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.
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