Professor Andrew Lee is a Professor of Public Health at the University of Sheffield. He is also Editor-in-Chief of Public Health, a journal of the Royal Society for Public Health (UK). He has extensive experience in public health leadership and management, both in the UK and internationally. His specialist research expertise is in primary care, health systems, emergency management, and public health protection.

Since 2020, Prof. Lee has been a member of a research team studying the impact of federalism on Nepal's healthcare system. This project is a collaboration between Nepalese and UK-based academics. In the meantime, Bal Krishna Sah of The Himalayan Times caught up with Prof. Lee and discussed Federalism and the Health System in Nepal. Excerpts:

Is the federal structure of Nepal moving in the right direction?

Federalization was a political decision. It was a necessary and political solution to the long-standing political problems that Nepal has faced. Is it moving in the right direction, then? This was the course that your elected officials and voters decided to take. So, yes, in that sense. However, federalization is a journey and it will take time for the health system to get to the final destination where it is functioning optimally.

How are our elected officials adjusting to the new system of governance?

They are still grappling with it on various levels. They are still in the process of determining their respective roles and responsibilities. Certain things remain a little hazy and unclear. Additionally, confusion may arise in situations where there is ambiguity, uncertainty, or confusion. That might lead to conflict between the different levels of government. It can create uncertainty as well.

Thus, that is most likely the reason for some of the discontent between the different levels of the system.

I believe there is less confusion within each level, but the health system is a multi-level system, though with three levels at the moment. Thus, those tiers need to work together. Although it is happening, it could be better. The absence of a collaborative culture was, I think, one of the topics that arose again and again during our research workshop.

I, therefore, think that these levels are likely to continue to function independently quite a bit. They have not yet mastered the art of close collaboration. As a result, the system is having difficulty settling in.

How can we make the best use of this system?

I want to be clear: we do not want to tell Nepal what to do because we believe it is a Nepali problem that should be solved by Nepalis. However, we can draw attention to a few key areas where we think action would be helpful, like how we can support the development of capacity at your lower levels to efficiently plan health services.

The second area that could be useful is how to facilitate communication and collaboration between the different levels. The third one deals with data. How do you ensure you collect good data? How do you ensure that you use data so that your decision-makers' decisions are informed by evidence, allowing them to make the best possible decisions?

People are at the heart of all health-care systems. Essentially, a health system is made up of individuals. People are working, seeking care, and providing care and services. I believe that investing in people, in health workers, in human resources for health-and we are not just talking about doctors, nurses, and midwives; there are many different types of health workers, all of whom must collaborate. Media health communication should also be improved to increase public awareness.

How has your research found the coordination and communication between the three levels of government?

More and more research is revealing that healthy systems function best when teams within the system collaborate well. Nor does it concern just one person. Just like in the IPL, the Punjab Kings spent 1388 million Indian rupees on Sam Curran (an English cricketer). But does that guarantee their success? Having a superstar player does not guarantee success in a team game. It is the same with healthcare systems.

The health system is comprised of numerous components, roles, and layers. And all of these components must work together in harmony. They all need to be working together. And when they do not work together, problems arise and they become less efficient.

What distinguishes Nepal's federal system from those of the other countries that have used it for a long time?

Nepal is still a baby when it comes to federalization. Many other countries are further down the road. Just look at Pakistan, Nigeria, or even the United States, which has a few hundred years of federalization history. As a result, it takes time to establish a new way of working and systems that people are accustomed to.

And I think you should not underestimate how difficult this is. This is akin to attempting to rebuild an airplane while it is in flight. You cannot halt the healthcare system. Could you imagine that? Can you imagine shutting down the healthcare system for five years while you try to reorganize it? You cannot do that. People will die.

Many of these changes are taking place while you continue to run services and care for people. It is very difficult.

As outsiders, we find it fascinating to observe, learn about, and witness Nepal's experience and processes. There will also be lessons from Nepal that other countries can learn. So, we believe that this research has the potential to yield significant benefits. The one thing that comes to mind that may differ for some countries-many countries have this-is the previously mentioned diversity. Nepal is extremely diverse in terms of geography, climate, culture, language, education levels, socioeconomic status, rural/urban, and a wide range of cultures. And that diversity makes it challenging. And it is hard. Federalism is challenging. If it were not so difficult, we would have done it already. If it had not been so difficult to solve or strengthen healthcare systems, we would have already done so.

We would have already resolved it. Politicians would have said, "I can do this easily, and I will get votes." So, it is difficult. That is why we have not completed it fully. Moreover, diversity is a strength. As a result, I believe Nepal has the potential to capitalize on its diversity. Then it will have its own lessons for itself, reflecting on what Nepal can do best while also learning from other countries. Even for high-income countries, this is not a project where they can teach low-income countries how to run their healthcare systems. Absolutely not. Nepal has much to teach the rest of the world. Every country can benefit from the experiences of others.