Health Federalism : The Role of Health Care Professionals in

Nepal has entered from its unitary system into a new “Federal Democratic Republic State.” The current constitution presents basic health care services as a fundamental right. The Ministry for Health and Population has been providing resources to meet health demands, but managers are wrestling to meet these demands. Persistent disparities between rural and urban and across regions resulted inferior health outcomes e.g. life expectancy in an urban district like Bhaktapur is 71 years, whereas in the rural district of Mugu it is 44 years. The poor health and poor access to health care in the past systems prompted people to seek a different model. Ultimately, all political parties except one have agreed on federalism. The exact number of federal states that are going to be created is unknown. In federalism, all federated states have to assume certain relationships between the locality, the region, and the nation that apply not only in politics but in health care too. Managing changes in health care organization during the transitional period and after restructuring the unitary Nepal into federal states should be carefully planned. In case, if new system also fails to deliver necessary health care services, the possibility of igniting of dissatisfaction, public unrest and even disintegration cannot be ignored. In order to outline a structure and give life to a health care system under federalism, health care professionals need to engage themselves seriously.


INTRODUCTION
The fourth amendment of the Interim Constitution of Nepal, 2007, declared the emergence of Nepal from its unitary system into a new "Federal Democratic Republic State".Part 3, section 16, sub-section 2 of this constitution presents the provision of basic health care services, free of cost, as a fundamental right. 1 As guided by the constitution, the implementation of basic health care services began with free delivery and free drugs (fi xed list) at district hospitals and lower level health care units.However, some in the medical, public health and allied health professions have raised question regarding the long term sustainability of these schemes.
When the envisioned and long awaited Constitution of Nepal is completed, it will almost certainly follow the spirit of the Interim Constitution.I wish to argue that Nepal could adapt some of the best available models of health care delivery in placed in 25 countries with federal system around the world, serving 40% of the world population. 2 In Nepal, life expectancy has increased from 42 years for males and 40 years for females in 1971, to 55 years and 54 years for males and females in 1991, and to 60 years for males and 61 years for females in 2001. 3The Ministry for Health and Population has been providing resources to meet health demands, but managers are wrestling to create the supply meet these demand.
The disparity between rural and urban, and across regions, is still alarming.For example, life expectancy in an urban district like Bhaktapur is 71 years, whereas in the rural district of Mugu it is 44 years. 4The doctorpopulation ratio in Nepal is one to every 18,000 persons on average, 5 while in remote districts it could be 3 to 4 times higher.This refl ects the availability of public health services.
The Human Development Index (HDI) of the United Nations Development Program (UNDP) ranks Nepal as 142 nd out of 177 countries, that is, close to the least developed one. 6How many years will it take Nepal to reach at least 20 th rank in HDI if current trend and pace continues?
Nepal has water towers but, unfortunately, little safe drinking water is available for needy people.Despite having second largest hydro potential resource after Brazil, loadshedding reached a record high of 16 hours a day in April 2009 that crippled daily activities of Nepalese.Nepal has abundant natural resources including medicinal plants, but the reality on the ground is depressing since the country could not utilize its own natural resources for the benefi t of Nepalese.Inappropriate development theories created by unprofessional planning could be one of the root causes of development failure in Nepal that should not continue in future.The poor countries continue to be chronically poor not only due to lack of resources, but also due to poor policy and management.
The concept of decentralisation has been adopted in Nepal over a long period to improve the health care system and to improve the delivery of 'health for all'.However, persistent disparities between rural and urban and across regions resulted from inferior health outcomes.The poor health and poor access to health care in the past systems prompted people to seek a different model.Ultimately, in Nepal, all political parties except one have agreed on federalism.
The number of federal states and their territories should be decided by political consensus at a macro level.On the other hand, the health care professionals should engage themselves in designing a 'health system in federalism' at a micro level.
Here, I wish to argue that Nepalese health professionals have to contribute to formulate appropriate policy and management of health development systems.

FEDERALISM
We still do not know the exact number of federal states that are going to be created for Nepal.However, once the Constitutional Assembly approves the new Constitution of Nepal, scheduled for the middle of 2010, and it comes into action, the existing health structure will be void.
In federalism, regions and states within a country need to share power and resources that could be a threat to the one as an invisible nation.This could create a great challenge to federalism as all federated states have to assume certain relationships between the locality, the region, and the nation that apply not only in politics but in health care too.
In Britain, federalism is often taken as a synonym for the threat of a bureaucratic European super-state.In Germany, the same term is used to describe an ideal of diversity within unity, emphasizing the element of devolution.German health care and social system is appreciated and taught by many universities.But, even within Germany, federalism has many critics.Those on the left of the German political spectrum tend to blame federalism for creating social inequalities between the richer and the poorer Laender (states). 7Within Germany some states have much better economic status than others.The federal system could be a good arrangement, only, if policy is formulated correctly and implemented accurately; and backed with necessary resources.In case, if new system also fails to deliver necessary health care services of appropriate nature, the possibility of igniting of dissatisfaction, public unrest and even disintegration cannot be ignored totally.
Nepal has 75 districts, but not all of them have district hospitals as of now.We are heading towards federalism with an intention to eradicate disparity in health care at all levels.In this scenario, transitioning into federalism, particularly the health sector could be very fragile in the absence of fundamental preparations and adequate homework.If a federal system is not designed and managed properly it could break up, as in Yugoslavia and Czechoslovakia. 8ithout a meaningful fundamental preparation, it will be unrealistic even to imagine having improved health in federalism.The signing of the long awaited Constitution of Nepal by the 601 members of the Constitutional Assembly will certainly not put every component of a health system together in a federal democratic state.
Comparing federal health system is like laboratory where specimen are analysed that enables scholars to understand strengths and weaknesses and also success and failure of others system.The positive points could be tremendous helpful lesson to formulate a federal Dulal.Health Federalism: The Role of Health Care Professionals in Nepal health care model for Nepal.In order to improve own system, policy can be learned from other systems. 9

HOW THE HEALTH CARE PROFESSIONAL COULD CONTRIBUTE?
Every component required for good health care must be considered and formulated in such a way that the health system functions in a concerted way.Who should work on this issue?Enthusiasm from health care professionals should come spontaneously or the government authority should make a mechanism to congregate experts.Active participation for designing health in federalism is the real need of this time.
The Nepalese health professionals have to be involved themselves uncompromisingly in designing a health system.Because they are the front-liners in delivering well-coordinated health care services to the public uninterruptedly under any circumstance.The new system would need to fulfi l the demands of the Nepalese people.
Neither is there any literature supporting X country's federal system as the best nor does any expert do so.Thus, it is hard to say what is best because context of federalism is so fundamentally important that no arrangements are truly transferable.Each federal society must fi nd out the problem and the solution as well.The context is important and every society is unique in important ways, clearly lessons can be learned from others whose societies share certain characteristics and similar problems. 10e federal states and their resources, and the units within the health care organization will be unexpectedly different and complicated over the fi rst few months and even years of their introduction.Therefore, initial discussions on how to establish a federal setup of basic organizational structure for a health care system should begin as early as possible.

HEALTH FOR ALL: A NEW BEGINNING
There are serious concerns whether the health care professionals have been involving in designing a safe, effective, patient-centered, appropriate, effi cient, equitable health care system for the upcoming federalism, based on scientifi c knowledge, or not.Although, few non-governmental organizations are raising attention and organizing discussions sporadically that is certainly appreciable, but not adequate.
Nepal should take the lead by involving its native experts.Those who have strong academic background on the theme and also people with more work experiences in the respective domain should be included.The developmental partners need to be prepared to help us.
The weakness many have felt in the past was that some Nepalese do less homework and ultimately become blind followers of a donor driven agenda where initial plans to produce a 'horse' have resulted in a 'zebra' in many instances.Now Nepalese have to change the history and write a new one that will produce a real outcome.
Nepal is extreme in many aspects like topographical, multi-ethnic and cultural and weather conditions.Entrusting the jobs to Nepalese health care professionals from the respective disciplines would produce better results because the natives would understand the cultural, economic and politics more deeply and sense it better than anyone else.The professionals in the respective domain could contribute immensely in creating a conducive health system within available circumstances.
Probably members of National Planning Commission responsible for health sector should take the lead in involving the academicians, 3-5 fulltime experts from various disciplines (clinicians, nurses, paramedics, public health experts, health policy designer, health economists) and also fulltime experts from various professional councils, associations and organizations, e.g.Nepal Medical Council, Nepal Health Professional Council, Nepal Health Research Council, Nepal Nursing Council, Nepal Ayurvedic Council, Homeopathic Hospital, Nepal Medical Associations, Nepal Nursing Associations, Public Health Association and Association of Private Health Institutions of Nepal.Generally, involvement of those who are willing to work fulltime and meticulously until a fi nal draft is completed would be assets in the projects.These experts should discuss and come up with an evidence-based, and most probable, structure and necessary components including fi nance, human resources, biotechnology.Once states are federated it should be made clear how a federal state's Health Ministry should coordinate not only with the Ministry of Public Health but also with the Ministries of Public Health in different federal states (proposed) (Fig. 1).
In the current organogram, there is only one Ministry of Health and Population, whereas under federalism the number of Ministries of Public Health will be equal to the number of federated states plus a federal ministry of public health.Those federated states will have to work on many fronts: neighbouring federated states, central level and resource management (acquisition), mechanism for quality control and supervision, law enforcement etc.
Here, in order to outline a structure and give life to a health care system under federalism, health care professionals need to engage themselves seriously as

NEED TO BALANCE ALL SECTORS
Health professionals, public health institutions, power of public health police and other suppliers of services (INGOs, NGOs and private sector), their rights and duties should not be contradicted at any point.Health responsibilities of the central government, federated states and lower levels of government in health should be well coordinated, but not escalating ethnic and political tensions with neighbouring federated states and the central government.
Managing changes in health care organization during the transitional period and after restructuring the unitary Nepal into federal states should be carefully planned.It will prevent unwanted confl ict scenario in health care organizations especially in public sector.

CHALLENGE AND OPPORTUNITY
The individual certainly understands how she or he could better work and co-ordinate to deliver service more effectively in current system.Once the new system will be introduced, hardly a very few individuals might know the health system structure and functions in the forthcoming ''Health in Federalism' if health care professionals fail to involve themselves actively in the creating health federalism.Nepal cannot afford lethargy anymore.If everyone focuses on his or her domain, better health in federalism can be realized.System is always dynamic universally.No one can be perfect, but health care professionals collectively could design a health system for federalism certainly better than other professionals.
As a professional you have to work based on the data and evidences, not the feelings.Some professionals including doctors who fall under health care domain may think that health care system designing does not fall within their domain.In global scenario, they are better experienced in care, well informed about health for the population, aware about purchasing capacity of public, Dulal.Health Federalism: The Role of Health Care Professionals in Nepal Figure 1.Projected federal set up of health care organization -Nepal areas requiring quality improvement, accountability of care, professional advocacy, etc. 11 Additionally, they are informed about the terrain, geographical distances, population size, disease pattern and even native wisdom available in different parts of Nepal that could be helpful with or without modifi cation.
Dulal.Health Federalism: The Role of Health Care Professionals in Nepal The health system to be operated should offer good sense of the federal states for which there is no readymade, easy and quick tools for success.There are many and serious issues to address and they require different talents to handle.Possibility of congregating native health care professionals is possible if the government has strong desire and comes in action.

Dulal.
Health Federalism: The Role of Health Care Professionals in Nepal they are the ones holding not only expert knowledge in their respective fi elds but also have abundant knowledge and experience about Nepalese situations.The health care professionals should exercise what the people expect and what is possible under evolving federal states' health care systems in the days to come.