How effectively are social accountability mechanisms being applied in mental health services within the newly federalized health system of Nepal? A multi-stakeholder qualitative study

BACKGROUND: The burden of mental health problems and inequalities in healthcare has emerged as critical issues, in Nepal. Strengthened citizen-driven social accountability (SA) is an effective strategy for building equitable health systems and providing quality healthcare services to all, yet SA in mental health is an under-researched area in Nepal. OBJECTIVE: This study explores changes in mental health service delivery in the re-configured federal health system and discusses the functioning and effectiveness of SA in the federalized context of Nepal. METHOD: This case study research used a qualitative approach to data collection. We conducted Key Informant Interviews (KIIs), and Focus Group Discussions (FGDs) with local stakeholders including people with experience of mental health problems. The audio-recorded interviews and discussions were transcribed and analyzed using a thematic content method. RESULTS: A total of 49 participants were recruited, and 17 participated in interviews and 32 participated in six focus group discussions. From the data, eight themes emerged: Policy challenges in mental health, Governance and service delivery, Tokenism in the application of social accountability processes, Weak role of key actors in promoting accountability, Complaints and response, Discriminatory health and welfare system, Public attitudes and commitment towards mental health, and No differences experienced by the change to a federal system. It was found that existing health policies in Nepal inadequately cover mental health issues and needs. The prevailing laws and policies related to mental health were poorly implemented. There is a lack of clarity at different levels of government about the roles and responsibilities in the delivery of mental health services. Poor intra- and inter-governmental coordination, and delays in law-making processes negatively impacted on mental health service delivery. SA mechanisms such as social audits and public hearings exist within government health systems, however, application of these in mental health services was found poor. Rights-holders with mental health problems had not experienced any change in the provision of healthcare services for them even after the federalization. CONCLUSION: Mental health is insufficiently addressed by the health policies in Nepal, and SA mechanisms appeared to be rarely institutionalized to promote good governance and provide effective healthcare services to vulnerable populations. The provision of more equitable services and honest implementation of SA tools may foster greater accountability and thereby better service delivery for people with mental health problems.