Today we received notice that our paper ‘The impacts of decentralisation on health systems: a systematic review of reviews’ has been accepted by the international journal BMJ Global Health.  This review of reviews was produced as part of the Nepal Federal Health System Project, examining the consequences for the health system of Nepal’s move to a federal government structure. This is a joint project (2020-2024) led by the University of Sheffield and in collaboration with Bournemouth University, the University of Huddersfield, Manmohan Memorial Institute of Health Sciences (MMIHS) and PHASE Nepal. This longitudinal interdisciplinary study is funded by the UK Health Systems Research Initiative [Grant ref. MR/T023554/1] and has resulted in four previous publications. [2-5]
The latest paper is a review which synthesizes evidence generated by previous reviews on the impact of decentralising health system governance on the six WHO (World Health Organization) health system building blocks. We systematically searched for reviews exploring the impact of decentralisation on the health system from five databases. Reviews, both systematic and non-systematic, published in the English language from 1990 to February 2022 were included. Nine reviews, each addressing slightly different questions, contexts and health system issues, were synthesised. They showed that devolution can have positive or negative impacts on the health system and its components. Moreover, impact assessments are significantly affected by complexities surrounding decentralisation and health system concepts: their dynamic mechanisms, inconsistent and often differently operationalized health system and health system component variables, and methodological challenges. For the WHO health system components, more negative than positive impacts were reported. The reviews highlight the importance of closely assessing (pre-)existing (political and non-political) characteristics of countries and their health systems to better understand impacts. This review of reviews concludes that decentralisation can have a negative or a positive impact on the health system and its components; the impacts are shaped by pre-existing country contexts. Generating conclusive and generalisable evidence of the impacts of decentralisation on health systems is challenging. Whilst decentralisation may seek to enhance community engagement and improve the responsiveness of decision-making, it has the potential to create serious challenges to the health system, the manifestations of which are likely to be context-specific.
Prof. Edwin van Teijlingen
- Sapkota, S., Dhakal, A., Rushton, S., van Teijlingen, E., Marahatta, S.B., Balen, J., Lee, A. for the Nepal Federal Health System Team (2023) The impacts of decentralisation on health systems: a systematic review of reviews, BMJ Global Health (forthcoming)
- Wasti, S.P., van Teijlingen, E.,Rushton, S., Subedi, M., Simkhada, P., Balen, J. for the Nepal Federal Health System Team (2023) Overcoming the Challenges Facing Nepal’s Health System During Federalisation: An Analysis of Health System Building Blocks, Health Research Policy & Systems 21(117) https://doi.org/10.1186/s12961-023-01033-2
- Sapkota, S., Panday, S., Wasti, S.P., Lee, A., Balen, J., van Teijlingen, E., Rushton, S., Subedi, M., Gautam, S., Karki., J., Adhikary, P., Marahatta, S., Simkhada, P., for the Nepal Federal Health System Team (2022) Health System Strengthening: The Role of Public Health in Federal Nepal, Journal of the Nepal Public Health Association 7(1):36-42.
- Adhikary, P., Balen, J., Gautam, S., Ghimire, S., Karki, J., Lee, A.C.K., Marahatta, S.B., Panday, S., Pohl, G., Rushton, S., Sapkota, S., Simkhada, P.P., Subedi, M., van Teijlingen, E. for the Nepal Federal Health System team (2020) The COVID-19 pandemic in Nepal: Emerging evidence on the effectiveness of action by, and cooperation between, different levels of government in a federal system, Journal of Karnali Academy of Health Sciences 3 (3): 1-11.
- Rushton, S., Pandey, S., van Teijlingen, E., Subedi, M., Balen, J., Karki, J., Simkhada, P. on behalf of the Nepal Federal Health System Team (2021) An Investigation into the Impact of Decentralization on the Health System of Nepal. Journal of Manmohan Memorial Institute of Health Sciences, 7(1): 3–14. https://doi.org/10.3126/jmmihs.v7i1.43146
The interdisciplinary research project ‘The impact of federalisation on Nepal’s health system: a longitudinal analysis’ was reported in several national media in Nepal last week. This project running from 2020 to 2024 is, funded by the Health System Research Initiative, a UK collaboration between three funders: the MRC (Medical research Council), the Foreign, Commonwealth & Development Office, and the Welcome Trust.
The 2015 Constitution brought federalisation and with it, significant changes to the health system. To understand these changes researchers worked in three provinces where they interviewed 243 stakeholders, at all three levels of government. They also conducted 31 Participatory Policy Analysis workshops at local and province levels. The team includes researchers from Manmohan Memorial Institute of Health Sciences (Kathmandu), and PHASE Nepal (Bhaktapur), and three UK institutions (the Universities of Sheffield, Bournemouth, and Huddersfield). It researchers from the UK and Nepal meet with Provincial and Federal MPs to discuss the interim findings of a federalisation and health study.
News articles appeared in national newspapers in Nepal, both in English and Nepali. The Nepali article appeared in the country’s oldest newspaper Gorkhapali, see copy here! Bournemouth University [Thank you Nathaniel Hobby and Stephen Bates] also publicized our press release on this project online. The journalist Nam Raj Bhatta published an item in the online Nepali-language newspaper NepalHealthOnline on April 13. The main meeting to discuss the interim findings of our project took place on Thursday 13 April an hotel close Nepal’s parliament. The interim results highlight how federalisation of the political system has affected Nepal’s health care organisation. The research team summarized the findings for the invited MPs and local and provincial political leaders, and invited their reflections on the political possibilities and obstacles to moving forward with the development of the country’s health system. The Himalayan Times published the article on top of this BU Research Blog as well as the special interview with the University of Sheffield based PI Prof. Simon Rushton.
Prof. Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal Health
Congratulations to FHSS academics Dr. Pramod Regmi and Dr. Nirmal Ayral who published an editorial yesterday in a scientific journal in Nepal. The paper ‘Experts warn Nepal Government not to reduce local Public Health spending’  was co-authored by Dr. Bibha Simkhada who has just been offered a post as Lecturer in Nursing in the Department of Nursing & Clinical Sciences, she shall be starting with us on November 1st. Further co-authors include FHSS Visiting Professor Padam Simkhada and Dr . Sujan Marahatta, the journal’s editor. He is based at Manmohan Memorial Institute of Health Sciences (MMIHS) in Kathmandu, Nepal. Bournemouth University has a long-standing research collaboration with MMIHS.
The editorial warns about the risks of losing the focus on public health and its wider national and global perspective in the recently changed political arena of Nepal. Since 2015 Nepal has moved from a central state to a federal republic, whereby the seven new Provinces have gained much more power and control in the decentralisation process. Moreover the first local elections for two decades in 2017 meant a lot of new and inexperienced local politicians were voted in. Many of these local people had little prior experience of political processes, governing health systems, the notion of priority setting, running sub-committees of elected representatives, political decision-making at local level, etc. The paper argues that Public Health can easily disappear of the radar. The untrained newly elected representatives with no political experience are most likely to be drawn into proposing and supporting popular measures including developing new buildings, black-top roads, hospitals, etc., rather than measures that increase the local or regional budget for teachers, Continuous Professional Development (CPD) for community health workers, and preventative public health measures in general. Buildings and roads are immediate demonstration to voters that politicians have done something useful, reducing maternal mortality by 2.6% or employing two additional health workers doesn’t give politicians neither the same publicity, nor do such policies have immediate signs of success, and hence are unlikely to be vote winners.
The Journal of Manmohan Memorial Institute of Health Sciences is part of the Open Access publishing of Nepal Journals OnLine (NepJOL) supported by INASP. The editorial also illustrates the kind of work conducted in Bournemouth University’s Integrative Wellbeing Research Centre (iWell).
Prof. Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal Health (CMMPH)
Simkhada, P., Teijlingen van, E., Simkhada, B., Regmi, P., Aryal, N., Marahatta, S.B. (2018) Experts warn Nepal Government not to reduce local Public Health spending, Journal of Manmohan Memorial Institute of Health Sciences, 4(1): 1-3.