Nepal
Arjun Karki, MD; Patan Academy of Health Sciences
Health Care Challenges and MDGs in Nepal: Some Reflections
Background
Nepal is a one of the low resource country sandwiched between two giant countries – China and India – which
are also rapidly emerging world powers. According to the national census carried out in 2011, Nepal has a total
population of 26.5 million of which >80% live in rural areas (1). About the same proportion of people depend
on agriculture for living. Though government data (2) show only 25% of the population is below the poverty
line (i.e. <1.25 US$ per capita income per day), many suspect the accuracy of this figure. The general
speculation is that the proportion of people living under the poverty line is somewhere between 40 – 50 %.
Given that 2/3 of Nepal's topography consists primarily of hilly and mountainous areas, a majority of people
living in such areas continue to be deprived of the fruits of development due to lack of proper access to,
among others, basic social services and employment opportunities.
Until about 50 years ago there was hardly any organized public health system in Nepal. There was neither any
official health policy nor any capacity to develop the required human resources for health in the country. A
central hospital in Kathmandu and a few smaller hospitals located in other cities were the only modern
medical facilities in the country, catering primarily to the elites of those areas (and their families and friends)
and to the general public living in and around Kathmandu, the capital city of Nepal. However, Nepal has made
enormous progress over the last 50 years. Compared to that era, we now have clearly defined health policies,
health programs and a health system. It is also worth mentioning here that the Interim Constitution of Nepal
(2007) clearly states “Every citizen shall have the right to basic health services free of cost from the state as
provided for in the law”. Even though the quality of performance is not uniform, we have rich networks of
primary health care institutions established throughout the country. There is a Sub-Health Post (SHP) for each
Village Development Committee, the most basic political / administrative unit of the country, operated by
middle-level health workers and these provide basic comprehensive primary health care services to a
population of 8, 000 – 14, 000 living in that area. There are nearly 4000 SHPs in the country (3). The public
health care programs provided through these SHPs are largely dependent upon community based women
volunteers, called Female Community Health Volunteers (FCHVs). These FCHVs have been publicly recognized
as the main contributors to the steady improvement of national population health indices and therefore
acknowledged as the backbone of Nepal's primary health care program. There are nearly 50,000 FCHVs in
Nepal (3). In the setting of a District, the other health care activities (both preventive and curative) that are
beyond the scope of SHPs are supported by networks of Health Posts, Primary Health Centers (reinforced by a
general physician), District Health Office / District Hospital. Activities and services that are beyond the scope
and capacity of these institutions are provided by the zonal / regional and national level hospitals / public
health divisions.
Current Health Care Challenges
It must be said that the investment made to create the current health system has paid off well. Many of our
national population health indices have improved considerably over last few decades. However, because of
the continuing geographic (urban-rural), economic (rich-poor), gender (male-female) and cultural (high caste –
low caste) disparities, this improvement is not even and in some cases widening further. Unfortunately, the
current health system has not been able to deal with the public health challenges of the day in an equityoriented, need-responsive and comprehensive way.
Nepal currently faces a triple burden of disease. Even though the incidence of common vaccine-preventable
diseases has been reduced substantially, the classic communicable diseases such as TB, leprosy and vector
borne conditions like malaria and Kala-azar still remain a challenge. On top of that HIV/AIDS is a big public
health threat. Noncommunicable diseases, which account for 44% of total deaths and 88% of outpatient
contacts (4), have emerged as a major public health issue in Nepal. In addition, conflict-driven violence, traffic
accidents and other natural disaster related injuries take a significant toll in terms of morbidity and mortality.
Likewise, despite a steady improvement in overall child survival rate, malnutrition is still affecting a significant
proportion of our children (4, 5). For example, almost half of our under-five children are estimated to be
malnourished.
As mentioned above, there exists a rich network of primary health care institutions throughout the country.
However, not all of them are easily accessible to the rural population. Official government reports state that
30 – 40 % of people living in the hilly and mountainous areas of Nepal need to walk for up to 4 hours to reach
these health care facilities (4). In addition to lack of adequate infrastructure, the regular supply, supervision,
effective deployment and retention of appropriately trained and motivated health workers are identified as
some of the key factors for the suboptimal performance of our health system.
It has been widely recognized, globally and nationally, that human resources for health (HRH), is a critical
component of the health system. Nepal started its first medical school in 1978, and there are almost 20
medical schools in Nepal, mostly private and for profit. The situation with regard to nursing schools and
schools of allied health sciences is similar. Unfortunately, however, rather than serving the public system, most
of the graduates of these schools prefer to work in private institutions or emigrate to western countries in the
name of further training and / or employment. In addition, HRH development has been rather skewed in
Nepal. The major focus has been in the training of physicians and nurses. Even in the area of public health, no
clear plan is in place to produce professionals in the areas with gross shortages, such as Health Policy and
Planning, Health Care Management, Hospital Management, Health Economics, HRH Planning and
Management. Due to the non-existence of professionals with adequate expertise in these areas, Nepal
continues to be at the mercy of expatriate consultants and thereby a victim of donor driven prescriptions for
the ills of our health system.
In Nepal there is no health insurance system in place. Out of pocket (OOP) expenditures still account for 55%
of health expenditure (4), and government and donor agencies’ contributions cover the rest. The OOP figure
was in the range of 75% until the government introduced, in 2007/8, free health care at primary level health
care institutions. When it comes to secondary and tertiary health care services, the private sector is the major
provider and at a cost unaffordable for the majority of people. Since there is no system of subsidy or charity, it
is the patient and / or the family who has to bear the entire cost. In the context of the fact that a considerable
proportion of Nepali people are living in poverty, treatment of complex medical conditions often precipitates a
financial catastrophe. Given this, the concept of universal health coverage is an aspiration.
It is also worth noting here that Nepal has committed itself to changing the existing unitary state structure to a
federal structure on the basis of “identity” and “economic viability”. However, specific details with regard to
the number of states and the roles and responsibilities of individual states and the central federal structure
remains unclear. Hence, it is a matter of speculation regarding the model of health care once Nepal establishes
a federal system.
Millennium Development Goals
Despite all these challenges, Nepal has been making remarkable progress towards achieving most of the MDG
targets, particularly the health related goals. Despite the decade long violent conflict, the progress that Nepal
made in reducing the child (4, 5) and maternal mortality (4) indicates that Nepal is very much on track in
meeting the health-related MDGs. This is extremely impressive, and is attributable largely to the role of FCHVs
in the community. According to the latest report by the National Planning Commission (6), Nepal is likely or
potentially likely to meet all the MDGs except the targets related to Employment, Reproductive Health and
Sanitation. While this certainly is encouraging, the same report also recognizes the fact that such progress
remains unequal with respect to the geographic location, gender and social groups. For example, though the
poverty level is said to have reduced from 42% in 1996 to 25% in 2009, the Gini coefficient has increased from
0.34 to 0.46 during the same period, indicating widening inequality (7).
Post Millennium Development Goals Era: The Way Forward
While Nepal aspires to achieving all the MDGs by 2015, given the current reality, it is unlikely to succeed
completely. While the agenda is still relevant to address the needs of our people, we have to continue our
efforts even beyond 2015. However, in order to succeed in achieving these goals, there is a need for
innovation in defining our strategies, identifying / acknowledging and prioritizing our problems / challenges,
designing effective and evidence-based, multi-sectoral interventions and allocating the necessary resources to
implement those interventions. We also need to focus on several other issues that are critical for the sustained
improvement of the health of the Nepali people at large. These include:
a) Political Stability: Without a stable government with a mandate to serve the nation for a reasonable
period of time, health system leaders may lack commitment to developing and ensuring implementation
of appropriate policies and. Though a big challenge, the promulgation of a new constitution would form a
solid basis for moving the country towards political stability.
b) Equity based Development: It is almost impossible to make a sustained improvement in the health status
of the people without improving their quality of lives. In other words, sustained health gain is not possible
without addressing the social determinants of health. This is particularly true in the case of poor,
marginalized and vulnerable citizens. They are the ones who have thus far been deprived of the fruits of
development. State support for their skill development accompanied by fair access to economic
opportunities is crucial. Only a pro-poor/pro-people government could undertake this in a just manner.
The continuing political conflicts / debate over the last 15 years have helped raise the political awareness
of ordinary citizens. There are also many formal and informal organized groups (e.g., mothers groups,
forest groups) in many parts of rural Nepal which have, and are, engaging in significant development work
for their communities. There is a big potential for such grassroots level organized activities to be
replicated and scaled up if assisted by appropriate policy measures This could create powerful pressure
and a monitoring mechanism for responsive and accountable government.
c)
Institutional Capacity Development: Because of lack of strategic planning and inadequate investment in
the area of HRH, Nepal continues to suffer from the ill effects of donor driven health (and development
related) “prescriptions”. This is one critical area that needs to be prioritized during the post-MDG era.
People’s Health Movement could assist in effective advocacy to compel donor agencies and external
development partners to take a long-term view and help the country develop its intellectual capacity as
well as supporting physical construction and short-term projects. We need urgently to gain Intellectual
“independence” to define, shape and realize our destiny.
d) Cultural Transformation within the “System”: Official policy / program documents appear appropriate,
coherent and logical. But the implementation of these policies through various programs and projects
results in sub-optimal outcome and impact. Part of the reason is the continuing political uncertainty and
instability (stalling of the constitution building process, absence of parliament, frequent change of
government and health ministers etc.) and the pervasive sense of lawlessness, confusion and ambiguity
among the rank and file within the health system and population at large. However, in addition to that
there are also deep rooted cultural issues such as absence of adequate level of work ethics, critical
thinking, long term strategic approach in developing policies / programs and, above all, genuine
commitment to responsive stewardship. There is no easy prescription to transform these values and
attitudes. Nevertheless, there is a need to recognize this aspect, which deserves critical reflection, as a
major element of achieving our health goals. Appropriate strategies and interventions should be designed
and implemented to bring about cultural transformation within the health (and other) system(s) to
overcome obstacles of this nature.
References:
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7.
Census Report. Central Bureau of Statistics, Government of Nepal (2011)
Nepal Living Standard Survey (2011). Government of Nepal
Department of Health Services Annual Report (2010-11). Ministry of Health and Population
Nepal Health Sector Program – Implementation Plan II (2010-2015). Ministry of Health and Population
Nepal Demographic and Health Survey (2011).
Nepal Millennium Development Goals – Progress Report (2010). National Planning Commission
Nepal Progress towards Millennium Development Goals (2010). Asian Development Bank