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

尼泊尔目前正在进行彻底的宪政改革。在冲突后的《临时宪法》下运作了近十年后，就该国未来治理模式达成一致的高度争议的政治进程终于在2015年底结束，制宪会议通过了新宪法。2015年宪法预示着该国政治体制的彻底重组，建立了一个联邦共和国，中央政府将权力和资源下放到七个新成立的省，每个省都有自己的立法机构。新宪法的实施已经在2017年底举行了20年来的第一次地方选举。新宪法带来了卫生系统的重大变化。尼泊尔的国家卫生系统历来是统一和集中的，卫生和人口部为全国提供资源和指导卫生服务。新《宪法》规定，提供保健服务的责任主要由七个新的省政府承担，重要的权力和责任进一步下放到市镇/农村市镇。所有这些都使尼泊尔的卫生系统进入了一个迅速而深远的转型变革时期，从理论上讲，这些变革为更大程度的地方主义和对社区卫生需求的反应开辟了可能性。实际上，国家卫生政策尚未修订以反映新制度。此外，人们担心新成立的省和市政府是否有能力成功地承担起新的角色，也怀疑卫生系统是否“准备好”适应这些变化。向联邦共和国的过渡如何在卫生系统内展开，系统本身如何对改革作出反应。这些问题是我们项目的核心。该项目利用“渐进式政策分析”（PPA）来真实的跟踪这一巨大的卫生系统改革努力，借鉴各级政府卫生系统行动者的经验、看法和专业知识。我们将与联邦、省和市各级的决策者以及社区一级的提供者（初级保健中心工作人员和在农村社区一线提供妇幼保健服务的女性社区保健志愿者）合作。该项目旨在揭示这一范围广泛的不同利益攸关方的看法，并使他们相互对话-在治理和实践层面之间架起桥梁-以查明新系统中可能受到改革进程影响并进而影响到改革进程的系统设计缺陷、交付差距和能力制约因素。研究小组将在建立新系统的关键时期，反复跟踪卫生部门、卫生系统所有组成部分和各级政府的发展和看法。这将使我们能够更好地了解这一转型变化的动态过程。我们将与利益攸关方合作，共同产生与尼泊尔政策和实践相关的新知识，同时也为其他地方的各种学术和政策受众提供知识。

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.