Localizing Health Leadership Meets the Moment for Nepal’s Shift to Federalism
In Nepal, the conversation about localization is accelerating, particularly in the context of technical assistance and capacity strengthening efforts. Abt recognizes the importance of working directly with local partners and putting them at the forefront of program design and decision-making processes. We also see that localization mirrors shifts in power and accountability from the central to sub-national levels as Nepal transitions to federalism.
In 2018, Abt was awarded USAID’s Strengthening Systems for Better Health (SSBH) Activity just as the country began moving from centralized administrative and political structures to more regional and local control. SSBH embraced localization, partnering with municipal governments to enhance management and delivery of equitable, quality maternal, newborn, and child health services and family planning.
Along with SSBH’s health work, the Activity strengthens data-driven planning, implementation, and monitoring of health interventions to advance equitable and accountable governance of the health system at local levels. This ably positioned SSBH-local collaboration during COVID-19, when USAID Nepal provided SSBH with additional funding to support emergency response functions.
Localization and capacity building in SSBH
From the outset, SSBH embodied various aspects of localization, including the following key features:
- Working in partnership with local actors. At local levels, the Activity operates through multidisciplinary technical assistance teams that create strong links between local staff and municipal and health facility stakeholders. The teams provide coaching and mentoring to improve the quality of health services and engage Health Facility Operation and Management Committees in planning, management, and oversight for service delivery, as well as data collection, recording, and reporting. The multidisciplinary teams advocate for use of this data to develop evidence-based interventions during the annual municipal work planning and budgeting process. Finally, team members support drafting of municipal health acts and policies. Their relationships and credibility with local government actors proved to an important platform for the COVID-19 emergency response work.
- Promoting data-driven approaches. SSBH is committed to institutionalizing capacity and practice for analysis and use of health data. The team has created online Municipal Health Profiles to help municipalities visualize and update a range of demographic, health resource, and health-sector performance data. The public has access to the data through links on municipal websites. That enables local stakeholders to understand how the government uses health resources, track progress in relation to health programs and services, and hold local leaders accountable for delivering equitable, quality services.
- Strengthening capacity through differentiated approaches. Municipal governments implement approaches based on locally identified needs and priorities with the backing of the Activity’s consultative assessments, analyses, and reviews of the health system at local levels. Local actors work with the Activity to develop plans for customized technical assistance, including training and data collection. Routine monitoring further supports customized implementation appropriate for each local context.
Additional work and ways forward
Localization is multifaceted and exists on a spectrum. As SSBH nears completion, we have identified a few priority areas where localization in the Nepali health sector is ready for further expansion.
Reaching the unreached. While SSBH has achieved some success in helping to ensure equitable and inclusive delivery of health services, challenges remain in reaching populations that are excluded. The root causes of exclusion differ significantly within and among communities across the country. Those causes include intersectional factors such as gender, caste, ethnicity, religion, physical or neurological differences, economic status, gender and sexual identity, political affiliation, age, and geographic isolation. Customized solutions to increase access to services require better understanding of unique local barriers to accessing health services for unreached individuals and groups.
Involving the private sector. Health systems are not complete until they fully link the public and private sectors. SSBH has supported a “public-private mix” approach to in-service clinical training that includes providing relevant government policies and clinical protocols to private providers, clinics, and hospitals to develop referral networks. The Activity also helps provincial and local governments regulate private sector health services. Going forward, Nepal has ample opportunities to increase collaboration between the public and private health sectors. They include making government-led clinical training, guidelines, protocols, and policy dialogue more accessible to private practitioners, helping standardize quality and consistency across the health sector. Another option is to contract out specialized services to the private sector—where appropriate—to gain efficiency and free up public resources for primary care. The government could engage the private health sector in critical public health programs to enhance government reach. And it could strengthen incentives for the private sector to adhere to routine recording and reporting requirements to enable more robust understanding of population-level health status.
Strengthening the role of provinces as stewards of the health sector. Provincial health authorities still require more resources, greater capacity, and stronger systems to effectively fulfill their role in Nepal’s three-tiered health system. With full responsibility for hospital-level services, provinces have an important stewardship role to play in guiding, advising, and providing technical support for delivery of basic health services at the municipal level. They can help translate national policies into local action and can identify opportunities for cross-learning and collaboration among municipalities. However, without wielding funding incentives, provincial authorities must find their place through the exercise of positional influence, for which they need to demonstrate their value. This is where external development partners can help through capacity strengthening aimed at developing softer skills such as influencing, alliance building, and facilitating change.
Expanding the capacity of municipalities and local health teams by networking them with peers. Ultimately, federalism in Nepal has shifted decision-making to local levels, which supports local innovation and adaptation for municipalities to meet challenges in health service delivery. While this allows for local needs, contexts, and evidence to inform interventions, Nepal can further build overall capacity and quality in the health system by creating more opportunities for peer learning and sharing. We have seen how well this works at all tiers of government as SSBH facilitates semi-annual and annual meetings to share health facility information at municipal, district, provincial, and federal levels. These meetings could be enhanced through further backstopping from partner agencies and other projects. As these levels of government learn from each other, they can work together where it makes sense, collectively advocate for common needs, and better identify how they fit into the overall health system.
