Author: Anup uprety, MD
My name is Anup uprety. I am an anaesthesiology resident working in Tribhuvan University Teaching Hospital in Nepal. As a medical doctor, I am describing the current situation and challenges of our health system in South Asia. Nepal is a low and middle income country sandwiched between two largest growing economy India and china. With a population of 28 millions, life expectancy of 69 years and per capita GNP of USD 620, it is trying to tread its path towards the prosperity. The health system that was introduced in 1956 as a general health plan has now been expanded mainly focusing on primary health care. A robust health network system with sub health post as a basic unit and district hospital in the periphery form an important part of health care delivery system with regional hospital and tertiary care center providing speciality care. Since then progress made in field of medicine in remarkable. Following National health Policy in 1991 which opened door for private sectors to invest in health, there is mushrooming of private hospitals accounting for major chunk of health service delivery. Currently there are 366 private hospitals incomparison to 123 government hospitals.
The constitution of Nepal has stated health as a fundamental right and every citizen has the right to basic health service free of cost. Range of health care services and certain drugs have been made free of cost at government funded health facilities. To encourage institutional delivery, government has made deliveries free of charge at government health centers and some private facilities along with cash incentives upon institutional delivery. Government of Nepal also started offering subsidy in treatment of cancers, spine injuries, heart disease upto $1000 although not adequate to cover all cost and has made renal transplant and hemodialysis free of costs. Although very primitive but community based health insurance system is currently piloted in 6 districts which covers upto $500 for family of 4 members on payment of annual premium of USD 25. Nepal achieved most of the UN MDGs targets with some partially achieved.
Despite, the constitution of Nepal has guaranteed health as fundamental right of the citizen, reality is still a far cry. Nepal has only 0.67 doctors and nurses per 1,000 population, a figure significantly smaller than WHO recommendation of 2.3 per 1000 poulation1. The rapid growth of private sectors in delivery of health services has not only crippled the already underfunded government but has also increased the cost of treatment in a country where out of pocket expenditure in health is more than 50%. When I worked as a house officer in ICU of Teaching hospital, I witnessed many people forced to withdraw treatment because they did not have money or they were bankrupt. And it is a pity that one get to choose his treatment on the basis of credit on his bank account since we don’t have a robust health insurance system to cover the health expenses. In background of lack of government supremacy in health care delivery, more than 70% share of private sector investment in health facilites and no good insurance system, the out of pockets (OOP) expenses will definitely escalate. And as report says that if OOP expenses grows more than 20% it impoverishes the population. This problem definitely warrants government to aaddress aforementioned problem if ‘Right to health’ as stated in an article of universal declaration of human rights is to be ensured.
Nepal has entered into new system of federal republic state. Currently there are 7 federal states. Until now health care delivery system was revolving around primary health care system with networking of small peripheral health facilities with female community heath volunteers in the frontline. However, the current heath system needs a massive restructuring if health for all and equity in health to all is to be delivered. The current spending on health which is 1.8% GDP also needs to be raised along with integration and cooperation with neighbouring countries.
Where are we in South asia
On December of 1985, in order to promote regional trust and cooperation along with working on commonground for economic and social prosperity, seven nations; India, Bangladesh, Pakistan, Maldives, Srilanka, Bhutan and Nepal adopted a charter to form South Asian Association for Regional Cooperation (SAARC). Being one of the most populated region accounting for 22 % of global population, the countries in this region share common health problems, majority of people are under poverty line, are affected by similar natural calamities. Infectious diseases are still a major killers in these region with Srilanka only making a remarkable progress in these region. All countries have been adopting WHO and UNICEF supported immunisation programs and IMCI program targeted for diarrhea and acute respiratory infections. There is increasing threat of non communicable diseases in this areas due to epidemiological transition.
In Bangladesh, Nepal and India OOP Expenses on health is estimated to be 48 to 69 %. Such situation will definitely push citizens in those countries in brink of financial exhaustion. All countries are investing less tha 4% of GDP in Health contrast to WHO recommendation of at least 6%. Like Nepal, in India 78 % of health care is provided by private sector. Majority of people in all countries of these region live in rural areas. The health Insurance coverage system is primitive in most of the countries. Advocacy of Universal Health coverage and Health insurance sholud be a major agendas that SAARC needs to collaborate on to ensure Health to all.
1. International labour Organisation Migration of health workers from Nepal. A Report.