constitution of 2015 adopted federalism as a key principle, providing considerable powers and functions to local governments. The Constitution also established health as a fundamental right and stipulated public health as a concurrent function amongst all three levels of government. Under the Constitution, Nepal is divided into 77 districts and 753 local levels (including six metropolises, 11 sub metropolises, 276 urban municipalities (nagar pallikas), and 460 rural municipalities (gaon pallikas). The urban municipalities are headed by a mayor and deputy mayor and the rural ones by a chairperson and deputy chairperson.
By the Local Government Operations Act (2017), it is solely the local government's task to deliver basic health care services to the community. The Act makes municipalities responsible for registering, licensing, and monitoring primary-level hospitals, including private health facilities and their community outreach activities. Local governments can and do make additional laws and add to the basic services packages. |
| Results |
Each local unit or municipality should also have as its main care centre a 15-bed hospital. These serve a population of about 10 000 to 25 000. Beneath these are basic health units, also known as health posts, located in vadas (villages or wards). Many of these are five or 10 bed community hospitals, which also come under the administration of local governments. A health post, covering a population of about 5000 would have six staff, two of whom have auxiliary nurse or midwife qualifications, one is an 18-month trained auxiliary health worker, and the head is three-year trained with a diploma in general medicine (health assistant). There are about 98 medicines available in each basic health unit. By law and by the National Health Policy of 2019 all care, including drugs and diagnostics in the basic package, are free.
Regarding primary-level health care, all peripheral health facilities in Nepal have a local health facility management committee to manage funds, human resources, and health programmes, based on the principle of health sector decentralization. Each health facility management committee comprises nine to 13 representatives from the village development committee or municipality. In order to ensure everyone has a voice in the health facility management, membership needs to include the clinic manager, the village development committee chairperson, and elected members, including schoolteachers, female community health volunteers, and at least one of each of the following: Dalit, Janajati (an ethnic group), and female representatives. The health facility management committee contributes to monitoring and feedback mechanisms. The municipalities provide land for community hospitals.
Regarding intermediate levels of health care, there are about 10 municipalities under a district and about 10 districts under a province. District hospitals are administered by the province, but most provincial headquarters hospitals that have more than 25 beds are directly administered by the federal government.
The main strengths of such decentralization are a much higher level of support and ownership by local communities with respect to the public health facilities. Decentralization also helps close infrastructure and human resource gaps. This is enabled by the transfer of funds and human resources and related powers to the municipalities. Municipalities can raise additional funds through taxes. Decentralization helps deal with variations in demand for services and improves efficiency in addressing the many local barriers and problems, which local entities understand well. The municipalities are also a major platform for convergence across sectors.
The other set of problems relates to basic health units and primary-level hospitals, which require a considerable degree of technical support, and referral institutions at district and provincial level that can provide higher levels of care. The clarity of roles and administrative powers of districts and provinces about the local unit can be difficult to establish. This leads to problems in medical supplies since most medical supplies and equipment must come from a higher level. There are also considerable problems for continuity of care. The current policy sees secondary and tertiary care as being largely provided through the insurance mode, but in the absence of adequate hospitals and specialists at intermediate levels, the problems persist, and many services remain out of reach. As one official put it: "This level of decentralization is recent, and it is still on a learning curve. Currently the communities are enjoying their new-found freedom, and this has brought a lot of positive energy. But they are also beginning to recognize that everything cannot happen at the local level, and there must be a development of institutions and capacity at intermediate levels as well."
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| Discussion/Conclusion |
Nepal's recent experiences with decentralization have involved a considerable amount of energy and community engagement, but it is also faced with several challenges, the more so as the programme extends beyond basic health services to address a more comprehensive health care package. The strengths of decentralization have been greater community ownership and the remediation of many gaps in local capacity. However, there is uneven development across municipalities, and it remains a challenge to assure the right to health for all. The linkages and continuity between central, intermediate, and local levels about health care and administration still require focused attention. |
