Professor Julie Balen is Chair and Professor of Health Systems and Global Change at Canterbury Christ Church University, UK. She is also an Honorary Senior Research Fellow at the Medical Research Council Unit, The Gambia, at the London School of Hygiene and Tropical Medicine, UK, and a Visiting Professor at Manmohan Memorial Institute of Health Sciences, in Kathmandu, Nepal.

Julie has over 20 years of experience as a global health researcher, instructor, and supervisor, having worked across numerous Asian and African contexts. This includes more than a decade of studying the Nepali healthcare system, during which Julie has published dozens of articles and reports and presented her research findings to Nepali and international academics, practitioners and policy makers.

At present, Professor Julie Balen and Professor Simon Rushton co-lead a long-term study investigating how federalism affects Nepal's health system. Julie also presented findings from her team's research on the impact of federalisation on the health system in Nepal at the 10th National Summit of Health and Population Scientists in Nepal, organised by the Nepal Health Research Council on 10-12 April 2024.

Julie's enthusiasm lies in improving health for those most in need and in fostering personal and institutional capacity building initiatives. She has instructed and trained multiple groups of Nepali academics and students in both the UK and Nepal.

Bal Krishna Sah of The Himalayan Times caught up with Professor Julie Balen on Federalism and its impact on the healthcare system. Excerpts:

What is your current impression of Nepal's healthcare system?

Nepal's health system is in a period of transition. I have been coming to Nepal regularly over the past ten years and I have seen a lot of changes during this time, particularly since the new constitution in 2015 which brought about federalization. This recent change is exactly what our current research project is looking into, as we try to understand the impact of federalization on the health system in Nepal.

When I first visited Nepal in 2014, I learnt that the country's health-care system was rapidly developing, particularly in terms of maternal health where there had been significant progress for over 20 years, albeit from a low starting point. Then, in 2015 the series of major earthquakes set things back for many communities. At that time, together with colleagues from Nepal and the UK, we conducted research on the earthquake's impact on the health-care system. This was a very challenging time for the country because, while the earthquake did not affect the whole of Nepal, it did cause severe damage in the affected areas. The health system was undoubtedly negatively impacted by it.

This was followed by federalisation and then, soon after, the pandemic in 2020 which brought about further challenges. Thus, a number of difficulties have arisen over the last few years. Yet, Nepal's health system is quite robust and it has been able to continue offering services in spite of these multiple challenges. Part of our ongoing work is to help it become even more resilient to such setbacks.

Nepal's health system is also fragmented and this is an issue. We found that the impact of federalism has not been uniform throughout the system - it has strengthened certain aspects of the health system, while also weakening others. Consideration of the system as a whole is crucial because, although the system is made up of different layers and components, each of them are interconnected, relying on one another. For the system to deliver high-quality care, its different layers and parts must all work together as a whole. And if all of these components operate well together, service delivery, which is the primary function of the health system, will be improved.

One of the strengths of the Nepali health system, especially in rural areas, are the Female Community Health Volunteers. They ensure that some basic services are provided even in areas where there are very few formal services available. However, there is also a limitation, as these women are all volunteers. They work very hard to improve access to health but they don't get any money for this and very little training. Imagine being a journalist, or any other occupation, and working for free without training-it would be very tough! So at community level the system really needs capacity strengthening.

What impact has federalism had on Nepal's health system, based on your research and observations?

To give one key example, the overall goal of federalism is to bring services closer to the people. Our research has shown that it has - to some extent, accomplished that, and that is a good thing. However, there is still some way to go with that. Previously, as a unitary system, most decisions were made at the central level in Kathmandu, but now there is an opportunity to make some decisions at the local level - closer to where the need is. This means that solutions are localised and not 'one size fits all'.

However, local leaders and key personnel need to know how to best make and implement these decisions, and this is a new challenge they face, as they are not so used to doing so. In our current project, we are therefore working with these local leaders to help increase their capacity for health system governance, leadership and management. These are critically important aspects of the health system that can still be improved and federalism has made these improvements more urgent.

What are our drawbacks? And how can we mitigate them?

As I indicated before, the system is in a transition phase, which I believe is contributing to some of the current challenges. In our research we have found that during this transition phase, there are elements of the new federal system as well as elements of the previous unitary system operating in tandem. For example, there is outdated or interim legislation that still requires updating, and new policies that have been created but not yet put into practice. This mix of old and new causes confusion, and it creates room for a lack of accountability and poor-quality services amid the confusion. This is very common with any major change, because change usually happens gradually, over time.

Mitigating this is not easy, but we can do so by supporting and fully completing the transition to the new federal system and letting go of the old unitary one. This will offer some more stability and a platform from which to further develop and address new challenges. Another challenge that our research uncovered is that the three new layers of the government-federal, provincial and local-are still learning about how to work best together.

How can cooperation amongst the levels be strengthened?

There need to be more opportunities for the people working at each of the levels to come together. One of the things we have been doing, as part of our research, is bringing representatives from the municipal, provincial, and federal levels together in one room for participatory policy workshops. Many of these individuals have never shared a room before, so bringing them together is key to increasing their communication and helping them build trusted relationships, which are so important for fostering cooperation and working together.

However, beyond just getting everyone into the same room, the real goal is to get them on the same page. This requires a shift in mindset. We have found that although the system has changed to a federal one, the mindset of many stakeholders may not have shifted. So I believe that this is the real challenge now-we are in the same room now, but not yet on the same page.

What were the public opinions or reactions to your research questions about the healthcare system?

All the people we spoke to, for example people who work in or somehow influence the health system in our study sites, have been extremely interested in our work. They have been very engaged. As a result, we have been able to conduct hundreds of interviews and workshops with them. The ethos of our project is that we, the research team members including both Nepalis and non-Nepalis, we are not the experts. We are the researchers, but not the experts. The experts, in this case, are the people who work in and with the health system in Nepal, as they are the ones introducing federalism and working within its context. Similarly, if we were researching a specific health issue, the experts would be those people who live with and experience that health issue.

Are Nepal's policies and directives grounded in reality?

Although our current research does not focus on precisely this question, it is a very important question. We found that many new policies have been created since federalism, yet Nepal has interim legislation in operation that requires updating, and new policies that still need to be written.

But drafting new policies is not so hard; the real difficulty lies in how to put them into practice. The implementation of a written policy is important as, without implementation, the policy is just a piece of paper or electronic document with some text. Thus, the challenge is partly how to translate research findings and reality into policy, and mostly how to translate research-based policy making into action. While new policies are necessary, the process should not end there because, after all, nothing changes if a policy is written down but not implemented. That, in my opinion, is the most critical task.

If I may just pause and bring us back to what I mentioned at the beginning about the system being in a transition period. It's important to remember that this transition goes beyond just the healthcare system-it is the entire political system in Nepal that is transitioning to federalism. Our research has examined the health system, however, other systems such as in the education sector, the environment sector, the transportation sector and so on are also undergoing federalism and should be examined. All of these systems also interact, especially at the local level, and they compete for resources, so we need to better understand them and how they influence the health system.

Furthermore, we must remind ourselves that when systems change we cannot cling to the old version of the system, because that is the one we are attempting to alter and improve. Currently, some parts of Nepal's health system are stuck in the old version. But clinging to the old just makes transitioning to the new more difficult. Changing the old unitary system is a political choice that has been made in Nepal. Nepal wished to change and to bring about something new-in this case federalism. Yet, Nepal may miss the chance to embrace and build the new federal system, if we are too afraid to let go of the old unitary one. New things can be daunting, with a degree of uncertainty, but if we can be bold and brave, we might be surprised at the improvements that come about.