HERD International, Kathmandu, Nepal.
Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
BMC Health Serv Res. 2024 Apr 4;24(1):428. doi: 10.1186/s12913-024-10755-0.
The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments.
We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation.
In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources.
The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.
COVID-19 大流行考验了全球卫生系统的弹性能力，并突出表明需要了解不同国家背景下弹性的概念、途径和要素。在这项研究中，我们评估了尼泊尔应对 COVID-19 的卫生系统反应，并审查了各级政府（包括各级政府之间的动态互动）的政策制定、沟通和实施过程。当 COVID-19 袭击尼泊尔时，该国正处于联邦化改革的早期阶段，角色明确和执行职能的能力是主要挑战，特别是在国家以下各级政府。
我们采用了横断面探索性设计，使用混合方法。我们对 2020 年 1 月至 12 月期间为应对 COVID-19 而出台的所有政策文件进行了案头审查，并在 2021 年 1 月至 3 月期间在三级政府通过 22 次关键知情人访谈收集了定性数据。我们在蓝毗尼省有针对性地选择了两个直辖市进行数据收集。我们的分析基于我们的研究项目“重建韧性”制定的一个韧性框架，该框架有助于通过吸收、适应和转变来了解卫生系统韧性的途径。
在新建立的联邦结构中，利用了现有的应急响应结构和计划，但在权力下放的系统中尚未经过测试。联邦政府有效地领导了政策制定过程，但几乎没有让国家以下各级政府参与。由于联邦制度的新颖性以及由此产生的缺乏经验、角色混淆、地方一级管理能力不足和治理结构不足，地方政府无法展示弹性能力，再加上人力资源、技术和财政资源有限，情况进一步恶化。
研究结果强调了强有力和灵活的治理结构以及加强国家以下各级政府有效管理大流行病的能力的重要性。研究从尼泊尔的经验阐述了有助于卫生系统弹性能力的关键领域和途径。我们总结了可应用于其他脆弱和易受冲击环境的经验教训。
