FEATURES NEWS THE RISING NEPAL (DAILY)

By Devi Prasad Prasai

HEALTH care is one of the fundamental human rights of all people. "Health for All" has been remained the popular slogan for last two decades over the world. However, over half of the Nepalese people are deprived of basic and primary health care services. Government as well as Non Government Organisations (NGOs) have made tremendous efforts to improve the health status of the people. Yet, only marginal changes could be observed as the impact of the health care programs. The annual progress reports reveal that the coverage of health care services is still confined within decimal change. Nepal’s health care indicators slightly changed in comparison to the South Asian countries over the last decade. With the beginning of the new millennium, many countries of the world have been moving towards non-communicable and degenerative disease control but the Nepalese people have been suffering from infectious diseases, child bearing and birth problem and malnutrition. Several health sector reviews had been done in the last decade; however only few structural changes have been initiated in the field of health system development. Health system reform remained under the shadow of traditional health care system.

The government’s policy makers as well as external development partners have hardly identified the core problems or issues to be addressed. Sharing the experiences of the health sector reforms of the UK, USA and our neighbouring countries, it is stated that the universal coverage of health care could be achieved after reforms. The UK has achieved remarkable coverage of health care after introducing national health care reform. Bill Clinton, the President of USA got popular by his health care reforms and millions of Americans came under the net of health care. Even from the South Asian experience, the coverage of health care could be improved if the states adopted multi-sectoral holistic approach for health development. In this context, the following reforms are proposed for discussion.

Greater multi-sectoral efforts: The health status of Nepalese people could not be improved by the efforts of Ministry of Health alone, the role and responsibilities of other Ministries like Education, Agriculture, Labour and Local Development are equally important. Awareness and demand-creating work could be done through the Ministry of Education. Similarly, school and community health care programs could be conducted by integrating with formal and non- formal education programs. The Ministry of Agriculture may play vital role to promote the nutritional status of the people. Cites and municipalities should establish hospitals and health care centres in the urban areas to reduce the unmet need. The Ministry of Labour should conduct occupational health care program to prevent the workers from accidents, injuries, hazards and occupational related diseases.

Decentralization: There are about four thousands sub/ health posts, 160 primary health care centres and 70 district level hospitals all over the Kingdom. Health workers constitute over one fourth in civil employees’ population. The optimum use of these health care institutions and health workers could be made, if they are controlled and managed by local communities, Village Development Committees (VDCs) and District Development Committees (DDCs). Participatory management would be the best approach at these levels. Experiences have shown that managers could not exercise the delegated authority because of central intervention and the fear of being withdrawn by the Centre. Therefore, the provision of devolution should be made to shift the ownership from the Centre to local levels. At present, these institutions are under-utilized because of the miss management and lack of ownership feeling at the level of stakeholders. The role of Ministry of Health should be limited to policy formulation, national and international coordination, technical support and monitoring and parental guidance.

Production and distribution of health workers: There is lack of human resource for health development especially in the hospitals in the remote districts and this problem is created by unfair distribution of doctors, nurses and paramedical staff. Over 60 per cent of the doctors have been working only in Katmandu valley and those who have posted in the remote areas hardly spent a year. When they became acquitted to the local health problems of that particular district they are transferred to the other districts. Hence the problems remain as usual. Experience has shown that coverage of health services increases with the increase in the length of doctor’s stay in the district. Existing production and distribution policy of human resource should be reviewed and incentives provided. Rather than transferring frequently, the doctors should encouraged to stay for a longer period.

GOs and NGOs partnership: Both GOs and NGOs have been working in accessible and socio-economically better off areas. Hence, there is an unhealthy competition between GOs and NGOs in these areas, whereas there is virtually no health care provider in remote, inaccessible and under-served areas. There is no regulatory mechanism for NGOs and their performance and costs are hardly monitored. To overcome these problems, NGOs should be encouraged to work in the under-served areas and should offer services to the marginalised and poor people. The role of NGOs should be complementary and supplementary to the national programs as per the needs. A partnership approach should be developed in order to avoid duplication and increasing the coverage of heath care.

Health care financing reform: Nepal is the country which is listed at the bottom of fair financing rank. Over 70% of total health care expenditure is constituted by out-of pocket payment, share of government financing is as low as 18 per cent in the total health care expenditure. There is virtually no health insurance schemes run by the government or private firms. Similarly, there is no other prepaid scheme to cover the poor people. Hence, there is lack of financial resource to achieve the universal coverage of health care. Therefore, social health insurance and other prepaid schemes should be developed to replace the out- of -pocket payment. Moreover, efficiency should be enhanced in allocation and use of resources in the field of public financing.

Equity and social Justice: Program priority should be given to women, children, elderly care and the people who are at the greatest need and are living in the under served areas. Similarly, the focus should be put on marginalized population.

Higher level strong political commitment: We all know, these reforms could not be a success with the commitment of the Ministry of Health alone. Hence, the government and political parties must have strong; action oriented political will for the success of functional health sector reform.

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