The Makwanpur Model: Making Public Healthcare in Nepal Work

March 11, 2017 marked a turning point in the administrative structure of the Nepali government. The Constitution of Nepal, which had been promulgated in 2015, mandated political decentralization through federalism. Under the previous unitary system, political power had been concentrated in the national capital of Kathmandu. Now, in addition to the federal government in Kathmandu, two other tiers of government were added; the seven provincial governments and the 3,157 former village development committees were consolidated into 744 local units. The local governments’ role was significantly expanded with the intention of giving the nooks and crannies of the nation greater administrative autonomy through increased resource-sharing among the various tiers of the government.

A year later, in 2018, the district of Makwanpur made a landmark decision in Nepali public health administration when it handed over control of the district’s 41 health posts and four primary health centers to its respective municipalities. This head-start in the federalization of the public health sector provided us with a window into this new administrative model’s challenges and opportunities. The Nepal government plans to expand universal health coverage (UHC), so we visited a municipality in this district recently to see whether this new-fledged approach is going to bring the district closer to the goal of UHC.

The Indrasarowar Rural Municipality in the Makwanpur district borders the Kathmandu valley, and is home to the Indrasarowar hydropower reservoir that powers the capital. Traveling only 50 kilometers away from Kathmandu, one can witness the legacy of centuries of political centralization. As per a 2015 study, “only 61.8 percent of the Nepalese households have access to health facilities within 30 min, with significant urban (85.9 percent) and rural (59 percent) discrepancy.” In the remote hills of Nepal, there is little profit incentive to set up private hospitals. Thus, public health posts are integral to providing basic health care to the roughly 18,000 residents of this municipality. However, these remote health posts were in an understaffed and dilapidated state due to decades of underfunding prior to the consolidation of local units. 

Tasked with rejuvenating the municipality’s public health facilities is Mannunath Adhikari, the health officer of the municipality. He told us his job had become much easier since the expansion of the local level. Before, “for every little decision, I had to go to the district headquarters for approval. But these days, I can get approval from within the municipality itself,” he said. Sometimes he had to go all the way to Kathmandu to obtain regulatory approval.