Health system decentralisation in Nepal: identifying the issues

Purpose – The purpose of this paper is to describe and discuss policy analysis in Nepal and review the wide range of choices feasible in decentralisation decision making. Design/methodology/approach – In this paper an iterative qualitative method was developed and used in the research, which consisted of focus group interviews, key informant interviews, document analysis, including descriptive statistics, and analysis of the policy context. Participants in the research reflected the urban/rural mix of districts and the geography of Nepal. Analysis combined transcribed interviews with findings from document searches and analysis of the policy context. Coding was pre‐determined during the training workshop and further codes were generated during and after the fieldwork. Findings – The paper finds that Nepal is in the process of decentralising public services from the central level to the local level, particularly to local bodies: District Development Committees (DDCs), Village Development Committees (VDCs) and Municipalities. Key contextual factors referred to are the overall structure of decentralisation, the social context of poverty and the political instability leading to a fluid political situation characterised by political tension, armed conflict, controversies and agreements while carrying out the research. The key issues identified and discussed in the paper are the policy process leading to decentralisation, the organisational structure and tension in the proposed system, the systems of resource generation, allocation, planning and management and lastly the forms of accountability, participation, public‐private relations and collaborative strategies. Originality/value – The paper discusses the challenges faced in conducting such a policy analysis, the broad ranging and unremitting nature of the decentralisation process, and the contextual setting of the process of change.