Federal restructuring and health care delivery in Nepal Post 22 / 24 (October 2018)

Restructuring of the whole governance framework with its all functional structure that includes health care delivery infrastructure is a humongous task and a historical event. In a way, we are lucky that all of us are witness to such a turning point in our Nepal history. At this juncture, however, our government should act “farsighted” and be “proactive” in foreseeing possible consequences, which could be either positive or negative or mixed that might be expected at the different level of health care delivery. For this, our leadership must act responsibly and in concerted effort engaging all stakeholder. This means that all political leaders must act above their party lines. At this crucial hour, let us rethink and reimagine of what should be streamlined ad course corrected in the deliverance of basic health service (BHS) package to all Nepalese citizen. This provision of BHS is stated as a basic fundamental right of every citizen and it's the responsibility of the state to translate those basic services through public health structure. It is therefore stated in Part 3, Section 35 of the New Constitution (2072 BC).

“The State shall direct its international relations towards enhancing the dignity of the nation in the world community by maintaining international relations on the basis of sovereign equality while safeguarding the freedom, sovereignty, territorial integrity, and independence and national interest of Nepal.”

In order to realize, translate and deliver those rights of all Nepalese citizen as basic services in the community, 4 directive principles have been promulgated in Part 4 Section 50 such that these directive principles “shall be the guiding principles for the governance of the State” stated in Section 49 of the same part 4 as follows:

1.     The political objective of the State shall be to establish a public welfare system of governance, by establishing a just system in all aspects of the national life through the rule of law, values and norms of fundamental rights and human rights, gender equality, proportional inclusion, participation and social justice, while at the same time protecting the life, property, equality and liberties of the people, in keeping with the vitality of freedom, sovereignty, territorial integrity and independence of Nepal, and to consolidate a federal democratic republican system of governance in order to ensure an atmosphere conducive to the enjoyment of the fruits of democracy, while at the same time maintaining the relations between the Federal Units on the basis of cooperative federalism and incorporating the principle of proportional participation in the system of governance on the basis of local autonomy and decentralization.

2.     The social and cultural objective of the State shall be to build a civilized and egalitarian society by eliminating all forms of discrimination, exploitation and injustice on the grounds of religion, culture, tradition, usage, custom, practice or on any other similar grounds, to develop social, cultural values founded on national pride, democracy, pro-people, respect of labour, entrepreneurship, discipline, dignity and harmony, and to consolidate the national unity by maintaining social cohesion, solidarity and harmony, while recognizing cultural diversity.

3.     The economic objective of the State shall be to achieve a sustainable economic development, while achieving rapid economic growth, by way of maximum mobilization of the available means and resources through participation and development of public, private and cooperatives, and to develop a socialism-oriented independent and prosperous economy while making the national economy independent, self-reliant and progressive in order to build an exploitation-free society by abolishing economic inequality through equitable distribution of the gains.

4.     The State shall direct its international relations towards enhancing the dignity of the nation in the world community by maintaining international relations on the basis of sovereign equality while safeguarding the freedom, sovereignty, territorial integrity and independence and national interest of Nepal.

Now is the time for all Nepalese citizen to rise as a nation of hard-working people, although the task ahead looks ambitious. To realize our fundamental right, in particular, to deliver BHS to the people, MOHP must be able to provide for free and of quality care. So it is important to think through the content of the package and make it realistic such that our 4 S (system, software, space, supply)  is capable of handling and delivery of those services. However, it is good to be up front and get prepared that there is a risk that MoHp will struggle fighting plenty lawsuits, given that our health care delivery is weak at present and after all the provision of BHS is law and if you do not provide these services, then one has every right to demand the service. So BHS has to be realistic based on current capacity and capability of local health institution to deliver all the elements of health services.

One can see the danger of making the package bulky from the very beginning without certainly of being able to deliver with quality to all from rural municipal of Humla to KTM. Here, we have to be  cognizance of possible risks that MoH has to face in the future if we are to overload BHS. It is here to remind us that MOHP is already providing free services for certain groups for cancer, kidney disease etc. Some commenters are saying that these free care services need not go in BHS package since GoN will not have enough funds to cover such costs. Also, it is said that some diseases have geographic concentration, these need not go into BHS package, while local government could prioritise these diseases and allocate additional resources from their revenue. It  is also shared as an opinion that few disease (KA/Malaria/Leprosy) that are in the verge of elimination may require focused attention and quality must be ensured or else the elimination goal may be off track. Such priorities can be best handled as a dedicated  programs and need not be included in BHS package. For now, health experts have done a good work in defining the services for BHS package, but still it is sad that the list is too long. Financial costing could be one of the way to review the package and come up with a realistic one.

Mental Health Care Delivery in Nepal Post 21 / 24 (September 2018)

It is not an overstatement that mental health care delivery is one of the sector within Nepal health system that gets little or not attention at all. However, the burden of this same illness, which is one of the most prevalent illnesses inflicting our human kind, is increasing every year  with the rise of modernity, rapid urbanisation, poverty, social upheavals, breakdown of social fabrics. This applies the same in Nepal, where taboos related with mental illnesses is intense such that we may consider, there such practices, such condition as “unworldly possession” beyond modern medicine and care. Therefore, there is a growing consensus among leaders, health professionals and thought leaders that this global as well as national phenomenon  need to be addressed before we drown ourselves, families and community with the rising burden of mental health problems.

In order to bring mental health issues at the policy table within the ministerial function and space, we need to start discussing mental health (its burden, causes, socio-economic, political and its overall management) as new policy dialogue. For this, we need to acknowledge that “without mental health, there can’t be healthy and wellbeing of citizen, family and our community”. We need credible “data” that state the ground reality and people’s suffering with various mental illnesses like anxiety disorder, affective disorders, schizophrenia and those many others classified in Diagnostic and Statistical Manual of Mental Disorders (DSM - 5). For now, we need to seriously analyze all the data gathered through HMIS platform. Our guess, although there is concern related timeliness and completeness as well as the quality of data, there is an acceptable level of basic mental health data from all levels, including health post, district hospitals, regional and tertiary hospitals. Also, we can safely say that there are numerous academic papers as well as program reports, which we can review and get fair pictures of the mental health situation in Nepal. Based on such analysis, as well as landscape analysis to assess the mental health care services, we may be able to get the panoramic view of Nepal’s mental health scenario.

To repeat again, “there is no health without mental health”. According to New Constitution of Nepal (2072 BC), every citizen has inalienable right to live a dignified life and state has every responsibility to provide basic services that include mental health at the doorstep or near villages. Our country is also committed to Sustainable Development Goals (SDG), and in particular, since we are talking about people’s health and welling, the goal no 3 is about “good health and well being”. To achieve this goal by 2030, one the target is to “reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being”. Also, it is appropriate to stress here that this goal number 3 is related to all other goals like poverty reduction, reducing inequalities, ending hunger, economic growth, and social justice.

To achieve SDG targets by 2030, one of the essential pathway is to achieve Universal Health Coverage (UHC), which means according to WHO that “all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.” To achieve this grand goals, we need to work hard and secure health care financing and most importantly, we need to have dedicated human resource management, unlike current political interference.

Next Steps in Strengthening the Mental Health System, I have liberally sourced a conclusion form WHO - AIMS report on Mental Health System in Nepal. It is high time we read through it.

Excerpt from “WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN Nepal”

“To ensure the availability and accessibility of mental health services for all of the population of Nepal, and in particular for the most vulnerable and underprivileged groups of the population, mental health services have to be integrated into the general health services system of the country. Mental health care facilities should be developed and have an active and dynamic interaction with the communities they serve. Mental health services have to be made available at the regional, district and peripheral levels. They have to be integrated into general health services at all levels including primary health care. Mental health resources have to be distributed in accordance with the mental health policy, and an adequate supply of essential psychotropic drugs should be maintained. Research exploring the development of a more efficient and effective mental health care structure has to be undertaken, and an evaluation of the impact of such structures and services has to be made. Given that there are inadequate human resources in the area of mental health to address the need of mental health patients, mental health training for all health workers, preparation of personnel with a specialty in mental health, and training for groups are needed. There has to be adequate and appropriate mental health and behavior science components in all health workers’ curricula in the country. Mental health components have to be developed within the in-service training structures, especially at the National Training Centre and the Regional Training Centres. The manpower of specialists in mental health, i.e., psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers, etc., has to be further developed. Mental health legislation to ensure the rights of people with mental disorders has to be developed and implemented. Finally, awareness raising activities on the formulated rights have to be done as well.”

Source: https://www.who.int/mental_health/evidence/nepal_who_aims_report.pdf

Prevention and Control of Non Communicable Diseases 20 / 24 Post (August 2018)

Key facts

• Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally.
• Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these "premature" deaths occur in low- and middle-income countries.
• Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million).
• These 4 groups of diseases account for over 80% of all premature NCD deaths.
• Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from a NCD.
• Detection, screening and treatment of NCDs, as well as palliative care, are key components of the response to NCDs.

Source:

https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

Nepal National Micro Nutrient Status Survey (NNMNSS) : Key findings Post 19 / 24 (July 2018)

Following 2016 Nepal DHS final report dissemination, Ministry of Health and Population (MoHP), Government of Nepal (GoN) with support from UNICEF, USAID, European Union, CDC, New Era published another key document - Nepal National Micronutrient Status Survey (NNMSS) Report 2016

Key findings:

The Nepal National Micronutrient Status Survey (NNMSS) assessed micronutrient status among representative populations in Nepal, including specifically the status of vitamins A, iron, folic acid, iodine, zinc and the condition of anemia. To assess nutritional status andunderstand factors related to micronutrient status and anemia, the survey also collected information on anthropometry, infectious diseases (malaria, Soil Transmitted Helminths (STH), Helicobater Pylori (H. pylori), visceral leishmaniasis), blood disorders, and markers of inflammation. Additionally, the survey provided information on process and outcome indicators of priority for national supplementation and fortification interventions, and other key nutrition interventions in the country. 

Source: 

https://www.unicef.org/nepal/reports/nepal-national-micronutrient-status-survey-report-2016

Evidence Based Policy and Planning: Our direction for Quality and Safe health care delivery Post 18/24 (June 2018)

This week and prior week was time - spent well. In a sense, I utilised the opportunities plenty in and out of our ministry of health like interactive meetings, workshops, and sometime trainings. I also realised, as many concerned colleagues ask me regularly and i tell them that our ministry is so rich with "knowledge generating activities" as good as any universities. So, we are constantly able to bombard our "neocortex" with constant academic activities, unlike one journalised (although with good intention) recently wrote in a mainstream online news that we just arrive at office, mark our attendance and just go home. Well, that news was partly true that we are not assigned with any divisional role and responsibilities but not the whole truth. Otherwise, we are engaging regularly in various activities as I mentioned earlier. To be honest, I am enjoying this interlude of work experience from joining Ministry of Health and then assignment for Far West Regional Health Directorate and now recalled here at the ministry. It is such an interesting time to both observe and experience at the same time the implementation of federalism that this is our historical moment in the history of Nepal. 

In this climate of change, where we are partly influenced by what is called federal restructuring, I am definitely searching for an opportunity to be useful for our country. I also know that time is always victorious provided you continuously put an honest effort. In this light, I am pragmatic and share benefit of doubt balanced more towards to positive outcome in coming days. Therefore, I am of an opinion that this is an excellent time - period for reading and writing that relates to health related agenda, which is of paramount importance to our people, and in that context, our top tier health professionals need to focus in system strengthening (not fragmenting !!) and that too cemented by scientific evidences and open discussion. It is for that reason, I was fortunate to participate in an "Dialogue for Evidence Based Policy in Federal Context" organised by Policy, Planning and Monitoring Division under Ministry of Health and Population (MoHP) on 16 August 2018 and one day workshop "Evidence Based Health Policy and Planning: Our direction for Quality and Safe Health Care Delivery" organised by Nepal Health Research Council (NHRC) on 21 August 2018.

It was such an atmosphere of positive direction and excitement that Policy, Planning and Monitoring Division took an proactive role in starting the policy dialogue, which was announced that this event will be a regular monthly event in MoHP in the presence of Honorable Health Minister and Madame Secretary of Health. The dialogue went for almost 2 hours, and the topic was procurement and logistic management of medical procurement and logistics management system. The key objective of this dialogue were as following:

1. Discuss potential approaches and modalities of medical procurement and logistics management system in the federal context
2. Discuss on potential roles and responsibilities of the federal, provincial and local government on medical procurement and logistics management of medical products
3. Contribute to develop evidence based policy and plan on medical procurement and logistics management (evidence - based decision making space)

In overall - I found this dialogue rewarding such that we were discussing perennial issue of bottlenecks and red tapes re: public procurement. Although this issue has been lingering in public debate since decades, the representatives from ministry of federal affairs and general administration, ministry of finance (Public Procurement Management Office), National Planning Commission (NPC) and ministry of natural resource (National Natural Resources and Fiscal Commission) took account of opinion raised by participants that life saving medical products and other commodities (like cements/pebble/vehicles etc) can be governed by the same public procurement act. Therefore, there was strong voice raised for review and revision of public procurement act as well as its regulation. Another issue that brought heated discussion was on generic prescription, which is now of agreed consensus such that rationale prescription is what people demand for quality and safe health care and there should be no compromise for quality and safety of the drugs prescribed. Finally, there was proposed various models of public procurement in the context of federal structure. However, there was not single agreed model to be instituted in the changing 3 tier government. Therefore, there was a common understanding that there is need for further extended dialogue on this discussion re: how to adapt public procurement in 3 tier governance.

The workshop organised by NHRC was even more detailed and the key message that I was able to take home was that there is not short cut to health policy and planning without robust and timely evidence base. For that, we need to strengthen health research capacity thought system strengthening and long term investment. Also, we should not forget that there is need for continuous dialogue between research organisations, universities and all sectoral ministries. We should not also forget that health is a developmental agenda, which is also global health security issue of highest importance. In this light, 21st century is the time period for evidence based science, which is undoubted backbone for our future. For more details on this workshop, please visit the Link for the presentation Slides and Group Work Resources of the workshop organised by NHRC

27 August 2018
Kathmandu

The Burden of Disease (BoD) and its cost implication in Nepal Post 17 / 24 (May 2018)

-->

The constitution of Nepal (20 September 2015) has envisioned fundamental rights to be enjoyed by all Nepali citizen and duties of the state to make sure that these rights are secured relating to health, food, women’s health, child, senior citizens, housing, clean environment and all those rights that are directly or indirectly related with health and wellbeing of our people. In addition, Government of Nepal is committed in achieving key indicator targets that are set in United Nations Sustainable Development Goals (UNSDGs). Current global understanding as well as consensus is that “health and wellbeing” of our people is the key developmental agenda, which needs to be incorporated in every sectors of governance within our national as well as subnational planning process with “health in all” as a guiding principle. In order to achieve these national as well as global commitments, evidence based policy making or in other words, data based decision making is the best practice that has to be enacted in our work culture to deliver affordable, safe and quality public service care and sustain its positive impact in the people’s welfare in the community.

Scientific evidences suggest that the population health in Nepal is experiencing through the double burden of diseases such that there is rise in morbidity and mortality of non communicable diseases, while national health system is still overwhelmed dealing with communicable diseases compounded by rapid rise in urbanization and its population, environmental degradation and rising cross border “migration” related health issues. 2009 BOD study in Nepal reports  a shift over time from communicable diseases (primarily pneumonia and diarrheal diseases) to non-communicable diseases (primarily heart disease, COPD, and diabetes) as being the principal drivers of health loss. While understanding trends in the epidemiologic transition is critical to addressing population health, these trends are not immediately clear without comprehensive burden estimates from all conditions. Additionally, some top DALY contributors, including low back pain, migraine, hearing loss, and major depression, are major drivers of health loss; yet, they are largely unrecognized when looking specifically at fatal outcomes. Understanding the disease profile at a national level, and eventually subnational level, is critical to making the best and most informed decisions to improve health outcomes in Nepal at both the population and individual levels. In addition, 2018 Nepal multidimensional poverty index reported that 28.6 % of Nepal’s population is “multidimensionally poor’ and these “poors” as well middle class population are burdened by Out of Pocket Expenditure (OOP), which is alarming at 55.4 % of Current Health Expenditure  (CHE) in the year 2015/16.

In the previous and the existing recently organizational structure and its functional rearrangement, all experts and leadership agree that the health information system is functioning “inadequate” and its structure is fragmented and numerous information system running parallel contrary to the global practice of integrated and efficient health informatics system, which must function as the core system within the larger health system. Therefore, there is an acute need for the establishment of Health Informatics Unit, Monitoring and Evaluation Unit, Health Economics and Research unit within Ministry of Health and Population that work in close coordination and collaboration with Planning and Policy Division within health Ministry, National Health Research Council (NHRC), Central Bureu of Statistics (CBS), and various federal and provincial academic health research institutions.

Apart from small efforts in the 90s and 2006 -2008 there were not significant attempts to produce the BoD picture of Nepal so as to use it in the policy and planning. Whereas in the global arena, Institute of Health Metrics and Evaluation (IHME) at University of Washington produced the results of Global Burden of Disease (GBD) study 2010 in the year 2013 which also included the BoD estimates for Nepal. In November 2014, curative service division at the Ministry of Health and Population (MoHP) led a scoping exercise with technical collaboration with IHME which had the following aims:

• Identify opportunities to refine country level burden estimates for Nepal;
• Collaborate closely with country partners to ensure quality in country level estimates;
• Determine feasibility of estimating burden at the subnational level for Nepal in the near future.

Currently there are two sources of BoD estimates for countries around the world, one is produced by World Health Organization (WHO) and the other is produced by IHME (commonly known as the Global Burden of Disease (GBD) study group). Both has their own strengths. However, IHME has been producing BoD estimates annually since 2015. Understanding the need to providing a single source of BoD estimates, IHME and WHO Headquarter have recently signed an agreement to produce the BoD estimates jointly. With this, countries will have a single BoD estimates to use for policy and planning for the year 2018 and this results are expected to be available early 2020.

To work in line with enhancing capacity of MoHP and concerned stakeholders in the areas of BoD, there has been a MoU signed recently with IHME by MoHP and the Nepal Health Research Council through which in the coordination of NHRC and in close collaboration with MoHP the process for refining BoD estimates for Nepal has been initiated.

In order to address these alarming health related expenditure and its burden to household, Government of Nepal has implemented health insurance as one of the vital and sustainable preventive measures to safeguards families against catastrophic health expenditure, which is the key objective of Universal Health Coverage (UHC) and to achieve this commitment (NHP 2014) is the sole duty of Government of Nepal. However, to achieve what we have envisioned and committed to Nepal citizen, there is an acute need for objective measurement of “biomedical” as well as “economic” burden of diseases and health related events. Also, we need to be cautious that the biomedical approach of measuring BOD only focuses on the individual who is ill, while ignoring the burden of disease for families, households, and social networks.  Therefore, if we are able to capture the near – truth BOD, it would provide us with a powerful tool to guide the policy and program decision making of a country.

Key Actions To be taken:

First and foremost, MoHP should initiate extensive review of literature, national and internationally published reports on “health” and “well being” related data utilizing national experts. This will provide all of us with the broad understanding of the landscape on health related broad scenario along with gaps in overall data science management. This will enable us with realistic framework to work on and guide us in establishment of “dedicated” health informatics unit in the ministry and its federal structure.  This review also needs to answer the following questions:

• Which understanding of burden of disease is being used?
• Which aspects of burden of disease are being measured?
• Whose burden of disease is being measured and whose is not?
• How and where should we intervene to have the greatest impact on burden of disease, including prevention, control, and treatment?
• Who is likely to benefit least and most from specific interventions aimed at reducing disease burden?
• Will decisions based on disease burden measures have the best outcomes for a population that is already advantaged?
• How do we eliminate inequitable burden of disease?

   Secondly, establish an expert team under secretary of health to evaluate the need to establish a dedicated “health informatics center” that carry out health information management and that relates to data measurement like burden of disease (BoD) studies working closely with policy and planning division, monitoring and evaluation unit, information technology Unit, academic institutions, national health research councils and provincial wings of all health related bodies.

3     Specific Activities to be carried out to produce BoD for the country:

a.  Work closely with the GBD study group to fulfill the data gaps for Nepal both in the areas of morbidity and mortality.

b. Identify the gaps in data sources for disease and health conditions and plan surveys/researches or strengthening routine systems to collect the data on the areas where we need the most

c.   Initiate and expand the system for collecting cause of death data both from the hospitals as well as from the community

d.    For the cause of death data, the most important task that needs to be done in the next 5 years is having a good Civil Registration and Vital Statistics (CRVS) which can five death statistics including cause of death. For this in the initial stage we can follow sample registration system which has been globally adapted with success.

e.     Include all these improvised sources of data in the BoD estimation process.

f.    Be involved as closely as possible with the global groups working on BoD such that national capacity is enhanced, and with this in future Nepal can think of producing the Bod estimates on its own with only limited support from the global group.

g.    With this Nepal can also produce the provincial level BoD estimates in around 2 years’ time which is not available now.