Reorganising Public Health Services in Nepal

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Reorganising Public Health Services in Nepal

It is very important that the medical treatment has to be cost-effective and affordable even to the common man. These necessitate avoiding unnecessary, high priced prescription and diagnostics.

--BY JAGDISH PRASAD AGRAWAL

Riding on the whirlwind came Corona in the month of December 2019 crying “Veni, Vidi, Vici (I came, I saw, I conquered) and so it was. The Pandemic has already taken the lives of over 400,000 people all over the world and six million Covid-19 patients are struggling in the hospitals for their lives all over the globe. Though the pandemic storm has slowed down, its dark shadow looms over the lives of the people as its cure is uncertain and unpredictable as yet. The researchers in their labs are working overnight to find a solution to this gigantic health issue and it is hoped that success is not far off. However, it will take years before the remedy will reach the masses. They assume that the pandemic itself will find its own solution in terms of developing self-immunity against this disease over time as was the case for the flu.

Covid-19 by its dimension and contagious nature has adversely impacted social, political and the economic lives of the people -mostly at the bottom- so severely and seriously that it is becoming difficult for them to stand up and run as before. This awful darkness and uneasy silence all around has thrown up a varied nature of challenges to the ingenuity of mankind. One of them relates to undue pressure on the public health system in the developing as well as the developed world. The handling of the corona pandemic by the public health institutions has been of a diverse nature and intensity and the most effective has been found to be those which focused on prevention. In fact the corona pandemic has stressed the necessity for a preventive public health system to be more desirable, cost effective and lucrative than the prevailing curative approach. The recommendation of W.H.O for containing the spread of corona virus are all preventive in nature whether a) washing hands b) Social distancing c) Keeping indoors, or d) wearing masks.

The strength and power of prevention beggars no description. The health of a person has many dimensions. Normally when a person falls sick, the cure obviously is the primary dimension, for which the government builds hospitals, pharmaceutical industries produce medicines and the medical schools churn out thousands of doctors to man the system. It is estimated that of the total world G.D.P. an average 10% is spent on building and maintaining this curative approach. Though it may look enormous, it is inadequate as the statistics show that the masses in each and every country, developed or developing do not have satisfactory access to health facilities. Covid-19 has accentuated this inadequacy in different proportions the world over. Rich countries on an average spend 12 percent of their GDP, middle income groups just half of it and low income groups not more than 4 percent on their health programmes. This is an irony in that in the low income group where health issues are varied, interrelated and enormous at the bottom, the resource allocations are very low. In the case of Nepal it is not more than 3 percent of the GDP. This allocation gets further diluted if corruption in public spending is factored in.

The inadequacy of our public health system surfaced glaringly during this pandemic when we found that we had neither men, nor machine or materials to cope with the crisis. Such crises have come in the past also in the form of floods, earthquakes, landslides when people got injured, stranded or fallen sick and the government has played its role of a saviour admirably. But the pandemic is a totally different ballgame. What matters the most is the immunity of the person i.e. general condition of his health.

It is not to say that hospitals are not needed, rather it is to emphasise that if prevention is focused on, the same number of hospitals can give better services. If prevention is not focused on, no matter how many hospitals the government builds, they will always remain inadequate.

Any public health service has to build a response capability to address any outbreak, which can cater to multiple crises in the quickest time possible on its own without reliance on foreign aid.

The robustness of the health of a person depends more on many non-medical factors of which a) nutrition b) air pollution c) water quality d) sanitation and hygiene are four crucial sectors and these sectors are tied up with social and economic development of the country as well. Though, these non-medical factors are the core of our developmental efforts, they perhaps have never been looked at from the angle of human devastation. Instead of meandering like a river our socio-economic development should exclusively focus on these four sectors which will have a direct positive impact on the health of the people and on the cost of maintaining and building too many hospitals in the public sector.

The government for the last few years has been giving lip service to strengthen public health plans. This lackadaisical approach on the part of the government has encouraged private sector participation in a big way in building medical colleges and hospitals, they have not been able to be a part of the public health system catering to the masses. On the contrary these private healthcare institutions have attracted the best brains in the medical profession to themselves leaving the public health system high and dry. Cost of treatment has become prohibitive. Doctors do not want to go to rural areas as the private sector in urban areas provides unending opportunities.

In order to provide health at low cost to the masses, Nepal’s health system has to be government led. Private sector can only play a supplementary role. Our rural society still believes in fate, a curse from above for many of the diseases. Sometime such belief wreaks havoc on the family not only in terms of financial ruin but also permanent disabilities. It is upon the government to 1) educate the rural mass about the causes of any disease, 2) explain the role of nutrition and other non-medical factors on the well –being of a person 3) provide treatment at their door step at low cost 4) give preventive focus on prevalent disease in the region 5) train one member of the household on attending emergencies and last but not least 6) publicize through workshops and public-get-togethers on preventive aspect of important health issues.

Health education should be a compulsory subject in class X to XII and post marriage the female member of every household should be encouraged to take a short course on fertility, child care, nutrition, sanitation and hygiene. These trainings should be funded by the local government and a standardized curriculum be developed.  

In order to remain healthy there are certain do’s and don’ts which apply to all irrespective of rural or urban habitation. Whereas the urban youth is becoming fitness conscious, the rural resident takes it for granted that their life-style itself is fitness-prone. Diseases in the rural sector are as intense and diverse as among the urban population.

Concept of fitness as against fate has to percolate in every human being. This is all the more necessary among female members of the family. Though in urban areas the value of exercise, yoga and meditation is gaining ground, in the rural sector these activities do not merit much attention.

Medical science lately, has been giving high importance to the special care a child deserves from the date it is born and a person the day he crosses 60 which is unavailable in our hospitals, rural or urban. Though the maternity facilities are now universally sought, the paucity of quality services still persists. The mortality rate of birth in Nepal is low compared to our neighbouring countries but still we have a long way to go to get to world standards. Maternity rooms in every village with at least four well trained mid-wives from the local community and the adequate infrastructure need to be provided by the government and this centre must be attached to a referral hospital and a designated doctor by an App to facilitate child-birth in villages without any hazards. This facility can be made compulsory, to be built, trained and maintained by every local village body.

The local primary health care centres are the building blocks of any public health system of any country. But, in the absence of any incentives to work there, centres in Nepal are mostly non-functional. Doctors do not wish to go there. Medicines are not available. Problem is that of manning them. The problem can be overcome if the status of these centres are scaled up to that of a junior hospital and the salaries  of medical professionals manning these centres are supplemented by special allowances and promotions are linked up to a specific period of service in them.

Of late, the private sector has invested in the health sector enormously which is welcome. More important is that the common man has relatively more trust in their quality of medical services than that being provided at public hospitals. It is not that the government hospitals lack infrastructural facilities, the problem is that of efficient management and the corruption inherent in the system. To overcome the issues of management, the public hospitals can be entrusted to the private sector for management on PPP model or on a lease basis. The private sector is qualified and experienced to run them. Private clinics are an integral part of the Nepali health system; these clinics operate very informally without any regulation by the government. A separate law to prescribe certain standard minimum facilities in those clinics and to ensure quality treatment at a reasonable cost will be a welcome move.

It is very important that the medical treatment has to be cost-effective and affordable even to the common man. These necessitate avoiding unnecessary, high priced prescription and diagnostics. In a low and middle class family there is not a separate budget for health and hence for any affliction they have to depend upon loans. The medical colleges run by the private sector can introduce courses for the management of health services. The private sector medical college can also provide refresher courses of six weeks to practicing doctors on their specialty and also on the relationship between a patient and a doctor which is totally missing in our health care system.

The cost-effective objective of the public health system for our country will be less hospitalisation, a decentralisation of essential health services and emphasizing on preventive measures. The hospitals should take up challenges to update themselves on new knowledge in treatments and disseminate them to the prevalent health system comprising the primary, public as well as private clinics. There is a tendency among government hospitals to ignore new challenges and new discoveries. They do not prepare themselves for any future eventualities and are caught lacking even if something minor but off the track erupts. We need to correct this.

Under the circumstances, the role of the hospital in the public sector needs to be reviewed. The bigger hospitals have to be the depository of knowledge and its dissemination. They have to organise essential health services and ensure, along with the quantity, the quality and reach of services to the remotest corners of Nepal. There are many peripheral services which are part and parcel of any public health programme. Availability of blood and the services of quality ambulances are two such glaring examples which need improvement and regulation. The old, children and newborns are treated much better at home than in hospitals. The old practice of home-visits by doctors, if it can be revived, not only takes care of the most vulnerable at home but also reduces pressure on hospitalisation.

One very important component of preventive medical health system is screening which in our society has recently started in the form of charitable camps. Though they are doing a commendable job, they are repetitive and the experiences gleaned from such camps are not collated for research and / or future reference. Screening is an evolving latest science. It has its own methodology and its scope is expanding from the traditional eye camps to cardiac / blood / sugar / cancer / thyroid etc. Our prime hospitals, in fact, should ingrain in their internal programmes the screening of people for certain diseases so that the public health system can be geared to specific needs. The new role of selected big hospitals should be to focus on a few high-priority services and diseases.

The state of health is directly related to our way of living. Diseases such as small-pox, polio, typhoid, malaria etc which used to be the dreaded scourge in the past are no more so. However, new diseases are erupting unnoticed, but the most satisfying part is that the medical profession is so highly evolved that it can address any challenge of any nature very quickly. The preventive and curative medical science and entered into a very sophisticated advance technology driven domain which claims to be able to address any issue sooner or later.

This capability has been acquired by mankind through enormous investment in terms of perseverance of labour, time and money. Though all the above capabilities are exclusively available with the rich nations now, the spin off by way of new treatment, medicines, and diagnostic tools etc is reaching out to poorer nations also sooner than before. Nepal perhaps, cannot do its own research but it can adopt new knowledge to update its health system from time to time and it can also contribute to world research by making available data and information on the selected diseases. It can be a tie-up for mutual benefits with the global research centres.

Technology driven public health system will facilitate networking of all government health workers and the hospitals digitally. Drones can be used to deliver blood and medicines to remote areas quickly. Even diagnosis of the patient can be more accurate and prescription very precise. Surgery by laser, use of robotics and artificial intelligence in forecasting endemic health issues are going to be the game changer in the future. Whereas compulsory health insurance with full coverage will go a long way in reducing costs for families, the stress on non-medical factors for improving the day to day living will definitely reduce the financial burden on any public health system. The recent years have seen the mortality rate going down in most of the developing countries including Nepal because of enlarging public spending in health. However, the sky is the limit, the allocation of resources as percentage of GDP can be raised to approximately 5-6% and if spent wisely, coupled with technology, Nepal can build a vibrant public health plan, which will reduce mortality rates to world standards as well as reduce cost on health for an average family to a reasonable level.

Agrawal is Chairman of Nimbus Group.

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