One of the biggest threats to our health seems to be our expensive healthcare system itself. The mind-boggling question is what mars our health system despite so many efforts. The answer is not simple. Perhaps the frequency of creating action plans and the lack of action is one thing to ponder. As a medical officer, I used to work at Shukraraj Tropical and Infectious Disease Hospital, Teku several years ago. Many patients suffering from enteric fever, acute gastroenteritis, food poisoning, viral hepatitis and other food and waterborne diseases visited the centre daily. The first thought that came to my mind was about the plight of the rest of the country if the denizens of the best-served area in Nepal were suffering from such preventable ailments. I found out later that patients living far away from the capital city had to visit this centre. It is ironic that the only hospital specialised in tropical diseases is not located in the country's tropical zone, and due to this, the indirect costs of healthcare financing is high.

As part of my residency programme in Community Medicine and Tropical Diseases, beyond the sundry lectures and dry textbooks, I have visited rural villages—and that has helped me understand the lives of the people behind poverty, pathogens, disease and death. Today, the market is brimming with poor quality diets filled with fats, chemicals, toxins, and our livelihood and occupational environment have become polluted. Mortality due to non-communicable diseases in Nepal as estimated by the World Health Organisation is up to 66 percent. The only sustainable way forward for low and middle-income countries like ours would be to prioritise and focus on the preventive aspect aimed at primary levels of disease prevention. Thus, it is high time to work on improving the health literacy of the population.

The accessibility of medicines of acceptable quality at affordable prices has become a challenge where developing nations including Nepal have continuously failed. Pharmaceutical expenditure accounts for the biggest share (over one-third of all healthcare spending) of the escalating health expenditure, and it is a major factor keeping out-of-pocket payments at a high level in Nepal. Anti-microbial resistance is yet another real threat to our collective future with an ever increasing number of resistant superbugs, and this dreadful problem is being described as apocalyptical.

The basic tenets of global health must address the challenges and needs of vulnerable populations worldwide through innovation and cooperation with the stakeholders. However, the use of innovation in places of desperate need is hindered because of a weak health system due to lack of resources such as infrastructure, lack of sustainable financing and shortage of skilled manpower. This is all aided by corruption—an enduring problem in many low and middle-income countries.

Overt privatisation of the health sector has turned the healthcare system into a profit-making industry. The deregulation of the market and policy manipulation in favour of the free market has profound effects on the health of the world population. Due to lack of public financing, out-of-pocket payments as a percentage of the current health expenditure in South Asia have been estimated to be up to 60-70 percent. In the past few decades, countries have forged a consensus that was formulated as the Sustainable Development Goals, and global actions are being directed towards achieving these goals by 2030. William Easterly has written in his famous article ‘The Trouble with the Sustainable Development Goals’ that they are about as likely to result in progress as beauty pageant contestants’ calls for world peace.

The other issue in low and middle-income countries is community participation. If a large section of the population is constantly thinking about where their next meal is coming from, how can they focus on health promotion and prevention? As we keep talking about an apple a day, or the preventable part, a statistically significant number of people are buried under the poverty line; and most of them do not find the ‘apple’ that would fulfil their daily necessities. Beside several constraints, corruption has been constantly crippling the developmental process in the low and middle-income countries. In South Asia, Nepal remains one of the most corrupt countries, ranking third in corruption after Afghanistan and Bangladesh.

Socio-economic inequality fuelled by bizarre politics and endemic corruption has had rampant effects on every sector of Nepal including the healthcare system, turning it into a quagmire for the marginalised. Following the change in the political climate and administrative framework of Nepal with the implementation of federalism, can we anticipate something different, if not total change? Hard to be optimistic, and hate to be pessimistic.

 Basnet is a resident doctor studying for an MD in Community Medicine and Tropical Diseases at the BP Koirala Institute of Health Sciences, Dharan