In October 2017, Nepal’s Parliament passed a landmark bill to ensure health care for all.
Mandatory health insurance for the citizens is the major provision of the Health Insurance Bill, which in Clause 21 states that it will consider each household as a unit and all family members must enrol themselves in the programme.
But a recent study puts a spotlight on the country’s fragile health system. It has taken the birthing centres into consideration.
More than 70 percent women of Kaski district bypassed their nearest birth centres in favour of facilities with “adequate drugs and equipment” and “competent health staff”, according to the study.
The trend of bypassing nearby health facilities shows that health facilities are ill-equipped, their service quality is not up to the mark and they lack essential medicines and competent health workers.
These inadequacies reflect an obvious, but largely neglected breach in Nepal’s health system, according to a report published by the Lancet Global Health Commission’s recently.
“The Lancet report is an eye-opener for our policymakers about Nepal’s health care services,” said Mahendra Prasad Shrestha, spokesperson for the Ministry of Health and Population.
According to Shrestha, ineffective health care system will largely affect Nepal’s efforts to meet the Sustainable Development Goals.
“We cannot achieve SDG targets without improving the quality of our health services,” he said.
Nepal needs to reduce the maternal mortality rate, which stands at 239 per 100,000 live births, to 70 by 2030, while the country needs to bring neonatal deaths to 12 per 1,000 from the existing 21 and under-five mortality to 25 per 1,000 from the existing 39 to meet the targets.
Low quality health care increases the burden of illness and health costs.
Only by strengthening the health care system can Nepal achieve SDG targets and universal health coverage, experts and analysts say.
Gagan Kumar Thapa, a lawmaker from the Nepali Congress, who during his stint as the health minister lobbied strongly for the universal health coverage, said: “Lack of access to health care facilities and lack of services at those facilities are the same things.”
“It’s high time we set our priorities right when it comes to health care,” he said. “The country must ensure quality care and patient’s satisfaction while designing the health care facilities,” Thapa, who is also a member of the Lancet Global Health Commission, told the Post.
Nepal was one of the nine national commissions that participated in the “Lancet Global Health Commission on High Quality Health System in the Sustainable Development Goal (SDGs) era”.
“Only those who cannot afford private care or afford to go to cities or abroad have been receiving treatment at government health facilities,” said Dr Baburam Marasaini, former director of the Epidemiology and Disease Control Division. “But the government has hardly invested in strengthening health care facilities and ensuring quality care. This will certainly mean we will fall short of meeting our national commitments and global targets.”
The World Health Organisation recommends 21 health workers per 10,000 people, but in Nepal there are only seven health workers available for a population of 10,000.
There are a little over 1,300 doctors serving in government health facilities–central level hospitals, zonal hospitals, district hospitals, and primary health care centers.
The National Demographic Health Survey 2016 shows only around a half of the health facilities in Nepal provide normal vaginal delivery services. Just over one third of facilities that offer normal vaginal delivery service had at least one staff member who had received relevant in-service training in the preceding 24 months.
Six out of 10 facilities that offer normal vaginal delivery care have emergency transport available.
On an average, 11 percent of the facilities had all medicines regarded as essential for delivery care. A majority of health care facilities even lack blood pressure apparatus, weighing scale and stethoscope.
“Why would one put their life at risk?,” said Thapa, when asked about people bypassing the nearest health facilities. “Only when the state ensures quality health care and trained doctors for their services will people visit health facilities near them,” said Thapa, stressing the need to invest more to strengthen the country’s health care system.
The Lancet report also highlights the shortcomings in the existing model of predominantly disease-centric, donor-driven and vertical programming which it says undermine the government’s capacity and responsibility towards ensuring that people have access to high-quality comprehensive health care.
“Poor care not only jeopardises the health of individuals; it erodes trust and puts the entire health system at risk,” reads the report.
SDGs and universal health coverage both aim at ensuring health care services to all, especially the ones who are the most vulnerable and to achieve both, the only way is setting up a strong and effective health care system.
Professor Bhagwan Koirala, a cardiothoracic surgeon at Manmohan Cardiothoracic Vascular and Transplant Centre, said the focus should be on multi-dimensional aspects to ensure quality care.
“For that, we should ensure quality products–quality of doctors, quality of medicines, quality of infrastructures,” said Koirala. “We need to make our health workers and health facilities competent, monitor them on a regular basis, and make all the people involved accountable.”