An open letterSignificant reforms are required to improve Nepal’s health landscape
Honorable Health Minister Gagan Thapa, As a member of the Constituent Assembly, you have passed one of the most progressive constitutions, guaranteeing ‘free access to basic health services’ by the state. Realising this commitment will, first and foremost, require your bold leadership to initiate reforms that will fundamentally change the health system and make it more responsive and accountable.
Planning and programming
One of the first things that needs a closer review is the basic health package of services, ostensibly provided free-of-charge to the public. To begin with, there is ambivalence among health professionals and even a larger gap in the public’s knowledge about the full range of services. Multiple attempts to fully define the package, including medicines, supplies and lab tests, have remained unsuccessful, resulting in its inconsistent implementation. Second, basic health is only available to the public within the district health system, depriving the large and growing urban residents of their constitutional right. When one looks closer at the functioning of the district health system, there, too, the government is failing to protect the fundamental human right of access to free and basic health care.
Your ministry should cement basic health package of services with a regime of periodic reviews. Simultaneously, it should guarantee universal and free access to health services, including in urban areas, by swiftly funding its delivery in every public hospital, and where appropriate, through innovations, such as satellite clinics. Regular attendance of health care and other staff is an important first step to delivering quality health care; therefore, all staff must be required to report to their assigned posts with immediate effect.
Perhaps the most significant reform that is required is an overhaul of the ministry’s planning and programming processes. Kathmandu continues to unapologetically guard key responsibilities for planning, programming and budgeting, against the established legal precedent of the Local Self Governance Act (1999). While significant portion of the ministry’s budget ‘goes to the districts’, its health offices are relegated to implementing the decisions made in Kathmandu, resulting in disjointed health programmes and uncoordinated care. If we are to bend the curve of health inequities in Nepal, the districts must be authorised to plan and fund initiatives, tailored to the needs of vulnerable or difficult-to-reach populations. For this, approximately 80 percent of the budget needs to be disbursed to districts based on a formula that considers key factors such as geographic area, population size, number of health facilities, among others. Federal authorities will continue to play a critical role in identifying national priorities, translated through policies, regulations, indicators and their targets.
System and governance
Historically considered one of the most advanced systems in the region, the ministry’s manually intensive and archaic information systems have fallen behind. They were designed to capture data limited to the district health system and to report to ‘higher’ authorities. Understandably, the private providers and large public sector hospitals often under-report with limited consequence to the ministry’s planning. Public health information systems need to be digitised and made capable of collecting and analysing data from a diverse set of public and private providers that allows for swift and effective response to communities’ health needs.
I wholeheartedly support Dr Govinda KC’s crusade to reform the country’s medical education and rid itself of excessive political meddling. That aside, councils must be required to better regulate their respective professions. To date, a one-time license allows professionals to practice for a lifetime, contributing to the birth of quacks in the sector. All councils must be required to review their respective processes for licensing and, more importantly, initiate re-licensing with immediate effect. The ministry cannot allow uninformed health professionals to deliver care, both in the public and private arena.
Quality and management
While you have publicly expressed your satisfaction with the care your daughter received at Kanti Hospital, the larger public is forced to endure the well-documented and persistently abysmal environment at public hospitals. A significant part of the problem is the Development Board Act (1956), which establishes development boards at public hospitals that are more accountable to senior officials in the government than to the clients they serve. A new act is urgently needed that ensures accountability to clients by establishing Hospital Governance Boards with full authority to nominate a chairman from among them and appoint a Chief Executive Officer. While its responsibilities should remain at a high, strategic level, the operations and management, including key hires, should be assigned to the CEO. The composition of the governing board and its key decisions should be periodically updated on its website and posted in a noticeable location.
Let me say a few things about the quality of care. After the unsuccessful implementation of the Quality Assurance Policy (2006) due to its weak legal basis, the government endorsed the ‘Health Institution Establishment, Operation and Upgradation Guideline’ in 2014. It sets up a licensing regime for private providers with criteria for multiple inputs. While promising, its uptake has been slow because the ministry has not added extra staff to manage the increased workload. What is more concerning is that the public remains uninformed about this process, taking away people’s ability to hold providers to account. Therefore, all the monitoring committees, created by the guideline, must be required to maintain a website or a publicly accessible database with the licensing status of all providers and the nature of findings, if any, during (re-)licensing. The providers, too, must be required to post the same in a visible location. Meanwhile, public sector facilities also need to be assessed against the same criteria, followed by an immediate recovery plan. In the long run, however, a consistent licensing mechanism is needed for both the public and private sector institutions through an independent quality assurance body.
- Aryal is a public health professional and can be reached at firstname.lastname@example.org