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.