4073.0 Opportunities and challenges of federalism in the implementation of the package of essential non-communicable (PEN) disease interventions in Nepal

Session: Chppd Poster Session 3 - Student Research II

Program: Community Health Planning and Policy Development

Time: 10:30 - 11:30 AM

Presenter:

Donna Spiegelman, ScD

Abstract

Background: In 2015, Nepal transitioned from a unitary system to a three-tiered system of governance - federal, provincial, and local. The advancement of federalism in Nepal empowered the provincial and local governments, creating several opportunities for the health system. But the structural reform related to federalism also led to multiple challenges in implementing the national programs.

Objective: This study analyzes the opportunities and challenges of federalism in implementing the Package of Essential Non-communicable Disease Interventions in Nepal.

Methods: Between April 2021 and September 2021, we conducted 23 key informant interviews (KIIs) and 47 in-depth interviews (IDIs) with health service providers directly involved in PEN program implementation. We purposively selected the participants and conducted interviews in person, via phone calls, or via Google meetings. We used a semi-structured interview guide that captured the opportunities and challenges through the lens of the World Health Organization’s six building blocks of the health system. All interviews were audio-recorded, transcribed verbatim, coded using a codebook developed by the inductive-deductive method, and analyzed using a thematic approach using the Dedoose software.

Results: The key challenges of federalism to implementing the PEN program include: i) inadequate PEN-trained staff due to staff adjustment, ii) unavailability of NCD services in primary healthcare facilities, iii) poor recording and reporting of NCD-related data, iv) inequitable distribution of medical supplies, v) ambiguity of roles and responsibilities within the three tiers of the federal government, vi) poor monitoring supervision for the PEN program, and vii) high workload among health service providers at primary healthcare units. Despite some challenges, federalism gives rise to several opportunities for the local government through improved budgeting and decision-making. As a result, some primary healthcare facilities have increased the supply of medicines and resources for PEN service delivery.

Conclusion: Federalism creates several opportunities for the local government to work closely with healthcare workers and NCD patients at the primary level. Effective mobilization of human resources, medicines, and equipment and improved coordination between three levels of government would help in the smooth implementation of the PEN program in Nepal.

Public Health Implications: Lack of PEN-trained staff in primary healthcare facilities and poor coordination between different levels of government are the pressing challenges related to structural changes of federalism. The government should outline clear roles and responsibilities for all government levels and provide PEN training to areas that lacked trained human manpower.