The impact of federalisation on Nepal's health system: a longitudinal analysis

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Nepal is currently in the midst of a process of radical constitutional reform. After almost a decade operating under a post- conflict Interim Constitution, the highly contested political process of agreeing on a model for the country's future governance finally came to an end in late 2015, when a new Constitution was adopted by the Constituent Assembly. The 2015 Constitution heralded a complete restructuring of the country's political system, creating a Federal Republic with significant devolution of power and resources from the central government to seven newly-created Provinces, each with its own legislature. Implementation of the new Constitution has already delivered the first local elections in 20 years, which were held in late 2017.The new Constitution brings about significant changes in the health system. Nepal's national health system has historically been unitary and centralised, with the Ministry of Health and Population providing the resources and directing health services for the entire country. The new Constitution places the responsibility for health service provision primarily with the seven new Provincial governments, with significant powers and responsibilities being further devolved to Municipalities/Rural Municipalities. All of this has put Nepal's health system in a period of rapid, and far-reaching, transformational change.In theory, these changes have opened up the possibility for greater localism and responsiveness to communities' health needs. In practice, national health policy has not (yet) been revised to reflect the new system. Furthermore, there are fears regarding the capacity of the newly formed Provincial and Municipal governments to successfully take on their new roles, as well as doubts about the 'readiness' of the health system to adapt to the changes. How the transition to a Federal Republic unfolds within the health system, how the system itself responds to the reforms. These concerns are central to our project.This project uses Participatory Policy Analysis (PPA) to track this immense health system reform effort in real time, drawing upon the experiences, perceptions and expertise of health system actors from across all levels of government. We will work with policymakers at the federal, provincial and municipal levels, as well as with community-level providers (primary health centre staff and the Female Community Health Volunteers who are on the frontline of delivering maternal and child health services in rural communities). The project aims to uncover the perceptions of this wide range of different stakeholders and to bring them into dialogue with one another - bridging governance and practice levels - in order to identify systemic design deficits, delivery gaps and capacity constraints in the emerging system that may be impacted by, and in turn impact upon, the reform process.Supporting the PPA with a mixture of quantitative and in-depth qualitative work, the research team will iteratively track developments and perceptions within the health sector, across all of the health system building blocks and all levels of government, over a vital period in the creation of the new system. This will allow us to better understand the dynamic process of this transformational change. We will work with stakeholders to co-produce new knowledge of relevance to policy and practice in Nepal, but also to a variety of academic and policy audiences elsewhere.