Primary health careThe actual implementation of the legal instruments and policy provisions has been lacklustre.
The last four decades have witnessed significant strides in the area of global health and international development in terms of quality, coverage, access, and healthcare service delivery. Several historic declarations and universal goals have been endorsed. These historical events have substantially influenced the trajectory of the health system and service delivery patterns in Nepal, too.
In 1975, the first long-term health plan was introduced with the objective of providing essential health services to the vast majority of the people in the country. The Fifth Five-Year Plan contained initiatives which aimed to raise life expectancy by reducing mortality. The health priorities of the Fifth Plan were continued in the Sixth and Seventh Five-Year Plans.
In 1991, the National Health Policy was established primarily to guide the sector by improving the health standard of the majority of the rural population. The idea was to do so by strengthening primary health care approaches, making the health system effective, and readily responding to the health needs of local communities. This triggered other policies and guidelines including the National Mental Health Policy 1996 and Safe Mother Guideline 1998.
The Mental Health Policy 1996 was designed to ensure the availability and accessibility of essential mental health services for the entire population, with a focus on the most vulnerable and underprivileged groups, by integrating mental health services into the general health service system, and by adopting other appropriate measures suitable to the community.
In 2014, the government introduced the New Health Policy with the guiding principles of free essential health services and equitable access to the same. It aims to achieve the Sustainable Development Goals by reducing the infant and maternal mortality rates, moving towards controlling non-communicable diseases, and ensuring quality services to all including senior citizens, people with disabilities, single women, and communities at risk. The Constitution of Nepal 2015 declared health as a human right.
Nepal has made noticeable progress with many success stories. The significant reduction of maternal newborn and child health morbidities and mortality is one among others. For example, in the 20 years between 1996 and 2016, deaths declined by more than half. Nonetheless, it does not reflect the availability and quality of health services at the sub-national level. The situation is even more worrisome with regard to rural communities. As there is a limited number of government-run health facilities in remote areas to cater to the health needs of the people, giving birth on the way to a health facility or still depending on the alternative health system is a reality of the people residing in particular geographic areas.
Despite making substantial progress in some areas, the actual implementation of the legal instruments and policy provisions has been lacklustre. This has led to a wide gap between policies and practices on the ground. Consequently, there are unaddressed health needs and persistent inequalities in health that are yet to be mainstreamed. Worryingly, this trend has been gaining in recent years.
In principle, the health system has to fulfil these obligations: Catering to the health needs and requirements of people irrespective of culture, caste, creed, gender, occupation and place of domicile; delivering quality health care to all including people with disabilities and marginalised and vulnerable groups in their respective communities; and combating rising cases of non-communicable diseases.
The existing health system has not improved in an expected way to deliver quality health services across communities. There are not many non-governmental organisations providing service in rural areas. Poor coordination and collaboration among the key actors and organisations is another challenge in the health system at all levels.
Adequate research has not been done on the health system and its implementation. But such research could have contributed to appropriate planning and effective implementation. The situation is more critical as there is a lack of desegregated data, mainly on vulnerable and marginalised groups. Similarly, there is no strict monitoring and an effective and regular supervision system which has influenced the quality of services at all levels.
There is no strong political will to translate all the policy provisions into action, and design and develop appropriate and acceptable policies and programmes as necessary. Further, people perceive health as a technical issue about which they are little aware, and hence cannot make the expected contribution. This directly affected their participation in the planning process of health projects and programmes at the local level. Finally, the concept of health for all, universal health coverage and health as a human right—all of these are social calls that need to be translated into action to make them more meaningful.
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