Mela, Mobile and Matadan (Election)

Mela is the centerpiece of Nepali rural peasant life. While Mela conjures up notions of a celebratory event in the urban dictionary, it has a distinct rural meaning. Once able-bodied men and their well-tended oxen are done doing the crude work in the fields, seeds soggy with hopes and livelihoods are planted. These seeds burst out into the wild world, oblivious to the whims of the nature, and aspirations of their planters. They have to be taken care of. Weeds need to be removed, fertilizers must be applied, soil might have to be heaped up around the plant; each crop has its own specific demands that need to be met before able-bodied men and their well-tended oxen will again storm the fields to deconstruct this whole exercise reaping the outcomes of the toil. Those work days between these pitches of masculine contributions are the Melas. Participants of Melas are almost entirely women. They start after the sun reaches some degree of brightness until close to the sunset; modifications dictated by seasons. As these women work, they chat, they might even sing together. They are not seeking private space to concentrate upon certain task, they are looking for each others' company to dampen the monotony and physical pain of manual labor that might assert with silence. It forces this workday to be a social endeavor. They exchange gossips, news, information in the process.

These women do not pull out a calendar and plan out when they will gather for Mela is whose fields. The schedules are the outcomes of mutual convenience. It's a fluid process. They talk with each other and dictated by availability, weather and convenience, Melas happen. On a recent visit to village I learned that these days they do most of the coordinating through mobile phones. Everyone in village has mobile phones. Earlier, rural life demanded of cash for salt, sugar and spices. To the list has been added mobile phones. Everyone must have it; they find ways to finance them. But how did these women dial the numbers to call? Because, remember, many of these adult women are illiterate. Literacy rate for adult Nepali women was meager 17% in 1991 and 34% in 2001. Rural women are obviously likely to fare poorer than these average statistics.

I learned of how one woman, who did not recognize the numbers in the dial pad, placed her phone calls. She had asked a youngster to assign pictures to common phone numbers that she needed. So when she had to call, let's say Saili, she would find an elephant; for kanchii she would fetch butterfly using the scroll key and Hira didi would be an ant.

That is the ingenuity of the rural women. Deny me numbers, I will find pictures!

That is also the ingenuity of the bottom rung in the power structure of this unjust society. This country has pushed the powerless to extremes of repression, indignation and depravity. And in turn, the powerful have a tendency to see themselves as quite distinct, "superior" and "sophisticated" than the powerless common folks. However, the truth could not be farther. The powerless in this society do not speak their language but they know what is good and they know how to make that "good" work. They might not know the numbers in the keypad of a mobile phone but they will find ways to make that phone place the desired call. Unfortunately, however sophisticated the languages of our elites sound, we have yet to see them make things work. It would be a mistake to think that the powerless in this society are somewhat fooled by the sophisticated styles and languages of the power holders. They understand it in their own terms that are visceral and crude: less prone to entanglements of falsely sophisticated languages.

It is not hard to understand the results of these elections if we understand that a large majority of the voters are these common, powerless folks who might be illiterate but not ignorant. 

Health Care in Federal Nepal

In the previous posts we looked at the declarations on health care in the manifestos of four major political parties. There is one commonality that I noticed: all of them want to ensure universal access to health care and especially to the most vulnerable amongst the Nepali citizens. It is a great political consensus to a great cause. We should be grateful to the political parties for this commitment. However, when it comes to specifics of how they are going to achieve it, we are handed a rendezvous with a toddler who happened to gulp down a full glass of his dad's whiskey. While the political commitment to universal access to health care alone is quite a big achievement for the Nepalis, I think, it is still important to debate some of the issues that are largely political concerning how universal access is achieved. I don't know when the proper opportunity for that would be. Because, in all likelihood, even if mechanisms are somehow worked out for universal access to health care it will be devised by experts from WHO, GIZ, DFID, USAID.. with some interspersed odd statements to accommodate outlandish comments from Nepali counterparts (perhaps some bloated bureaucrats). I allow this cynicism about our bureaucrats to run free here because we have rightly lost trust on any of our power holders. Their distance from us, our livelihoods, our problems, our plights is so great that we live in entirely different worlds. They see us as slaves to be tamed, we see them as bloated fat cats to be despised. Enough!

Anyways, this cathartic exercise aside, it would do good if some of the specifics of implementing universal health access enter a reasoned public debate because the health care system will be one of the most important part of our collective society. Besides, any chance of success of the policies devised will depend on how much the public owns the idea.

I was involved, a little while back, on an exercise of dreaming about new health care system for federal Nepal. After discussion with a few friends, colleagues and mentors I had drafted a sketch the primary intent of which was to be used for discussion and debate (not a ready-made prescription). I would like to put it up here since we have indeed invested some ink (or keystrokes!) on this issue in the premises of upcoming election. Any criticisms or comments would be highly welcome.

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Health Care in the Federal Structure of Nepal

Nepal’s history of modern health care is short. Scattered health care facilities started being established during the Rana period (1). But these were dependent on the goodwill of autocratic rulers. A short exercise of democracy saw a start of planned health care system development during 1951-1963 which expanded during the Panchayat period as well. A massive expansion of medical colleges and health care institutions started after the democracy in 1990. As it exists now, health care services in Nepal are delivered by an ill-defined mixture of public hospitals, private for-profit organizations, non-governmental organizations, medical shops, ayurvedic and traditional practices. Some successes have been impressive, one particularly worth mentioning is an impressive reduction of childhood and maternal mortality despite an ongoing decade long conflict (2). The credit for this achievement is awarded to the community engagement through Female Community Health Volunteers (FCHVs). But the state-of-affairs, in general, remains poor. Out-of-pocket expenditure accounted for 55% of the total health expenditure in 2006 with government and external development partners spending accounting for the rest (3). The poorest quintile spent 2.4% of household budget in 2008 on health care which turns out to be USD 0.45 per person per month (4). Furthermore, the patterns of diseases are changing. Non-communicable diseases account for a majority of the deaths in Nepal and are projected to grow further (5). These diseases are chronic in nature and demand for a long-term care and monitoring which drain the resources of the patients. In our country where the majority of the cost of health care is borne by out-of-pocket spending this carries a potential to impoverish the population. It thus creates a vicious circle where poverty predisposes to ill-health and ill-health further impoverishes the population.

We are thus at a juncture where the question of addressing the health care issue is central to the overall development and stability of our society. Even our short history of modern health care offers examples of successes and failures upon which we can draw lessons. In addition, we have to learn from the world experience with an open mind to draw the right conclusions.

This document attempts to envision a health system for the future Nepal.

1.       Defining health for Nepali health care system:

In 1946, World Health Organization defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Transformative as it was for its time, its absoluteness is increasingly being recognized as a limitation. A proposed alternative definition of the health is “an ability to adapt and to self-manage.”(6)

We recognize this debate and lean towards the practically achievable aspect of the notion of health which can guide the philosophy of national health care system. Implicit in this positive definition of health is a state of suffering that happens with the lack of health. It is this suffering that concerns our philosophy of health care in Nepal. Most of the times, these sufferings will be easily recognizable. At other times, it may not be as clear. We recognize that our responsibility lies with acting effectively when the state of suffering is clear and build a genuine mechanism for debate and solutions when they are not as clear. 

2.       Health as a moral responsibility of the nation:

Interim constitution of Nepal 2007 mentions, “Every citizen shall have the right to get basic health service free of cost from the State as provided for in the law.”  While it is indeed appealing to endorse health care as a fundamental right, it unfortunately does not guarantee an effective service.  An obvious question is: what is basic health service? When these decisions are being made based on the rights based approach an empathetic element to health care gets sidelined. We believe in a better society which believes in a moral obligation to help those suffering within the society. We thus believe that it is the moral responsibility of the nation to provide health care services that tends to the suffering of its people.

3.       Health as a central issue in development

In our struggling economy, changing disease burden carry a potential to impede the economic development especially because they affect the productive segment of the population (7). More importantly, these diseases appear as markers of social pathologies. Why someone gets sick is determined by factors that extend beyond the biological processes. These are called social determinants of health and play a large role in disease predisposition (Figure 1)(8). The factors like social and political context, social position determine the health and well being. A child’s chances of living, having diseases and dying of diseases are largely different if she is borne in remote Jajarkot or in urban Kathmandu.  Furthermore, once someone gets the disease the outcome for that person is determined by many social factors including access to health care, affordability, quality of health care institutions, trust and relationship with health care institutions. 

Any effective strategy to address the health issues needs to address the social, political issues and thus spans across multiple developmental sectors. Health of the society thus reflects the social development of that society. Given this direct link, we view health as a central issue to the development of our nation.

4.       Guiding principles for the health care services delivery structure

Guided by the moral obligation to tend to the suffering of her people, these will be the principles for the design of our health care systems:

•           Care of the poor, destitute, marginalized, disabled in the society will take a precedence with an overarching goal of universal coverage, equity and fairness
•           Government will be the payer for the health care and will be committed to ensuring financial sustainability
•           Bureaucracy will be lean but efficient and accountable
•           Health care delivery will be decentralized
•           Patient safety and quality of care will be prioritized
•          Communities and individuals will be empowered in health care delivery structures
•           Involvement of women will be emphasized in health care delivery
•           Systems will be able to constantly learn from outcomes and progress

5.       Identifying the health priorities for the federal states

a.       Federal government’s role

Federal government will be fully responsible for the primary health care. A federal mechanism that includes representatives from the federal government, state governments, public health experts, clinical experts and civil society leaders will be established to recommend the elements that will be covered by the primary health care based on the national population health priorities.

In addition, population-health will also be a primary responsibility of the federal government. It will lead the population health departments of the state governments.

b.       State government’s role in identifying health priorities

State governments will have significant role in designing the content of the primary health care. Beyond that, state governments will have an unlimited flexibility in adding services to their state health programs in addition to what are already supported by the federal government.

6.       National health care database

The state governments bear the responsibility for maintaining a state level health database system specified by the federal government. The federal government will establish a national health care database by obtaining the required elements from state government databases.

7.       Health care service delivery

a.       Model of health care system

The health care system will be publicly funded (by federal government), administered by federal and state governments and health care services delivered through private providers.

b.       Financing of health care

A universal coverage of essential health care services will be provided. However, financial sustainability of these efforts will be given an utmost priority. A task force will be created to recommend a model of health care financing that would be applicable to our context.

c.       Organization of health care

The federal government will be primarily involved with financing, oversight and price control. The state governments will be involved with the administration of health care delivery structures at state level. Health care services will be delivered primarily through private providers who are paid by the national insurance scheme administered through the state government. This will include emergency care, hospital care, long-term care, outpatient care, and prescription drugs. However, primary care services and population health services will be mandated to be run by the state governments.

d.       Oversight of the health care system

Federal government will establish mechanisms to regulate prices (essential drugs, technologies). It will also create mechanisms to monitor corruption in the use of universal health coverage. Federal government will also create a national accreditation mechanism for health care institutions.

e.       Community engagement

Community engagement will be given a high priority in the delivery of primary health care services. The work done by FCHVs, outreach clinics and immunization programs has made a significant change in the health outcomes of our country. The community’s role in these efforts will be expanded. Individuals with high-school level of education will be recruited from the communities, given short-term trainings to deliver primary health care services including immunizations, behavioral risk factor counseling, basic health screening services, maternal and child health care services.

f.        Human resources

It will primarily be under the purview of the states to develop human resources for health. At the federal level, appropriate support mechanisms will be created to help states develop their human resource needs.

g.       Intersectoral collaboration

As the determinants of health span across multiple sectors, it is important to get multiple sectors on board to effect a meaningful outcome. All the policies at the state level will be mandated to undergo a “Health Impact Assessment”. A guideline will be developed by the federal government on performing health impact assessment. If concerns are raised from this assessment, department of health at the state level will provide technical assistance to address the health concerns related to these new policies.

h.       Implementation and monitoring

State governments will have a primary role in the implementation of the health care programs. It will be involved in administering the national health insurance scheme at the national level, organizing primary health care, coordinating and working along with federal government for population health issues, creating environment for the private providers to open up health care delivery structures. States will be required to create their monitoring mechanisms for the implementation of these programs and also the outcomes.

i.         Accreditation and monitoring of health care delivery institutions

In order to ensure basic minimal quality of care and consistency in care across the nation an independent national accreditation board of health care institutions will be created. This board will be autonomous that functions on an evidence-based objective accreditation system.

j.         Safety of health care: drug safety, patient safety

An independent drug safety board will be established that will monitor the safety of any new drugs or medical devices being introduced to the country. In addition, this board will investigate any issues related to safety of drugs and devices within the country.

Patient safety issues will be addressed at the state level by the regulation and licensing authority of the state.

k.       Non-allopathic practices

Non-allopathic practices will be allowed in the country. However, unless they have undergone scientific evaluation on efficacy and safety they will not be reimbursed by the federal government.

8.                   Ethics of practice of health care

We believe that the profession bears the moral responsibility for an ethical practice of health care. Accordingly, the violations of ethical conduct in the profession should be first taken upon by the profession itself. For this, ethical boards will be created in each federal states and a central ethics board. The representatives in these boards will be elected by the members of the profession. These boards will be required to have utmost transparency in their conduct of operations.

Bibliography

1.        Marasini B. Health and hospitals development in Nepal: past and present. Journal of Nepal Medical Association. 2003;42:306–11.

2.        World Health Organization. Global Health Observatory [Internet]. [cited 2013 Jan 5]. Available from: http://apps.who.int/gho/data/?theme=main#

3.        Government of Nepal. Ministry of Health and Population. Nepal Health Sector Programme- Implementation Plan II(NHSP-IP 2). 2010;

4.        Nepal Rastra Bank. Household Budget Survey. 2008;

5.        NCD Country Profiles, 2011 [Internet]. [cited 2013 Jan 5]. Available from: http://www.who.int/nmh/countries/npl_en.pdf

6.        Huber M, Knottnerus J a., Green L, Horst HVD, Jadad a. R, Kromhout D, et al. How should we define health? British Medical Journal. 2011 Jul 26;343(jul26 2):d4163–d4163.

7.        World Health Organization. Global status report on noncommunicable diseases. 2010.

8.        CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. World Health Organization, Geneva.; 2008.

Health Care in UCPN-Maoist's Manifesto

My Scoring: (Please see my earlier blog for the scoring system)
- Relevance: 3
- Coherence: 2
- Practical Achievability: 1

Declarations on Health Care in UCPN-Maoist's Manifesto: (My translation from Nepali)
Access to health care will be established as fundamental right and free basic health care will be provided to all Nepali citizens. People of Karnali and similar other backward districts, marginalized and endangered ethnic groups, children below 15 years, elders above 70 years, people below the poverty line, individuals who have been injured or disabled during their involvement in people's war or other political struggles will be provided all types of health care for free and all women will be provided free maternity-related health care. All Nepalis will be insured for 50 major illnesses. Although World Health Organization recommends 2.3 health workers for every 1000 population, we have only 0.31 health workers for every 1000 population; especial focus will be placed to bridge this gap. When producing health care workers, appropriate priority will also be placed in producing health workers related to Ayurveda, Homeopathy, Yunai, Acupuncture, Acupressure, Naturopathy and Yoga. At least one health care facility will be established in each VDC and "One VDC one doctor" production will be given especial priority. Especial facilities will be arranged for doctors serving villages and remote areas. Mental health care will be integrated with health care. To ensure access of general population to mental health services, it will be considered part of basic health care. Discrimination, violence, social exclusion for individuals with mental illnesses will be considered crime, and legal equity and secure environment will be created for those with mental illnesses. Also including the private sector, modern fully-equipped hospitals will be established to attract foreigners for health care and to discourage Nepalis from going overseas for health care.        

My Comments:
There's a repetition of many of the issues we had already discussed in other parties' manifestos. I will very quickly brush through the document. 

They commit to ensuring access to everyone and emphasize priorities to the most vulnerable ones which is very welcome. But they put out the candy of "free." As I had mentioned earlier, there can be no free health care. It is very naive (and damaging) to talk about "free" health care; it raises false expectations in people. The document has used this populist tool liberally. 

For universal insurance they pick "50 major illnesses." How did they come up with this number? The main question is, can you ever pick illnesses that you want to insure? The relevance of tuberculosis for someone dying of cancer versus a young laborer, the sole breadwinner in family, is entirely different. It is naive to think that you can pick diseases to ensure a fair health care system. 

UCPN-Maoists also take a dip in the mud of alternative medicine (I have already discussed about the inherent problems with this fascination in the comments of MJFN's manifesto). 

"One VDC one doctor": It might be a thing that could be discussed during production of manpower but is wasteful if that is their plan of distribution of doctors. It is completely wasteful sending manpower that requires such long training to meet the local health care needs. We have to send health manpower commensurate with the health care needs. It might be rather damaging if we get indulged in this exercise of trying to send doctors because  doctors will not go there and in the mean time we lose the time/resources that could have been used to prepare and send appropriate health workers to VDCs. 

They have spent a few sentences on mental health which is very appreciable. 

Then, they talk about the proverbial "health tourism" and "private sector." I have discussed about it before. And my message is the same: if we are able to build something that is so good, you parties (the parties that claim to be fighting for the rights of the poorest, destitute and most vulnerable amongst us) should be bringing policies that would try to channel this good to the most needy amongst us: not to the medical tourists or "Bangkok Biramis."

In summary, UCPN-Maoists have thrown in a lot of pseudo-technicalities in their health care section. On deeper analysis, however, they are largely naive and populist. Their commitment to ensuring access to the majority of the citizens is appreciable. 

Health Care in MJFN's Manifesto

My Scoring: (Please see my earlier blog for the scoring system)
- Relevance: 4
- Coherence: 4
- Practical Achievability: 2

Declarations on Health Care in MJFN's Manifesto: (My translation from Nepali)
- Access to health care is a fundamental right of every citizen. Following policy will be adopted for the development of health sector: conduct primary health care under the local government; implement preventive, curative, promotive and rehabilitative policies for health care; encourage production of doctors and specialists within the country; arrange necessary mechanisms for production of quality medicines and equipment within the country; give emphasis to yoga, naturopathy and traditional treatments; promote Ayurveda, homeopathy and yunani treatment methods; make local health care facilities and maternal and child health more effective; end privatization and commercialization of health care; ensure health care access to ethnic minorities, those below poverty line, pregnant women, elderly, disabled individuals and orphans; develop a scientific mechanism to monitor quality of medicines and ban the production, import, use or distribution of quality less medications; in madhes, based on the population, upgrade or establish health facilities, determine the number of health workers, medications and equipment to be sent; ensure proportional representation of madhesi doctors and health care workers in the departments and divisions of health ministry; establish fully-equipped hospitals in each district; start a nation-wide campaign against killer diseases; ensure clean and purified water in each VDC; take appropriate measures for garbage management; start rural primary health insurance with local involvement and cooperatives.     

My Comments:
First off, they seem to have consulted someone with a knowledge in public health based on few of the terminologies used in the document. Let's look at some of the individual declarations. 

They commit to ensuring universal access to health care, which is a welcome statement. But it is an easy statement, it's hard to contest. Main question will be is there anything in their document that would give a sense of how they are going to achieve it? Nothing convincing. 

There is a consistent theme that they want to empower local government in the delivery of health care. However, they have committed to universal access. Local governments will be very widely variable in their capabilities, resources, commitment, assessment of problems, needs and priorities. So it is hard to imagine how a nation could achieve universal health coverage by asking health care to be run by local bodies. The document does not give us any idea about how they are doing to bridge the local involvement and the nation-wide goal of universal access to health care. 

They touch upon multiple aspects of health care delivery including human health resources, supply and quality of medicines and equipment, and health care facilities. This is a very appreciable thing in the document that it looks at the health care sector comprehensively. 

The statement about alternative medicine is very contentious. If the financing of health care is going to be risk-pooled, including alternative medicine becomes very tricky. For the things that have been scientifically validated within the alternative medicine practices, for example, yoga and breathing exercises in the context of psychological issues, it is easy to incorporate. But let's say you want to give "Yogaraj goggle" for rheumatoid arthritis. With no scientific evidence on effectiveness, side effects, risks and benefits, it becomes a mess. Let's say another Kabiraj claims that his concoction is far superior to "Yogaraj goggle", when the government has to purchase the remedy, which Kabiraj should they prioritize and on what basis?

I very much appreciate how they have identified vulnerable groups categorically and declared that they would prioritize ensured access to them. 

Another contentious issue in this documentation is ethnic representation in ministry of health and its branches/divisions. It is certainly a part of a larger debate. And this political party is explicitly based on ethnic identity. It should be a separate discussion. But this is where I stand in a nutshell: Madhes and madhesis have been utterly, unjustly and dehumanizingly treated by the rulers of Nepal in its larger historical context. Madhes' conscience carries that historical hurt. And it is extremely important for Nepal to right its historical wrongs. But I think it is an utter blunder if we take just one identity of madhes (ethnicity) to solve the actual problem which has many more facets to it. Reservations of positions at an institution is an example of the exercise using just one facet of ethnicity to solve the larger problems of madhes and madhesis. It might seem reasonable on the short-term but it institutionalizes the identity of madhes and its problems just based on ethnicity which, I think, on the long run would cause immense harm. Madhes and madhesis deserve much more than these populist ploys and candies. 

The document mentions about primary health insurance. For it: the devil lies in the details. We don't find those details here. 

Overall, I think it is quite a coherent document. It dreams big. Lets leave it at that because I dare not interrupt the dreaming when that has been pretty much what we have been doing for a long time. 

Health Care in Nepali Congress's Manifesto

My Scoring: (Please see my earlier blog for the scoring system)
- Relevance: 2
- Coherence: 1
- Practical Achievability: 1

Declarations on Health Care in Nepali Congress's Manifesto:(My translation from their document in Nepali)
- Nepali Congress's health sector programs will be conducted with the main aim of "Reliable, Quality and Accessible health care to all."

- The main aim of the health policy will be to ensure that no Nepali citizen living within the boundaries of Nepal dies prematurely because of treatable illness. 

- Our plan is for the government to provide equitable, socially accountable and transparent, and world-class health. There will be main policies that will direct short-term health plan, long-term health plan, national health report, safe motherhood and maternal health. 

- Necessary manpower and infrastructure will be developed to convert all sub-health posts to health posts. All primary health care centers will be converted to 15-bed hospitals. In all the wards of all VDCs, ANM training will be offered to local women to facilitate safe-motherhood and child health. Depending upon the population and needs, district hospitals will be converted to 25 to 50 bed hospitals. All zonal and regional hospitals will be upgraded to 150 to 300 beds  depending on the population. 

- Separate maternal and child hospitals will be established in each zones and regions. A state-of-the-art geriatric hospital that will prove to be a prototype for the whole of South-Asia region will be established. The government will increase funds for a state-of-the-art VVIP treatment treatment wing with full security at Tribhuvan Teaching Hospital and will end the culture of sending Head of State and other VVIPs overseas for treatment.

- State-of-the-art hospitals that can care for patients with cancers, heart disease, respiratory diseases and kidney diseases will be established in Far West (Attariya) and East (Charali). 

- Pilot programs will be started in next 5 years in 10 districts to explore private sector as providers of health care. 

- The rules and processes of sending doctors who received government scholarship or some other help will be made attractive and effective. 

- In the past, during Nepali Congress's governance, the policy of establishing one health institution in each VDC has resulted in health institutions at all the VDCs. Now we will bring policies and programs of providing ANM training to local women in each ward and employ them. 

- Programs will be conducted to ensure that every Nepali citizen has health insurance. 

- To reduce maternal and child mortality,  necessary mechanism will be created and effectively implemented. 

- To improve the infrastructure of community hospitals, arrangements will be made for tax-exemption and bank loans at low interest rates.   

- Enabling the private sector to provide health care of international standards, health tourism will be promoted and standards will be set and implemented for private hospitals and health centers. 

My Comments:
The manifesto starts well. There's a broad-stroke philosophical declaration that commits to ensuring access to all. But then the manifesto degenerates into a disconnected babble of specifics leaving us completely confused to where they stand. I am sure all the political parties will land into that mess if they dare to venture out into program/policy details but Nepali Congress has offered us the example here. So let's dive in. 

Nepali Congress seems to have identified government as the main provider of health care although this identification becomes blurry as we go down the document. For argument's shake, let's say NC identifies government as the main provider of health care, is it a good idea? We have to look into the current realities. Government (along with global help that is quite robust) has been quite successful with public health measures: vaccination, targeted disease programs (TB, leprosy, HIV). But it has been a grand failure in health care delivery (I mean hospitals and clinics or other facilities for care of illnesses) despite pouring rivers of money. You can look at the fully government-run Bir Hospital to see the level of problem. You will find technologies here but not the care. Lonely Planet says about Bir Hospital, "Government hospital where terminally ill Nepalis come to die; not recommended." Even semi-autonomous institutions like TUTH or Patan Hospital are examples of non-progress or downhill course as they exist now. Although we don't have direct data for Nepal, the global data for the developing countries is clear that the majority of health care is provided by private sector (that includes medicine shops) and there is no strong reason to believe otherwise for Nepal. So as it exists now, there are both government facilities and private for-profit enterprises doing health care delivery. Who should we choose? And Nepali Congress has, at least on a fragment of declaration, has taken up that question and chosen government. 

Before we take up that question, I think it is important to clarify what is good about any of these institutions doing health care. Is there any intrinsic nature of either of these institutions that would guide us? I am sure there are a load of people who have spent their lifetime studying these institutions but my amateurish assessment is that the answers are not black and white. Both of them have their strengths and deficiencies. If we were to stereotype, our government institutions breed sloth and corruption while private institutions teem with greed and lax ethical standards to quench that raging thirst for profit. What matters is how we nurture them. So the most important question we have to answer is why do we choose one from another and how are we going to make them work. The manifesto doesn't do that. It shoves down "government" without qualification. We don't need a democratic party to do that, Rajas and Ranas have done that to us for ages. For my part, as it exists now, we have to exit out of this dualism: either/or. None of them are going nowhere. Both are going to have to do the job, the main exercise should be in working out where government is likely to work, where private institutions are going to do the job, and how can we best utilize their strengths. 

The statement about upgrading subhealth posts and the number of beds in several health facilities is populist but amateurish. Infrastructure is the least of the problem in current health care system of the country. More burning issues are human resources, equitable distribution of the human resources, retention in local health care facilities, effective organization and management of health care facilities, provision of essential medicines and equipment, maintaining the available resources and equipment and having timely repair and replacement in case of malfunction, etc. Adding beds to the health care facilities alone will provide opportunity to get commission during hiring of contractors but does little to improve the health care of Nepali citizens. 

The manifesto has emphasized Auxillary Nurse Midwife (ANM) training for local women in each ward. They are obviously ignorant of the fact that 97% of rural wards already have Female Community Health Volunteers (FCHVs) who do a slew of local level health care related to maternal and child health. Indeed, we could do a lot if we could train local women in the areas of non-communicable diseases but that is not what the manifesto has in sight, they seem to be talking about maternal and child health (they mention ANM training specifically). Furthermore, ANM training is not easy, they are trained to conduct deliveries and they staff rural birthing centers. Every ward does not need a birthing center (we would have more birthing centers than grocery shops in many of these rural villages if that happens!). It is a dead-on-arrival proposal if we check reality. 

Another thing they talk is about having separate maternal and children hospitals in zones and regions. Why should they be separate from the zonal and regional hospital? Especially maternal hospital requires input from multiple specialities and would be a bad idea when using scarcely available manpower. 

The talk about creating a facility by tax payer money for "VVIPs" is ludricrous and outrageous. Why should we people pay money to stoke the luxurious appetites of fat cats in our government? Everyone should have a choice to go whereever they want to get their health care. But they have to pay for it on their own. If tax payers are paying for someone else, they should get the exact help the simplest of the tax payer receives when s/he is ill. 

"State-of-the-art" hospital is just a high talk. We need functioning, equitable, accessible health care now. "State-of-the-art" hospital can not be built, it has to evolve. We can look at New Bus Park. It was a "state-of-the-art" facility when built, now we will be looking at its ruins. We can look at TUTH. It was a "state-of-the-art" facility at the time it was built, now we will see a drunk, gangrenous, haggard geezer. We need to deal with our foundations first and not be carried away by these daydreaming sideshows. 

The statement about piloting private sector involvement in health care delivery is again absurd. We don't need to pilot it, there already is a large extent of involvement of private sector. I wonder if they meant getting them involved in government facilities. If so the extent and intent should have been further elaborated because the details would be extremely important for its success. And out of the blue they bring in statement of support for community hospitals. How are they going to fit in the larger picture of health care delivery?

The manifesto touches upon the process of sending doctors who have obtained government scholarships to rural areas in a vague way. It is only a small component of managing human health resources. As it exists now, it is an unjust system with several fallacies. It's good that it seems to hint that there are problems with current processes of managing doctors who have obtained government scholarships. 

Finally, something about the statement on medical tourism. They want to promote private sector to establish "international-standards" medical care facilities and bring in medical tourists. One question that comes to mind is: should the state aim to provide highest standards of medical care to her citizens or to tourists? Let me remind you, we are not talking about hospitality care in hotels or restaurants but health care to sick citizens of the country. And they talk about setting standards only in the context of these private hospitals geared to care for medical tourists. What is more urgent is actually having certain standards for all health care facilities regardless of whether they are private or government owned and run. 

In summary, it is hard to identify where Nepali Congress stands on health care. One thing that is consistent is that they want to ensure universal access to health care. But their details are mushy and incoherent. 
   

Health Care in CPN-UML's Manifesto

Source: http://www.cpnuml.org/

My Scoring:(Please see my earlier blog for the scoring system)
- Relevance: 4
- Coherence: 4
- Practical Achievability: 2

Declarations on Health Care in CPN-UML's Manifesto:
- Basic health services will be guaranteed as fundamental right of the people. Everyone will have access to free essential and primary health care. State funds will be mobilised to bring all citizens to a health insurance scheme.Contribution-based social security funds will be mobilised for health insurance for those in the employment.

- Maternal mortality rate will be brought down to the lowest minimum.State will take the whole responsibility for maternity protection. An air ambulance facility will be arranged for the protection of postnatal deaths in remote areas.

- Hospitals and health posts will be arranged in such a manner that increases every citizen’s access to health services. Prioritised health services will be made easily available. Enough subsidies will be provided for the treatment of heart, cancer, kidney and other chronic diseases. Tele-medicine facility will be promoted.

- Children of the families with the State Facility Identity Card will be provided with a child protection subsidy to ensure that the children are malnutrition-free.

- Access of all citizens to essential health services will be guaranteed through a health insurance scheme. No one will be deprived of basic health services due to the lack of economic support.

My Comments:
"Fundamental right" should be qualified. I think it is the moral responsibility of the nation to ensure health care access to all of her citizens. But using a legal approach to access to basic health care services is flawed primarily because it takes a mechanistic approach to a humanistic endeavor. The manifesto doesn't explain what it means by "fundamental right", I would welcome it if they meant it as a responsibility of the nation to her citizens. 

The manifesto mentions "free health care." We have to recognize that "free" is a populist approach. There can be no "free" health care. We can pool risks and try to pay as a collective effort but health care is something that needs materials and manpower that come with cost. It can never be free. 

They categorically address mother and child. It is a very applaudable thing. Especially, if we were to triage the current mortality trends based on our moral obligations. However, there is also a need to address other diseases/health risks because the current pattern of mortality is changing rapidly. Non-communicable diseases and injuries have already surpassed mortality related to maternity and childhood illnesses and communicable diseases. While it is urgent to keep up with the achievements in maternal and child health and set sight to lofty goals as the manifesto puts, we will also need to address other issues. We do have resources to work on all of them at the same time. 

Their statement about health care facilities is broad and non-specific. And that, I think, is good. They commit to ensuring access to hospitals and health posts which is clear but do not delve into the exercise of specifying how it will be achieved, which is a largely technical issue which needs expert debates. They have fallen into the allure of telemedicine. In countries like Nepal it is a mistake to bank too much on telemedicine. They can be accessories but there are much more urgent things that need priority (none of which, I believe, are going to be solved by telemedicine; it can be a separate discussion). 

Overall, I think CPN-UML's manifesto's health care content is well done. It gives a broad philosophical stroke to their political approach to health care. They have not relied heavily on populist declarations. They have ample space to maneuver on implementation because the declarations are broad and non-specific.  

(P.S. I downgraded my earlier scoring for Practical Achievability based on rereads of their statement)   

Health Care in Major Political Parties' Manifestos

Political parties have come up with their election manifestos. This ritual also includes giving their vision about health care sector. As I understand it, at its substance, this election is about creating constitution that gives a broad frame of how the country is going to be run. Accordingly, in health sector too, the debate should be about broad philosophical approaches to the structure of health care. What are these political parties talking about in health care? 

While we have to understand that whatever is written in their manifestos mean next to nothing in terms of implementation, it is still worth doing the debate. 

I will try to analyze the declarations in major political parties' manifestos in terms of:

- Relevance
- Coherence
- Practical achievability

Let me explain further:
- Relevance: Are they relevant to the current or future health care needs of the country?
- Coherence: Do the arguments go together well? Is there is central theme around which all the things revolve?
- Practical achievability: Are the declarations achievable in the current or future context of Nepal? 

I will score each of these areas from 0-5, zero being the lowest and 5 the highest in terms of aggreement with each of these 3 attributes (higher the better!). 

Let's start...