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Dec 29, 2018

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.

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Anuj in Himalayas

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