The Entitlement of Our Elites

An Indian diplomat to the US named Devyani Khobragade was arrested in New York on charges of forging visa documents for her house maid, making the maid work long hours, and not paying the agreed upon sum of money. The maid had filed the complaint. Ms. Kobragade lamented that she was handcuffed, strip-searched and treated like a "common criminal." The U.S. prosecutor involved in the case, Mr. Preet Bharara, defended that there was no violation of protocol. He asserted, "Is it for U.S. prosecutors to look the other way, ignore the law and the civil rights of victims or is it the responsibility of the diplomats and consular officers and their government to make sure the law is observed?"

The fury the arrest incited in India was astounding. The prime minister and the parliament expressed outrage against the arrest of the diplomat. They removed security barricade from the U.S. embassy, expelled a consular, blocked the flow of whiskey for the embassy staff (one has to wonder what incites creativity in Indians!). There were editorials condemning the U.S. There were enthusiastic flag burners in the street. Media reported that the maid's family was threatened. Even our own fierce proletariat Prachanda's foreign relations advisor penned an OpEd lamenting how was it possible for the poor diplomats to survive with a maid on meager USD 2000 per month if they pay the minimum wage demanded by the law of the land  (my simple advise to the advisor in such a profound dilemma would have been: not own a maid). 

I was flabbergasted by the Indian response. A person who had abused a vulnerable, powerless worker, lied to the authorities, was arrested following the law of the land following the complaint of the victim. And the whole country was vouching for the person who had committed the crime!

She howled, she was treated like a "common criminal." And the country said, "yes she is no common criminal, she needs to be treated special!" 

"It is a matter of our national pride, the pride of our mother country, the pride of our flag, the pride of our government and parliament, brothers and sisters!" said the Indians. "Yes!" everyone said. 

The crime vanquished from the conversation. Why bother what the grievances of the maid might be? The whole focus turned on: why was Ms. Khobragade treated like a "common criminal?" The turning of this beyond-common elite to a common was what hurt the conscience of the elite India. 

That is the entitlement of the elites of these regions. They have been so used to trampling over the rights, dignity and conscience of the powerless that if they are told otherwise they feel out of space. As if the reality has been distorted. I had learnt about it a little while back at smaller scales seeing our "Sirs" at public institutions. But I had never imagined that this can play out at the national scale as well. While at the smaller scales the tools of chauvinism are "insider"/"outsider", "senior"/"junior", "obedient"/"non-obedient", the tool at these national levels seem to be that of unreasoned nationalistic pride. 

In this perverse reality, countless of her citizens end up working in extreme conditions in middle east, her daughters and sisters raped and abused with none to voice the agony, her children denied basic dignity. Where is that diplomatic muscle where it is really needed? Where is that diplomatic muscle when it concerns the powerless? 

Dr. KC's Crusade

A paranoid schizophrenic man opened a fire in a public gathering of US congresswoman Gabrielle Giffords in Arizona in 2011. Six persons died, several were injured. Ms. Giffords was shot in the head; the bullet passed through her brain. She received immediate medical care and was operated emergently. She has made a remarkable functional recovery.

Dr. Peter Rhee, a trauma neurosurgeon who operated on Ms. Giffords took up the stage daily to update the press and the nation about her progress. However, he was an unconventional (almost exotic) character on the television news screen. Some people found his character to be even abrasive. Bottom line: this was a character not polished with the etiquettes of public speaking. He knew his trade; he had outcomes to support that but not the finesse of television talks.

We are also seeing our Nepali doctors on television screen on an almost regular basis now. There is a distinct difference of our doctors from Dr. Rhee. Their conversations on television screen are impeccable. They speak in language totally indistinguishable from that of our politicians or bureaucrats. There is a certain ease, smoothness and a natural flow. It is impressive!

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As a 16-year-old boy, when I first read “Satyagraha in South Africa” by Gandhi, a knot formed inside my throat, my stomach churned, and tears poured out ceaselessly from my eyes at some point in the book. A burly pathan had thrashed Gandhi, bloodying him, because he had made a compromise with the rulers. A heartbreaking agony seeped inside me upon learning this harmless creature being beaten senselessly. I wanted to rather receive the beating, if I could, to spare this saintly man.

Perhaps that was the power of Gandhi’s personal character that formed the foundation of his non-violent movement. People felt Gandhi’s pain as their own. The sheer passion evolved into a massive movement with means revolving around self-sacrifice. Indians succeeded in ending the imperial British rule.

Lately, we have seen revival of similar means in our region. In India, a saintly man named Anna Hazare challenged the central government to address corruption and a new party called Aam Admi Party (AAP) blessed by Mr. Hazare came into power in Delhi. In Nepal, an orthopedic surgeon Dr. Govinda KC has been using hunger strike to address political issues plaguing his institution- Institute of Medicine (IOM).  AAP is aiming to change Delhi government so that it serves the people. Dr. KC is aiming to change IOM so that it is a better institution. These movements gathered steam based on distinctive personal characters of their leaders, especially their demonstrated track record of self-sacrifice. Their personal characters have touched the chords of people’s heart. Perhaps similar to how Gandhi’s character had. However, I feel, there is a distinct difference in the struggles that Gandhi pursued and what these folks are pursuing. Gandhi’s was of justice, theirs is of building institutions. So we should ask: Is it likely to succeed?

AAP’s ascendency to the throne of Delhi government was dramatic and filled with drumbeats of radical change. But looking from surface now, their activity has turned into a circus.  We have no idea if the end result is going to make any difference in peoples’ lives the aspirations of which had buoyed AAP to the power. I have no in depth knowledge of Indian politics and I would like to leave it there. But I would like dwell a little bit more on Dr. KC.

Dr. KC is known to have a distinct personal character. He is single. He lives a very simple life sustained by sole salary from IOM. He abhors private practice and earning extra money. He spends long hours in patient care. He travels to remote areas of Nepal on his own to care for sick people. He even travels overseas in disaster struck areas to offer services for free. This compelling personality seems to have touched the hearts of people. When he staged hunger strike recently, the passion people had for him was apparent. The doctors closed outpatient services in majority of the public hospitals throughout the country, there were parallel hunger strikes in solidarity with Dr. KC, there were mass resignations from doctors, news channels had the hunger strike as top story for several days and the government heads had to scramble to address the demands this doctor had placed. After 14 days, the hunger strike ended with an agreement. It has been a few weeks since that agreement. Now, Dr. KC is back to hunger strike because the government has not implemented the agreement.

At the crux of Dr. KC’s struggle is the intent to have IOM as an autonomous institution protected from the savagery of political beasts that have incinerated a possibility of a decent society; although the language of his demands also includes many other issues pertaining to the overall health care of the country.  If the media reports are true, the extent of shameless savagery politicians, corrupt bureaucrats in government and officials at Tribhuvan University have exhibited in pursuing their interests is extraordinarily disgusting. In that light Dr. KC’s noble struggle is truly very welcome. And his means of using his moral connection with other people brought together by the influence of his extraordinary personal characteristic is praise worthy. However, before we get swept away with this inspiring movement, it is important that we ask if it is likely to achieve the end results.

What are those end results?

Based on the demands set by Dr. KC, it seems to be achievement of autonomy of IOM, barring permit to open up new medical schools (where there is allegedly a huge bribery going on under the table to get approvals) and holding corrupt people in the system accountable. These are clear demands that are possibly achievable by the means Dr. KC is using.

However, it would be a mistake to pin too much hope on the dream of having a better IOM or national health care and health education system even if these demands were fulfilled. The real end results that the public institutions have to deliver is: accessible, quality health care and manpower trained to deliver such health care in responsible manner to dignified citizens.

I am afraid, the top-down structural change that Dr. KC is striving to bring about has to be met with bottom-up institutional changes to succeed in achieving the ultimate goal. And, I am afraid, his struggle hardly acknowledges that component. The political component can rile up passions because it is so dramatic. But the mundane day-to-day functioning of patient care where every patient interaction is weighed in terms of fairness, justice, appropriateness, quality and dignity is too banal, and too tying down. Holding everyone in the system accountable to high standards of ethics and integrity in patient care is too tedious. Our public institutions have considered those aspects dispensable. This was all too apparent in Dr. KC’s 14-day hunger strike. Outpatient clinics were closed, patients admitted to the hospital for surgery were discharged. The doctors conducted clinics in open tents in some public grounds. It was a mockery to the plight and dignity of sick individuals. They deprived sick patients of care or threw them out of their care and to top it off rounded up a drama under the tents. These doctors’ insensitivity to patients needs demonstrated during these protests speaks of a larger problem in everyday functioning of these institutions. That is how they are used to treating patients, that is how these institutions have allowed them to treat patients and it’s just natural for them to behave so. That is the component Dr. KC’s struggle will not address. And Dr. KC’s political achievement will be meaningless without the corresponding changes in the intrainstitutional behavior.  The same forces that are abusing the system now will find ways to corrupt the system in the new setup unless the institution has that corresponding bottom-up changes. It will just force them to use newer tactics.  Dr. KC will have to continue his hunger strike forever. Would it be more fruitful if the man of such integrity use more creative ways to build institutions that would care for patients than doggedly swim against the tide that will only be changed by collective transformation of this society at peoples’ level and perhaps at intra-institutional level?

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Being a doctor is a political job (Virchow would convince you on this). We want our doctors to be political. But there is succinct distinction we have to make. Using prevailing political language is not equal to the political cause that the doctors should pursue. Our political language concerns the interests of our patients that are connected to the larger society. This language has connection to issues like justice to our patients, fairness, ensured access to health care, dignity, and quality of care. The further our conversations go from these, we have to ask ourselves: are we embarking on a different turf? That turf might still be extremely valuable. But we have to get out of the illusion that it is the only thing holding up from building our institutions.

The Thud

It is a thud

That precedes a void,

perhaps silent,

perhaps empty.

Beyond the realm of quantification,

beyond the definition of a moment.

Detached from the senses,

and its languages.

Perhaps it was the cosmic darkness,

that filled the gap left by an event too nimble for the notion of time.

Senses overwhelm as he comes out of this void

What happened?

What’s happening?

What to do?

The questions churn around in his head,

at a singular moment before he lands to the asphalt-paved road.

“Head, head, head,”

He recalls telling himself as he descends to the ground,

tangled in the cross-bar of his bike.

The doctor in him has planted itself deep, 

later he tells of this reflex action. 

The thud knocks him down to the ground.

Its gallantry is no joke.

Days and weeks follow,

that attest to the mightiness of the thud.

Roaring from afar,

in unassailable commands,

the thud orders:

Dependence

Uncertainty

Fears

Helplessness

Pain

Restlessness

To which he bows in solemn obedience.

Try, it might,

to lull the world in the reverberations of its sound,

but the thud meets a more powerful resistance.

That of:

Kindness

Love

Selfless care

Of

Family, friends, colleagues and complete strangers.

Almost overwhelming.

Indebting

To be paid by comparable terms or heaps of guilt.

The soulless, mighty thud has no lessons to learn.

It has no mechanics to learn lessons.

This leaves the witness,

He,

to mop up the floor.

To be so deeply grateful to how much goodness exists in this world,

To be again indebted to the kindness and love people are capable of pouring out.

On a Mission

A jar of buffalo milk in his hand, he ascended the stone steps to a village house. He politely called out the owner of the house: Maili ama, I have brought the milk. After she emptied out the jar he retrieved it and headed back. Indifferent to the new visitor to the village, I thought he was on a mission. A young, lean man perhaps in his late teens, what was he doing in this empty village? Later, I learned more of his story. 

He was indeed on a mission. A mission to get citizenship. He had come to the village to serve his father and cajole out a VDC (local government) certification of the relationship so that the government will award him citizenship. Here is a little more of the details: 

His father was away in India for most of his childhood seeking out a livelihood. Himself, his mother and a sibling lived with his paternal grandfather, a cranky old man. They lived in scarcity, on subsistence farming, toiling in limited lands, and tending to cattle, on partially filled stomachs with chronic hunger in a wretched village with a cranky old man. Father returned back on occasions from a distant land. But he wasn't bringing in fortunes. Depravity was the rule. 

The mother fell in love with another village man, a young man, neighbor just next doors. They knew they would not be able to live in the village so she eloped with this young man to Kathmandu. She left her children behind. Later she retrieved her children and put them to other people's houses, a common arrangement where the children do the chores of house and if the owners are kind enough they send them to school.

He grew up to be a young man doing chores in other people's houses. Lately, he has assisted microbus drivers; collecting bus fees from passengers, opening and closing the bus doors, running after the moving vehicle since he has to coordinate calling passengers to the bus and following the driver's whims of stopping and moving the vehicle. More recently, aspiring to be a driver himself, he took a driving course. But he was not allowed to apply for the driving license because he did not have a citizenship certificate. For citizenship certificate he needed a relationship verified, that he is the son of a Nepali citizenship-holding father. 

When he asked his father for help, his father, who has been back to the village with a new wife and several children, decided to take avail of the leverage the situation had provided him. He asked his son to help him in the village for a while before he would help with the relationship certificate thing. There he is, this young man, on a mission to cajole out a VDC certificate that attests that he is a son of a Nepali citizenship-holding father to fulfill his dreams of becoming a driver. Unfortunately, he has an uphill battle because the historical precedence is not in his favor; his sister had served for a fairly long time in a similar effort to cajole out a certificate, in vain. The father was not impressed. 

No chances to take. 

Stay on course, 

my dear. 

For the certificate awaits.

For the dream awaits. 

So, it was not indifference, but more likely caution to stay his course. Lay his head low. Pray in the dark to the distant god for his father's change of heart. And pursue that hope of ultimately earning a life where he can live on his toils. 

How much of control has this man had in his fate? What is responsible? Is there anything now that would change his circumstances?

These are the questions.

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.