Addressing the challenges to health sector decentralization in Nepal: an inquiry into the policy and implementation processes.

The objective of the study was to analyze the status and explore the challenges to decentralization policy implementation in Nepal. Thirty seven key informants rich in experience and knowledge, seven focus group discussions, observation of six health facilities and analysis of about 25 key policy documents provided the data for this study. The study identified the challenges to the implementation of decentralization reforms in the public health sector as: (i) centralised and weak management and programming practices of the government; (ii) weak legal and institutional framework; (iii) conflicting policy objectives; (iv) lack of implementation strategy; (v) poor financial and human resource management system; (vi) lack of adequate preparation for managing the reform; (vii) weak capacity at all levels; (viii) political instability. It was revealed that the implementation of the policy in Nepal was extremely poor as many of the important policy measures were either never initiated or they were only partially implemented. The challenges lie both at - policy design and implementation phase. Clear policy objectives, appropriate structure, sound planning, financing and human resources policy, adequate capacity, responsive information system, defined service packages, active participation of stakeholders and a conducive socio-political environment are considered imperative for successful implementation of the policy. Preparation for managing reform implementation at national and district levels is prerequisite for decentralization to work. Pushing for decentralization in a politically fragile environment may rather lead to further fragmentation, instead of strengthening government legitimacy.