By Shiva Raj Mishra, Brisbane
4 July 2017
For almost a year, we saw an amazingly talented and young leader serve as Nepal’s health minister. He contributed to high level meetings with global policy makers, participated in conferences around the globe where audiences were amazed by his knowledge of healthcare along with his spectacular fluency and clarity of expression in English language. He inspired researchers, advocates and the general public alike, both at home and abroad.
Now, with the dissolution of the cabinet, it’s time to bid farewell. So, “Thank you so much!” I am sure the entire country feels the same way as me. We expect you to ride well in your political career.
Your appointment to the ministry took its focus to non-communicable diseases and as a result the package for non-communicable diseases (PEN) in some districts is finally getting some momentum. Similarly, the long-awaited organ donation policy was revitalised and you yourself expressed commitment to donate your organs. That is simply commendable! Again, you brought the ‘make a commitment campaign’ which inspired many to take steps for a NCD-free life. Banning junk food at schools and canteens was another milestone you achieved. Kids will be indebted to you in the future as they will make less visits to doctors than their parents. They will be less exposed to cardio metabolic diseases as well.
You proved your leadership skills when you successfully managed the almost non-functional structure in the country’s oldest hospital, the Bir Hospital. This hospital has since gotten an improved management leading to greater efficiency. The improvement in the drug procurement mechanism that became possible following an amendment to procurement laws and regulations was yet anther milestone. As a result of the cabinet decision, the department of health began procuring medicines directly from the public sector alone. This effectively ended the hegemony of the private sector.
But I need to be more critical than merely giving lip service in your favour.
We all know that Nepal currently does not have an insurance system. A prototype of social insurance system was started in two districts and this will be taken to five additional districts this year. Furthermore enrolling in Rastriya Swasthya Bima Niti has been made compulsory for every citizen of the country. The government provides hundreds of thousands of Nepalese rupees for each case, for at least ten chronic diseases, with the hope that the poor will benefit from it. However, further evaluations in future will only demonstrate if the ‘poor’ indeed benefits from such scheme.
But all good stories may not have a happy ending. The appointment in Nepal Health Research Council was more of a political interference. It became a controversial decision and was brought to the court several times. Similarly, other councils were caught up in political appointments which again was very unfortunate. In a country like ours, the decisions we make as managers are easily manipulated by people around us. Hiring experts can help but it may not make political cadres happy.
The recent decision about doctors requiring to work full hours is a welcome initiative. As I spoke to some of my friends who are working as medical officers in district hospitals and primary health care centres, they are quite perplexed as there aren’t many things doctors can do without sufficient logistics. Holding them accountable is welcome, but the ministry really needs to provide basic amenities, such as reliable internet, access to medical libraries, research skills to help their everyday clinical practice so that they can continue working happily.
In a population of 30 million, people are suffering from a medical poverty. Starting of insurance scheme has brought a lot of hope but there are some woes that need consideration. People in the ministry and those at the peripheral level have a different meaning for the program. Some think this is like any other programs under the ministry where a lofty sum is distributed to the district supervisors for running programs while others see it as way to muscle power. However, the crux of social insurance, the framework for risk pooling structure is not clearly understood among the concerned stakeholders. Should we cover both public and private services? Regulation and accreditation of private providers: how can we regulate them? Health technology assessments (HTA): (linking inclusion of expensive medicines and procedures into the service protocols), do we really have a structure for HTA? Doctors migrate and quacks rule the countryside: how can we stop this? These are very common questions among people. As a member of the public, I am free to ask these questions but I don’t necessarily have the answers. But it would be fair to expect that the concerned officials in the ministry have a satisfactory answers to them.
Despite packaging hopes and distributing penny, the ministry and its allies (public and private sectors, international agencies) should think of putting forward actionable projects and continuing past activities and initiatives. No ‘quick fix’ because health system does not need a Jhandu bam. Short term initiatives in the past incurred heavy expenses but failed to make any difference. The sustainability of every initiative is important, and we should work on the system as a whole rather than at its appendages.
Finally, as only a few days remain until the appointment of a new minister, we as the public should be thankful to our past health minister for inspiring Nepalese youths to dream. The younger generation is rising now, you could see it in the recent mayoral elections — specially in the one in Kathmandu. Change is definitely coming.