Building understanding of health system resilience in our Nepal learning site – a case study
ReBUILD for Resilience aims to understand and improve resilience capacities, particularly within health systems at the local level. In 2021, the HERD International team began measures to establish a ‘learning site’ in Nepal in order to strengthen a health system that had been shaken by natural disasters, disease outbreaks, and political instability. A process of federalisation had placed responsibility for building the health system in the hands of the municipality. Yet among the stakeholders given this task, both governmental and non-governmental, there were low levels of knowledge of how to assess and strengthen resilience, little understanding of the role of research in system strengthening, and limited experience of being part of research studies. This case study explores the progress made up to early 2022.
What problem is being addressed by this work?
Nepal faces various developmental, political and environmental challenges and ranks as a ‘High warning’ country despite improvements in the fragile states index in recent years. Nepal’s health system was adversely affected by a decade-long civil war from 1996 to 2006, the devastating earthquake of 2015 and the COVID-19 pandemic since 2020. Amidst the fragility triggered by these unanticipated events and long-term stressors related to governance, Nepal federalised and promulgated its new constitution in 2015. Afterwards, the country was politically transformed into a federal democratic republic with three tiers of government: federal, provincial (seven provinces) and local (753 municipalities).
Municipalities are the governments closest to the people and are delivering basic health services. Although municipal offices are undertaking some activities to strengthen the health system and have been tackling challenges arising from natural disasters and epidemics, the concept of resilience is relatively new for government and non-government stakeholders at this level.
However, to understand how to assess and build the resilience capacity of municipal health systems, it is first necessary to have a clear understanding of features of resilient health systems and the interconnectedness of different subcomponents.
What did we do?
We introduced participatory action research in Kapilvastu municipality of Lumbini province through an embedded ‘learning site’ approach. Learning sites allow researchers, communities and managers to co-produce insights and knowledge about health systems and decision-making practices. The overall process of enquiry is emergent within a broad framework and with a commitment to joint ownership, co-production of knowledge and rebalancing of power dynamics. Researchers are embedded in the health system and through their research activities come to understand the daily routines and challenges faced by health managers.
When we started the process, we encountered three core challenges:
1. A lack of a clear and common understanding of the concept of resilience and its subcomponents. This meant we could not comprehensively assess the current resilience capacities of the municipality and thus identify and prioritise areas for strengthening.
2. Municipal stakeholders did not fully understand the importance of research in the process of strengthening local health systems and instead had expectations of financial and logistical support.
3. Stakeholders had little experience of participatory action research and their potential role in the learning site.
Based on secondary sources, we prepared a district profile that covered demographic, socio-economic, geographic and health system related information for the district. This enabled us to become familiar with the various aspects of fragility that were challenging the municipality health system. This was complemented by meetings with local stakeholders. We conducted a stakeholder mapping exercise, identifying concerned stakeholders in the district and municipality and their roles in health system strengthening, focusing on how closely they are working with the health system. This was a helpful step to identify and better understand potential stakeholders for future engagements in learning site activities.
We visited the learning site and interacted with governmental and non-governmental stakeholders to further broaden our understanding about the local health system and prevailing challenges. Before meeting municipality officials, we had a meeting with partner organisations who had been working to strengthen the local health system and mapped the potential expectations of the municipal officials. This was useful in addressing the concerns of the municipal officials whom we met, including the Mayor, Deputy Mayor, Chief Administrative Officer and Health Coordinator. Apart from municipal officials, we also engaged with the Health Office at district level, which is a unit of the provincial government responsible for providing technical support to municipalities inside their district.
To help municipal officials better understand the concept of resilience and research, we prepared and handed to municipal officials an evidence summary in the Nepali language covering the concept of resilience, a learning sites approach and the potential role of the municipality and different stakeholders. This document was also useful to municipal officials in explaining the study to Municipal Assembly Members (responsible for policy decisions at local level) or to other concerned officials.
With the objective of reaching wider stakeholders and harmonising efforts in strengthening the resilience capacity of the local health system, we conducted a workshop involving governmental and non-governmental stakeholders working at district level.
We presented an animation that HERD International developed as an introduction to the ReBUILD project in Nepal (watch that video here), showing how disasters, disease outbreaks, and political and economic crises could impact the local health system. To simplify the concept of resilience and develop a contextual understanding of the issue, we then moderated a discussion where participants shared their experience of responding to COVID-19 (first and second waves), a recent cholera outbreak in the district and other natural disasters in recent years. The discussion was focused on four broad themes: i) Research innovation and use of evidence in decision making; ii) Health workforce management; iii) Resources (physical infrastructure and financial resources); and iv) Leadership and governance.
We then made a brief presentation showing the ReBUILD resilience framework in the Nepali language and explained how different issues/challenges they shared are interconnected, and how participatory action research could be useful in addressing similar challenges in future outbreak/disaster responses.
Multiple rounds of consultation with stakeholders, brain-storming workshops and communication products such as project briefs and videos contributed to developing an understanding of health system resilience among stakeholders.
Based on the interactions with the municipality officials and the Health Office chief, we can see that they have developed a broader understanding of resilience, the features of a resilient health system, its components and interconnectedness.
On the basis that health system resilience is a constant process of improvement, they pointed out the need to continuously document their learnings and reflections in the future, and hoped research could serve this purpose.
Although our new partnership is different from their initial expectation of logistical and financial support, stakeholders reported that the research and learning site could be useful in enhancing their future responses to different forms of shocks and stressors and expressed their commitment to the study.
Subsequently, the municipality provided approval for the study and officially agreed to embed our field researcher in the municipality office, who is providing technical support throughout the research process. The municipality further agreed to implement actions for strengthening their local health system with support from HERD International through a co-design approach.
Image: A HERD International participatory action research workshop with stakeholders in Kapilvastu municipality, Lumbini province, Nepal