Mapping health system resilience in federal Nepal: perspectives and lessons from local government level

Health systems worldwide are vulnerable to both acute shocks, which strain the health system for a relatively short period of time, and chronic stressors, which place persistent pressure on the health system. Given Nepal’s frequent exposure to public health threats, recent transition to a federal structure and systemic constraints, strengthening resilience at the local government level has emerged as a critical priority. We assessed the health system resilience capacities and identified gaps at the local government level to inform later interventions. We conducted a cross-sectional study using a mixed-methods approach in the local governments of Kapilvastu District. Data collection involved: a review of 21 policy and programme documents, 13 key informant interviews (KIIs), and one stakeholder consultative workshop. Additionally, we conducted secondary data analysis focusing on minimum service standards (MSS), human resource availability, health infrastructure, and the incidence of disasters in the study area. Qualitative data and the workshop reflection reports were analysed using NVivo 11, adopting a thematic framework approach, while quantitative data were descriptively summarized using Microsoft Excel. We shared the key results and validated data with health officials in a local government in Kapilvastu district. Local health systems in Nepal encounter both acute shocks, such as frequent episodes of disasters (floods, fires, landslides) and disease outbreaks, and persistent stressors, including an increasing burden of chronic diseases. Although there are some opportunities with quick decision-making and good understanding of the local context among decision makers, the resilience capacity of local health systems is undermined by unclear roles and responsibilities across three tiers of governments, weak coordination, sub-optimal institutional capacity, poor evidence use practices, weak disease surveillance, insufficient financial and human resources and limited financial flexibility. Gaps in medicines and infrastructure were found to reduce public trust and thus the utilization of services. Addressing these issues requires capacitation of local governments to undertake the responsibilities assigned to them, strengthening governance mechanisms, increasing financial flexibility, and improving multi-sectoral coordination. Amidst vulnerability to different shocks and stressors, local governments in Nepal encounter substantial capacity gaps. These challenges originate from unclear roles and responsibilities across three tiers of governments, misalignment between responsibility and capacity, insufficient resources and inadequate coordination across the three tiers of government and various sectors.