Over the last decade, Nepalis embarked on a historic transition that aims to alter the fundamental structures of government. After 240 years of a monarchy, a devastating civil war, nearly a decade of transitional government, and 11 years of wrestling to build a devolved system of government, a constituent assembly promulgated a new constitution in 2015. As a result, Nepalis cast their ballots in the first open election in a generation in 2017. As many remain hopeful for more responsive governance in the new federal system, questions remain on how longstanding social accountability mechanisms will evolve and adapt, including in response to the COVID-19 pandemic.

Despite the lack of formal local-level government structures over the past 20 years, Nepalis remain resilient and found ways to address their communities’ needs. Since opening in 1988, Pact Nepal has had a front-row seat to this rapidly-changing accountability ecosystem. Social accountability mechanisms and citizen groups emerged in the early 2000s. Even with the challenges of fully operationalizing such structures, Health Facility Operation and Management Committees and Female Community Health Volunteers became important channels that formalized the integration of citizen feedback into health service delivery.

Through projects like USAID’s Sajhedari Bikaas: Partnership for Local Development activity and the current UK FCDO-funded Social Accountability in the Health Sector (SAHS) project, Pact has critically examined and engaged in these questions. We have investigated the country’s health sector and shared our analysis to promote best practices and learning for effective social accountability in the health sector.

Building an Accountability System from the Bottom-Up

In 2020, Pact’s SAHS project synthesized key insights, trends, and recommendations in These included applied political economy analyses, case studies, and situational analyses anchored in primary qualitative data collected from key informant interviews and focus group discussions from seven provinces, 22 districts, and nearly 1,500 respondents. Pact’s analytic work has focused on how the federalization process – devolving power and building municipal governing bodies – has affected social accountability mechanisms in Nepal’s health sector.

The results offer a window into the accountability ecosystem in Nepal and, alongside it, some of the challenges accountability advocates may face around the world, particularly in places undergoing the federalization process. The full report, entitled Leaning into Local: Impact of Federalisation on Social Accountability Processes in the Health Sector of Nepal, explores the impact of federalism on social accountability in the health sector and examines some of the challenges Nepal faces devolving power to the municipal level.

In future posts, we will unpack the findings of the report relevant to social accountability practitioners, focusing on the two main themes that emerged: the (tempered, but persistent) optimism of local government, CSO, and community actors that federalism and investments in social accountability will lead to more responsive governance, and how Nepalis are wrestling with questions of substantive and symbolic inclusion for marginalized groups in the new federal system.

In both cases, it’s clear that making good on the promises of elected governance while addressing issues of marginalization will be the work of generations. The SAHS team has identified priority areas for social accountability advocates that we believe can strengthen the foundation for democratic governance in Nepal and beyond.

• – There are important lessons to be learned about how municipal-level officials learn how to inhabit their new roles and expand their competencies. In particular, the process of “learning by doing” has helped officials tremendously. While trainings were valuable for sharing knowledge, real confidence was built through information exchanges and applied experience. Emphasizing hands-on learning should be a priority for future capacity building efforts.
• – The process of strengthening the knowledge of local leaders is also critical. Newly elected officials may be unfamiliar with the array of programs and services offered by government or may not fully understand how they work in practice or their historical legacy. Building greater awareness of the utility of social accountability mechanisms, and how they can be used to improve service delivery and increase accountability, can increase buy-in from local representatives, and in turn, help institutionalize them.
• – There are clear gaps where more research would be useful. In Nepal for example, public perception data would help practitioners better understand what informs citizen views of federalism and social accountability mechanisms. Additionally, mapping which segments of the population have access to elected officials would also provide critical data to develop inclusive feedback mechanisms

These insights, while valuable on their own, have the potential to drive real change if in the hands of those who can apply it. Equipping Nepali change-makers with knowledge is one of the SAHS’ team’s primary objectives; by taking this a step further and sharing our work with the global community, we hope to empower likeminded practitioners around the world seeking to put citizen voice at the center of decision-making processes.

This blog post was written by Lauren Keevill, on behalf of the Social Accountability in the Health Sector in Nepal Team. 

We welcome your feedback on our reports. Please email Lauren Keevill, Senior Governance Officer, at lkeevill@pactworld.org.