As a nation, we have made remarkable strides to achieve better health and longevity rapidly in the past few decades. But we cannot sit on our laurels. There is much work to be done to improve health and wellbeing for all Nepalis. And, importantly, we are not on track to achieve the health targets we have set for ourselves, to meet our global commitments to the United Nations’ Sustainable Development Goals (SDGs) by 2030. When we speak about health, we must consider our progressive constitution, which recognizes the fundamental right of individuals to health and upholds health as an ultimate state responsibility.
From the outset in 2008, as drafters, we wanted our constitution to reflect the society we wanted to build for ourselves. Our firm belief was that accessible, affordable and quality health care for all must be at the core of our hard-fought democratic ideals. We recognize that guaranteeing the health of our citizens is both moral and a smart thing to do. That’s because healthy citizens maximize their contribution to society and are economically productive. Our constitution underpins universal health coverage—a key SDG objective. It guarantees access to basic health services without cost. It stipulates rights to clean air and water.
Aspirations vs reality
Every woman has a right to their reproductive health. Our federal framework grants local governments significant autonomy and responsibility to ensure healthy individuals and communities, which provides unprecedented avenues to make our health systems responsive and accountable to the people. However, there is a huge gap in our aspirations and reality. I witnessed first-hand the challenges we face in realizing our constitutional aspirations.
In Nepal, we lose more than 1500 young women during delivery every year, and 34 babies die every day before reaching 30 days of life. Pregnancies and childbirths are a celebration of life, a celebration of womanhood and motherhood but for many families in Nepal, pregnancies and childbirths are risky propositions, a gamble of life and death. Every year, 23,000 children die in Nepal before their 5th birthday. Among those that survive, one in four are malnourished, dampening their physical and cognitive abilities throughout their life.
Each woman that dies during delivery or each child that faces early death is one too many. We must do our utmost to protect every life. We must recalibrate our health systems to value every life and not see people’s lives and health as mere statistics and trends.
The glossy reports and publications in the health sector never fail to praise Nepal’s past efforts to decrease mortality rates and ratios. But we must remember that behind the rates and ratios are individuals. Each woman that dies during delivery or each child that faces early death is one too many. These are real people that we lose: Mothers, children, sisters, brothers, and friends. We must do our utmost to protect every life. We must recalibrate our health systems to value every life and not see people’s lives and health as mere statistics and trends.
People’s feelings, struggles and stories should not be lost amidst our discussions and figures of mortality rates and ratios. While access, quality and financing are necessary guiding principles for our health systems to advance universal health coverage, our systems and institutions must also be guided by empathy.
We have seen considerable increases in access to healthcare services in the last few decades, though the access is not equal across population sub-groups of different socio-economic and geographic attributes. The overall increase in service access, coverage and utilization has not been able to lead to desired outcomes, and we are still way behind our ambitions to achieve Universal Health Coverage (UHC). Poor quality has increasingly been acknowledged as a key issue hampering further progress in health outcomes, not just in Nepal but also in several other low-and middle-income countries.
I had the honor to be part of the Lancet’s Global Health Commission on High Quality Health Systems in the SDG Era. The Commission highlighted that health systems are under greater pressure to produce better health outcomes and greater social value to meet the changing health needs, growing public expectations, and ambitious new health goals. The Commission asserted, in their own words: “…Providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a high-quality health system—one that improves health and generates confidence and economic benefits—is primarily a political, not technical, decision.”
In line with their recommendations, I urge the government of Nepal “to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation.” Universal Health Coverage is also not possible when a large proportion of the population is deprived of healthcare because they cannot afford it. Public investment on health in Nepal is much lower than the global benchmark for a country like ours.
Out of every hundred rupees spent on healthcare, an average Nepali has to pay around 60 rupees directly from their own pocket. We still have more than half a million people pushed below the poverty line every year because of catastrophic healthcare costs. Many others forgo healthcare risking deterioration and loss of life simply because of the unaffordable costs. All this despite the implementation of several social health protection schemes, which are so fragmented, they are not able to show meaningful impact.
It was when I was the health minister in 2016-2017, we made extensive efforts to prepare the ground for a social health insurance program that covered every single Nepali and provided financial protection for healthcare, including the ultra-poor through government subsidy. The National Health Insurance Act was developed under my leadership. However, our national health insurance program is still far from achieving the objectives due to its design flaws as well as delivery failures.
Seven years after its implementation and geographical coverage of the whole country, except the Kathmandu valley, only one in four Nepalis is part of the program. The Social Security Fund, another major social protection scheme of the government of Nepal, also offers health insurance to its members. This is just an example of duplication and fragmentation of schemes managing public resources which has certainly not been helpful. A thorough examination of these two large schemes, as well as several other small ones, is essential to diagnose why social health protection remains elusive.
What the government should do
The government then needs to come up with a holistic solution to achieve financial protection for health by 2030 – all under the leadership of the Prime Minister, as this is not merely the responsibility of one sector ministry. We must recognize that many factors shape our health. Health is not an isolated issue. It is also a cause and a consequence of our social, economic and development related to many SDGs. Policies and actions of other sectors can have significant bearings on health.
Consider that the environment around us—the air we breathe, the quality of water in our taps, the physical infrastructure surrounding us, the quality and variety of foods in our markets, the nature of our jobs and professions, our habits and behaviors and accessible health services—plays essential roles in our health. When we understand and internalize these health intricacies, we will have crossed a significant milestone on our journey towards healthy citizens.
Therefore, ‘health in all policies’ is paramount to achieve broader health goals and impact. ‘Health in All Policies’ is paramount to achieve broader health goals and impact. A system of mandatory review of government policies of different sectors from a health lens can ensure that a new or revised policy will, at the least, not harm the health of a common person, and, to the extent possible, will generate positive health dividends. It is also important to ensure a comprehensive and holistic response to the giant challenges posed by non-communicable diseases (NCDs), malnutrition and poor mental health and the impact of climate change—all of which require multi-sector and multi-level efforts and interventions.
It is worth recalling the Constitutional provisions that Health is a joint responsibility of the three tiers of government, and hence, all policies need to align and aim towards one common direction. Citizens’ voices, too, are critical in shaping the broader health agenda. We need to listen more to them and communicate more with them. I have found many in my own constituency who are unaware of their health entitlements and the state’s health provisions. Citizens need a clear pathway to provide feedback or voice their needs, which is lacking. We need to catch up on the importance of people’s needs in our health discussions.
As a government, we have discussed about universal health care in Geneva and adopted it in New York, but we have yet to discuss it with our own public. As taxpayers and users of the system, their needs and aspirations should shape our decisions. Unfortunately, I cannot confidently claim that our health systems in Nepal are tailored adequately to meet the need of our citizens. As a result, our public health sector faces a crisis of confidence. People are losing faith in the government’s ability to address their health needs and its commitment to improving their health. We cannot afford to continue investing in health systems people do not trust, value or underutilize. We must rethink the design of our health systems and overhaul our institutions and approaches.
We cannot afford to continue investing in health systems people do not trust, value or underutilize. We must rethink the design of our health systems and overhaul our institutions and approaches.
In Nepal, the discourse around health is yet to sufficiently reach our politicians, democratic institutions and the larger public. Despite recent rhetoric on inter-sectoral action, most government line agencies are yet to espouse health in their strategies and activities. In reality, health remains an ‘internal agenda’ of the ministry of health. However, solutions to the pressing health challenges we face today and contained in the SDGs do not exclusively lie in our health ministry alone. We know that when women have opportunities to access education, they are significantly more likely to survive childbirth and more likely to have healthy children. Our agriculture and food systems have a direct influence on our nutritional needs. We can only curb road traffic accidents with the leadership of the transportation sector. Despite knowing the importance of a whole-of-government approach and even after putting in place multisector plans in areas such as nutrition and NCDs, we have struggled in Nepal to harness collective action among different sectors.
Political will is a key
We cannot advance health and the larger SDG agenda without a strong political commitment. Resources spent on health are an investment for a brighter future of Nepal and its people. With the current levels of investment and efforts, we will not be able to achieve the health, social and economic goals. As parliamentarians, we also need to be more responsive and use the levers at our disposal to anchor different government line agencies to advance our people’s health. We should hold the government to account and champion public debates and discussions about the importance of our people’s health.
I have recently established a new model of urban health facilities in my constituency in Gyaneswor of Kathmandu. I’m encouraged by the willingness of many political leaders to replicate the model in their respective constituencies. We need to keep working on galvanizing our parliamentarians and political leaders to establish health as a prominent political agenda and rekindle the political spirit to realize the health aspirations of our progressive constitution. Let us work together on this noble goal. Professor Amartya Sen in his keynote address to the fifty-second World Health Assembly said the following: “Development has to be primarily concerned with enhancing the lives we lead and the freedoms that we enjoy. And among the most important freedoms that we can have is the freedom from avoidable ill-health and from escapable mortality.”
[The above article is an abridged version of the keynote speech Gagan Thapa delivered on the occasion of Swasthya Khabar Health Award ceremony organized by Nepal Live Group in Kathmandu on September 8. Thapa, currently the General Secretary of Nepali Congress and an MP, was the health minister of Nepal in 2016. Nepal Live Group, the publisher of Swasthya Khabar Patrika, Nepal Live and Nepal Live Today, honors health professionals and institutions contributing to Nepal’s health sector with awards every year.]