“Access to Health services represents quite a significant challenge for countries like Nepal.”- Solutions

Before I start up with the challenges that the health sector is actually facing in the country, let us have a quick glance at the current status of the health infrastructure in the country. These days, taking a tour of health access services in the country has become easier due to the use of technology like Health Management Information System (HMIS) where we can find the steps and hierarchy of the health access services available in the country. Therefore, the major part of our discussion will be based the reporting institutions in the HMIS as that is the most authentic source for the review.  The latest annual report published by the Department of Health Services is the Annual Report 2067/68, so the data referred will be from them and the findings will also be based on the following report.

According to the reporting status in the HMIS, there are 95 public hospitals, 209 Primary Health Care Centers, 676 Health Posts and 3129 Sub-Health Posts. Besides these major entities, there are others also providing more of the preventive services rather more than the curative services. There are 12,790 Primary Health Care/Outreach Clinics (PHC/ORC), 16, 579 EPI Clinics and 48,680 Female Community Health Volunteers (FCHVs). In an addition to this, reports have also been submitted by a total of 445 NGOs and 315 other private health service institutions. To compile what I wrote above, it can be understood that from all the districts of Nepal, 97.9 percent of public hospitals, 99.5 percent of Primary Health Care Centers, 99.2 percent of Health Posts, 98.6 percent of Sub Health Posts, 86.4 percent of Primary Health Care Outreach Clinics, 92.9 percent of Expanded Program of Immunization Clinics, 89.8 percent of Female Community Health Volunteers, 65.2 percent of NGO hospitals and 69.2 percent of private hospitals have submitted their reports to HMIS in the fiscal year. On the whole, 30.4 percent of the health institutions have only submitted reports timely.

Indicators	2065/66 (2008/09)	2066/67 (2009/10)	2067/68 (2010/11)
REPORTING STATUS (%)
Public Hospitals	79	83	98
Primary Health Care Centers	97	93	99
Health Posts	97	95	99
Sub Health Posts	96	93	99
PHC-ORC Clinics	80	81	86
EPI Clinics	90	87	93
Female Community Health Volunteers	86	85	90
NGO and Private Health Institutions	67	65	67
IMMUNIZTION COVERAGE
BCG	85	94	97
DPT-Hep B-Hib 3	81	82	96
Polio – 3	81	83	95
Measles	75	86	88
Pregnant Woman receiving TT-2	35	43	41

Source: Annual Health Report 2067/68, DoHS

Only looking into the data and explanation above, we come across one of the major challenges in the sector of health access. Most of the people in the developing and least developed countries believe that NGOs and private health institutions are the major entities that provide better health access to the general public but the status shows that these are the institutions not being transparent to the government regarding the services they provide. Look at their reporting rate, very poor reporting rate. This clearly signifies that NGOs and private health institutions are exploiting the public. They are taking very high service charges but they have not been reporting to the government what kind of services they provide. Therefore, the first and foremost recommendation to improve the health access in the country, especially in the urban areas is that the government should be able to compel the private institutions to report their service. Not necessarily, they need to give a cheap service but at least their service be transparent and that is the foremost requirement. Health is the most important thing and a good health must always be prioritized.

Looking into the hierarchy of the health service providers in the country, each of the development regions in the country consists of Regional Health Directorates (RHDs) which are responsible to provide technical backstopping to the health access programs and also supervise the health programs in the districts. And these RHDs are directly under the Ministry of Health and Population. Besides that, regional and zonal hospitals (15) have been established provided with the decentralized authority formalizing the Hospital Development Boards. Also, there are training centers, laboratories, TB centers (in some regions) and authorized medical stores at the regional level.

At the district level, the structure varies between districts. Sixty‐ one districts are managed by District Health Office (DHO) with support to the District Public Health Office (DPHO), whereas the remaining 14 are managed solely by the DPHO.  The DPHOs and DHOs are responsible for implementing Essential Health Care Services (EHCS) and monitor activities and outputs of District Hospitals, Primary Health Care Centers (PHCCs), Health Posts (HPs) and Sub-Health Posts (SHPs). The service delivery outlets in the country include 3,129 SHPs, 676 HPs, 209 PHCCs, 65 district hospitals, 10 zonal hospitals, 2 sub-regional hospitals, 3 regional hospitals, and 8 central level hospitals (DoHS, 2012). 

A sub-health post is the first institutional contact point for basic health services. SHPs monitor the activities of FCHVs as well as community-based activities by PHC outreach clinics and EPI clinics. The health post offers the same package of essential health care services plus birthing centers in the respective VDC and monitors the activities of the SHPs in their geographical area as well. However, a SHP also functions as the referral center of the volunteer cadres of Female Community Health Volunteers (FCHVs) as well as a venue for community-based activities such as PHC Out-Reach Clinics and EPI clinics. Each level above the SHP is a referral point in a network from SHP to Health Post (HP) to Primary Health Care Center (PHCC), on to district, zonal and regional hospitals, and finally to tertiary level hospitals. This referral hierarchy has been designed to ensure that the majority of population receives public health and minor treatment in places accessible to them and at a price they can afford. Inversely, the system works as a supporting mechanism for lower levels by providing logistical, financial, supervisory, and technical support from the center to the periphery (DoHS, 2012).

Now, here comes the second major problem of the access to health services in the country. The OPD (Out Patient Department) which is in the hospitals here finally comes to prove it illegal. What a mess with the policy? On one hand, the policy suggests that there are referral points in the hierarchy of the health service system and on the other hand, there are tertiary hospitals in our country which are actually going against the own governmental policy. If you make a policy, a governing law in your country, then you must have guys to implement or else what is the use of policy and calling your country said to be governed by “Rule of Law”.

Female and Community Health Volunteers (FCHVs) are the volunteers who provide the basic health services at the community level. There are other individual entities in the local level providing the basic health services like ANM (Auxiliary Nurse Midwife), VHWs (Village Health Workers) and MCHWs (Maternal and Child Health Workers) but the tragic part of the health policies in the country like ours remain that they are not even valued to their dignity. We keep ourselves busy talking about the countries like United States of America, Germany, United Kingdom, Australia, etc. but the major difference holds on with the execution of the major policies which they do and we don’t.

When we look into the strategy paper of Nepal, these are the strategic directions provided to the government:

·         Poverty reduction

·         The agenda to achieve the health MDGs by 2015

·         Essential health care services free to patients/clients and protection of families against catastrophic health care expenditures

·         Gender equality and social inclusion

·         Access to facilities and removal of barriers to access and use

·         Human Resource Development

·         Modern Contraception and safe abortion

·         Disaster Management and Disease Outbreak Control

·         Eradication, elimination, and control of selected vaccine preventable diseases

·         Institutionalising health sector reform

·         Sector-wide approach: improved aid effectiveness

·         EDP harmonisation and International Health Partnership

·         Improved financial management

·         Inter-sectoral coordination, especially with MLD and Education

·         Local Governance: devolution of authority

·         Health systems strengthening, especially monitoring and evaluation

Nepal is also committed to achieve the MDGs by 2015. Reduction in the poverty status, achievement of the health targets like reduction in child and maternal mortalities are some of the major health objectives that the country is meant to achieve. When gender equity and social inclusions have come up as an issue in every sector, how can health sector be capable to deny that, therefore even health sector wants gender equity and social inclusion through its updated and recently managed plans and policies in the human resource management. Looking into the intensity of the disease, the upcoming health strategies are to eradicate, eliminate and control the selected vaccine preventable diseases. We must know how important institutionalization is in every sector. When the Balance of Payments of Nepal was negative for the first time during 1984/85, then the restructuring or institutionalizing came into real practice. Then the actual institutionalization was done in the Nepal Rastra Bank and the government-owned commercial banks then, thus the status of the financial situation improved. In the same way, when the public hospitals and few other heath institutions are restructured and institutionalized, things might get different. Global Fund, WHO and UNDP are the major entities providing aid to the health sector measure of aid effectiveness thus becomes important. Finally, it is the local governance and the improved financial management which can develop the health access further in the un-accessed part of the country.

Talking on few other health policies failures, long back Dr. Upendra Devkota once tried to develop the free health services but one should understand that it is not that easy. On these regards, Nepal has to learn from Germany. Germany is the country where the health service is free now but it took them 81 years to do so. The moral is you should develop the free health service slowly starting it from 1% and so on, not ambitiously trying to make it free at once. Besides that, life is something that has the maximum risk, so the pay scale of the medical professionals should be significantly good. Worldwide, medical studies are one of the most expensive studies, the reason being that it is concerned to the “LIFE”. So it should be valued higher.

The Government alone cannot reach the remote rural communities and deliver more basic health services, especially to the poor and excluded, without partnering with the NGO community. Failing to deploy and retain health care providers, particularly doctors and nurses in remote areas, persists and will continue to damage quality of care at PHCCs and district hospitals. Posting teams at district hospitals for comprehensive emergency obstetric care must be pursued if Nepal is to continue reducing maternal mortality. Logistic management, especially procurement of quality drugs at bulk pricing, distributed to facilities based on consumption nationwide, must be improved to reduce stock outs of essential drugs. Maintaining and procuring equipment for district hospitals must also be a high priority. New schemes to solve both problems are underway. Access to health care facilities continues to be a problem in rural areas, especially for the most disadvantaged. They are too few in number and often not built at a location likely to provide access to those who need care the most. New construction is costly and time consuming. Building standards need to be established. There is some evidence that local management of health facilities is improving health care but the local bodies have little capacity to govern and manage. Minimum standards will need to be developed and local committees oriented. Supervision by district health office will become more critical to delivery, as will monitoring of pro-poor programmes (Health Plan Nepal, 2010-2015).

A very discrepancy among the private and government sector health service providers is big hurdle to the locomotion of medical professionals in the rural areas. Once there is the ceiling in the earnings made by the medical professionals on the grounds of what intensity of work they do, this problem of locomotion can be solved to some extent. Besides that, there are usual issues of political interference in the public hospitals and that those who are capable of paying higher fees for treatment are looking up to the free medical services provided by them, law should be made strict enough so that the facilities are used by the deserving ones. The final verdict remains that we are neither poor with the medical professionals nor the health service-providing institutions; rather we should make ourselves capable enough with the execution of the health policies.