In this post - I try to express the observation, bewilderment or even confusion while trying to make sense of state restructuring from federal to provincial to local level. We like it or not, the restructuring is in full swing refurnishing "health system service delivery". This is a topic of great importance and requires highest level of systematic understanding of the health system. Sadly, I am not an expert on this topic but it is my sincere intention to document what is going on and how we are trying to preserve and capitalise this historical opportunity within our country.
We are all in the early stage of changing our governance practice principally based on federalism. This is all what we hear everywhere - while in tea stall conversation, in print media or social media and popular among them - Facebook and Twitter. We also have to accept without a doubt - this political change, that is visible and becoming vibrant each day, is the direct result of people's aspiration for their wellbeing and to live a decent life. Nothing more, nothing less - life with a dignity. We are hopeful that our political "leadership pack" is worthy of trust people have put on them.
For our benefit, it is our intellectual honesty to explore the meaning of key words first: federalism, governance and health care delivery before we express specific opinion(s) on this hot topic. All of us have heard the word "federalism" thousand times and many of times - we may be surprised that we hardly look up or google the actual meaning of it. I am not surprised by the way - we tend to skip the basics and hit around bush and make the explanation complex losing its very meaning. This is our usual problem and somewhere we seem to be lost. The net effect would be and could be that we are victim of this kind of mental habit commonplace. Here - we will not repeat the same mistake again (at least in this blog). So the same question - what is federalism (संघीयता)? My understanding so far (without first looking up the dictionary or google) is that federalism is a system of governance where people and community manage their political as well as socio-economic affairs themselves through their own elected representatives. In this effort, people are the boss, while the bureaucracy reports to elected leaders. So all the leaders and the public service system are accountable to people only, unlike unitary governments of the past, where all crucial decision making rested on "central" government or kings in feudal system of Shah dynasty.
Federalism:
Now, let us refer to more reliable sources to understand better, the meaning of federalism. First why not Google - Wikipedia defines federalism as "the mixed or compound mode of government, combining a general government (the central or "federal" government) with regional governments (provincial, state, cantonal, territorial or other sub - unit governments) in a single political system." That means - there is a division of powers among 2 or more tiers of government. In Nepal, we are creating 3 tiers of governments - federal government (1), provincial government (7) and local government (753 - 6 metro, 11 sub - metro, 276 - municipalities, 460 - rural municipalities). For now, we will not go into details of functional restructuring, which has created so much transitional confusion in line ministries and equally among elected representatives mostly at local and provincial levels. However, we should not forget to highlight the key directive principles that were promulgated in our new "The Constitution of Nepal" (20 September 2015).
(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.
Within these 4 directive principles - there stands out one prominent key word, which is justice (न्याय) and sometime - we find this word elusive in a sense that we talk and write a lot on this topic but historically we have stories to write of injustice faced by Dalit or marginalised people. Here in this post however, I will not try to delve into this complex topic for now (leaving for next post somewhere in future).
Governance:
Now, let us go to next topic and explore the meaning of governance "शुशासन", which is defined as " the processes of interaction and decision - making among the actors involved in a collective problem that lead to the creation, reinforcement, or reproduction of social norms and institutions." While in simple terms, governance is "how society or groups within it, organise to make decisions." In our 2072 new constitution, the idea of "governance" is spelled out in SUB SECTION (B) Policies relating to political and governance system of State under SECTION 51. Policies of the state as below:
(1) to guarantee the best interests and prosperity of the people through economic, social and cultural transformations, while safeguarding, consolidating and developing political achievements,
(2) to maintain rule of law by protecting and promoting human rights,
(3) to implement international treaties, agreements to which Nepal is a party,
(4) to guarantee good governance by ensuring the equal and easy access of the people to the services and facilities delivered by the State, while making public administration fair, competent, impartial, transparent, free from corruption, accountable and participatory,
(5) ..................
(6) to develop and expand harmonious and cooperative relations between the Federal Units by way of sharing of responsibilities, resources and administration between them.
However, I am of the opinion that political and governance related transformation do not materialise unless the social and cultural aspect of the whole plural society is taken into account. Our country is an amalgam of multiethnic, multicultural, multi religious heritage so, it seems our constitution principally address such realisation that the "SUB SECTION (C) Relating to social and cultural transformation" also such principles which can be said are related with good governance:
(1) to build the society founded on cordial social relations by developing a healthy and civilized culture,
(2) to carrying out studies, research works, excavation and dissemination for the protection, promotion and development of ancient, archaeological and cultural heritages,
(3) to make community development through enhancement of local public participation, by promoting and mobilizing the creativity of local communities in social, cultural and service-oriented works,
(4) to focus on the development of arts, literature and music which form national heritages,
(5) to end all forms of discrimination, inequality, exploitation and injustice in the name of religion, custom, usage, practice and tradition existing in the society,
(6) to protect and develop languages, scripts, culture, literature, arts, motion pictures and heritages of various castes, tribes,and communities on the basis of equality and co-existence, while maintaining the cultural diversity of the country,
(7) to pursue a multi-lingual policy.
"SUB SECTION (H) Policies relating to basic needs of the citizens:
(1) to prepare human resources that are competent, competitive, ethical, and devoted to national interests, while making education scientific, technical, vocational, empirical, employment and people-oriented,
(2) ..................
(3) ..................
(4) to establish and promote community information centres and libraries for the personality development of citizens,
(5) to keep on enhancing investment necessary in the public health sector by the State in order to make the citizens healthy,
(6) to ensure easy, convenient and equal access of all to quality health services,
(7) to protect and promote health systems including Ayurveda, as a traditional medical system of Nepal, natural therapy and homeopathy system,
(8) to make private sector investment in the health sector service oriented by regulating and managing such investment, while enhancing the State's investment in this sector,
(9) to focus on health research and keep on increasing the number of health institutions and health workers in order to make health services widely available and qualitative,
(10) to increase average life expectancy by reducing maternal and infant mortality rate, while encouraging family planning for population management on the basis of Nepal's capacity and need,
(11) ..................
(12) ..................
(13) to ensure planned supply system by according special priority to the remote and backward regions, while ensuring equal access of all citizens to basic goods and services,
(14) ..................
(15) to arrange for access to medical treatment while ensuring citizen's health insurance.
"SUB SECTION (K) Policies relating to justice and penal system:
(1) to make the administration of justice speedy, efficient, widely available, economical, impartial, effective, and accountable to people,
(2) ...................
(3) to adopt effective measures for the control of corruption and irregularities in all sectors including political, administrative, judicial and social sectors.
(1) Every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services.
(2) Every person shall have the right to get information about his or her medical treatment.
(3) Every citizen shall have equal access to health services.
(4) Every citizen shall have the right of access to clean drinking water and sanitation.
In addition, the SECTION (38) on Rights of women has specifically articulated the following right:
(1) .............
(2) Every woman shall have the right to safe motherhood and reproductive health.
(3) .............
A call for Action: Beautifully written are these directive principles, policies and basic rights of all Nepalese people after decades of socio - political instabilities. So many lives were lost, so many people had to suffer hardship, which were like an "invisible hammer" thrusted into the livelihood of unfortunate people, sometime breaking apart their families and most of the time - misery, helplessness, destitute, poverty and not knowing who is responsible for this situation were usual norms in our day to day living. Now, we believe our future should be bright and worth taking pain, because we have suffered so much that there is not turning back and hopefully, these words black and white written in New Constitution of Nepal (2072) is not hollow. History is definitely in making after that historic day of 20 September 2015, our new constitution charted a path forward for holding successful local, provincial and federal level elections. We are all hopeful that people's aspiration will be fulfilled or at least majority of local governments will work hard to realise those promises of social justice, accountability, good governance, transparency, prosperity and harmony. Sure enough, all of us agree that health is now a developmental agenda, which requires multi sectoral approach involving all stakeholders from community to local leaders to professionals from all fields of pure science, social science to economics. With the dawn of 21st century, we are sure to face lots of challenges that are related with increasing population density, environmental degradation, changing life styles and demographics. To our advantage, however, we are bestowed with limitless possibilities such that fast pace developments in biotechnology and Information Communication Technology (ICT) have profoundly changed our day to day livelihood especially with advent of internet and now artificial intelligence. In addition, the fast paced innovation and discoveries in biotechnology, immunology, vaccinology, virology, proteonomics, genetics have brought about so much advances in the field of medicine that we have been able to tame communicable diseases up to the point even eradicating some of the most dreaded infectious diseases. We can tell confidently that 20th century saw so much advances in the control and elimination of infectious diseases like TB, malaria, HIV & AIDS. Now, it is reported worldwide that the burden of communicable diseases is in decreasing trend, while the non communicable diseases as a result of change in lifestyles and modernity have increased in its burden. This change has brought about an epidemiological shift such that the countries like Nepal are facing double burden of communicable and non communicable diseases. In oder to provide relieves for our people in all walks of life with quality and affordable health care services, we need to built a health system that is both resilient and robust guided by evidence based decision as well as policy making in our ministries. We can see silver lining in the dark cloud that IT as well as our youths entering the job market will definitely displace outdated and feudal mindset, which is still prevailing in our work culture termed "babucracy". Importantly, we need to separate the public service oriented bureaucracy from political serfdom, which is practically destroying our public service in Nepal. One opinion that resounds in every sane mind is how can a public servant can be both a political activist using the government platform and a bureaucrate? This is in a simple words - conflict of interests. Hopefully, the new hope and political aspirations that have injected into our government service delivery will address this chronic infestation in the name of trade unions. Therefore, I would call this period of 5 years pre and post popular local election 2074 BC - the best of time or the worst of time ? it is up to us to evaluate 5 years later for sure. We are pretty sure that we will be a testimony to history in making towards prosperous Nepal.
We are all in the early stage of changing our governance practice principally based on federalism. This is all what we hear everywhere - while in tea stall conversation, in print media or social media and popular among them - Facebook and Twitter. We also have to accept without a doubt - this political change, that is visible and becoming vibrant each day, is the direct result of people's aspiration for their wellbeing and to live a decent life. Nothing more, nothing less - life with a dignity. We are hopeful that our political "leadership pack" is worthy of trust people have put on them.
For our benefit, it is our intellectual honesty to explore the meaning of key words first: federalism, governance and health care delivery before we express specific opinion(s) on this hot topic. All of us have heard the word "federalism" thousand times and many of times - we may be surprised that we hardly look up or google the actual meaning of it. I am not surprised by the way - we tend to skip the basics and hit around bush and make the explanation complex losing its very meaning. This is our usual problem and somewhere we seem to be lost. The net effect would be and could be that we are victim of this kind of mental habit commonplace. Here - we will not repeat the same mistake again (at least in this blog). So the same question - what is federalism (संघीयता)? My understanding so far (without first looking up the dictionary or google) is that federalism is a system of governance where people and community manage their political as well as socio-economic affairs themselves through their own elected representatives. In this effort, people are the boss, while the bureaucracy reports to elected leaders. So all the leaders and the public service system are accountable to people only, unlike unitary governments of the past, where all crucial decision making rested on "central" government or kings in feudal system of Shah dynasty.
Federalism:
Now, let us refer to more reliable sources to understand better, the meaning of federalism. First why not Google - Wikipedia defines federalism as "the mixed or compound mode of government, combining a general government (the central or "federal" government) with regional governments (provincial, state, cantonal, territorial or other sub - unit governments) in a single political system." That means - there is a division of powers among 2 or more tiers of government. In Nepal, we are creating 3 tiers of governments - federal government (1), provincial government (7) and local government (753 - 6 metro, 11 sub - metro, 276 - municipalities, 460 - rural municipalities). For now, we will not go into details of functional restructuring, which has created so much transitional confusion in line ministries and equally among elected representatives mostly at local and provincial levels. However, we should not forget to highlight the key directive principles that were promulgated in our new "The Constitution of Nepal" (20 September 2015).
(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.
Within these 4 directive principles - there stands out one prominent key word, which is justice (न्याय) and sometime - we find this word elusive in a sense that we talk and write a lot on this topic but historically we have stories to write of injustice faced by Dalit or marginalised people. Here in this post however, I will not try to delve into this complex topic for now (leaving for next post somewhere in future).
Governance:
Now, let us go to next topic and explore the meaning of governance "शुशासन", which is defined as " the processes of interaction and decision - making among the actors involved in a collective problem that lead to the creation, reinforcement, or reproduction of social norms and institutions." While in simple terms, governance is "how society or groups within it, organise to make decisions." In our 2072 new constitution, the idea of "governance" is spelled out in SUB SECTION (B) Policies relating to political and governance system of State under SECTION 51. Policies of the state as below:
(1) to guarantee the best interests and prosperity of the people through economic, social and cultural transformations, while safeguarding, consolidating and developing political achievements,
(2) to maintain rule of law by protecting and promoting human rights,
(3) to implement international treaties, agreements to which Nepal is a party,
(4) to guarantee good governance by ensuring the equal and easy access of the people to the services and facilities delivered by the State, while making public administration fair, competent, impartial, transparent, free from corruption, accountable and participatory,
(5) ..................
(6) to develop and expand harmonious and cooperative relations between the Federal Units by way of sharing of responsibilities, resources and administration between them.
However, I am of the opinion that political and governance related transformation do not materialise unless the social and cultural aspect of the whole plural society is taken into account. Our country is an amalgam of multiethnic, multicultural, multi religious heritage so, it seems our constitution principally address such realisation that the "SUB SECTION (C) Relating to social and cultural transformation" also such principles which can be said are related with good governance:
(1) to build the society founded on cordial social relations by developing a healthy and civilized culture,
(2) to carrying out studies, research works, excavation and dissemination for the protection, promotion and development of ancient, archaeological and cultural heritages,
(3) to make community development through enhancement of local public participation, by promoting and mobilizing the creativity of local communities in social, cultural and service-oriented works,
(4) to focus on the development of arts, literature and music which form national heritages,
(5) to end all forms of discrimination, inequality, exploitation and injustice in the name of religion, custom, usage, practice and tradition existing in the society,
(6) to protect and develop languages, scripts, culture, literature, arts, motion pictures and heritages of various castes, tribes,and communities on the basis of equality and co-existence, while maintaining the cultural diversity of the country,
(7) to pursue a multi-lingual policy.
"SUB SECTION (H) Policies relating to basic needs of the citizens:
(1) to prepare human resources that are competent, competitive, ethical, and devoted to national interests, while making education scientific, technical, vocational, empirical, employment and people-oriented,
(2) ..................
(3) ..................
(4) to establish and promote community information centres and libraries for the personality development of citizens,
(5) to keep on enhancing investment necessary in the public health sector by the State in order to make the citizens healthy,
(6) to ensure easy, convenient and equal access of all to quality health services,
(7) to protect and promote health systems including Ayurveda, as a traditional medical system of Nepal, natural therapy and homeopathy system,
(8) to make private sector investment in the health sector service oriented by regulating and managing such investment, while enhancing the State's investment in this sector,
(9) to focus on health research and keep on increasing the number of health institutions and health workers in order to make health services widely available and qualitative,
(10) to increase average life expectancy by reducing maternal and infant mortality rate, while encouraging family planning for population management on the basis of Nepal's capacity and need,
(11) ..................
(12) ..................
(13) to ensure planned supply system by according special priority to the remote and backward regions, while ensuring equal access of all citizens to basic goods and services,
(14) ..................
(15) to arrange for access to medical treatment while ensuring citizen's health insurance.
"SUB SECTION (K) Policies relating to justice and penal system:
(1) to make the administration of justice speedy, efficient, widely available, economical, impartial, effective, and accountable to people,
(2) ...................
(3) to adopt effective measures for the control of corruption and irregularities in all sectors including political, administrative, judicial and social sectors.
Health System Service Delivery: In complete agreement with WHO definition of "human health" as "a state of complete physical, mental and social well being and not merely the absence of disease or infirmity" - the health system service delivery broadly "encompasses the management and delivery of quality and safe health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, through the different levels and sites of care within the health system and according to their needs throughout the life course" (WHO). In order to safeguard and guarantee the provision of quality and safe health services to all people, our constitution (2072) has clearly stated the following rights relating to health under SECTION (35):
(1) Every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services.
(2) Every person shall have the right to get information about his or her medical treatment.
(3) Every citizen shall have equal access to health services.
(4) Every citizen shall have the right of access to clean drinking water and sanitation.
In addition, the SECTION (38) on Rights of women has specifically articulated the following right:
(1) .............
(2) Every woman shall have the right to safe motherhood and reproductive health.
(3) .............
A call for Action: Beautifully written are these directive principles, policies and basic rights of all Nepalese people after decades of socio - political instabilities. So many lives were lost, so many people had to suffer hardship, which were like an "invisible hammer" thrusted into the livelihood of unfortunate people, sometime breaking apart their families and most of the time - misery, helplessness, destitute, poverty and not knowing who is responsible for this situation were usual norms in our day to day living. Now, we believe our future should be bright and worth taking pain, because we have suffered so much that there is not turning back and hopefully, these words black and white written in New Constitution of Nepal (2072) is not hollow. History is definitely in making after that historic day of 20 September 2015, our new constitution charted a path forward for holding successful local, provincial and federal level elections. We are all hopeful that people's aspiration will be fulfilled or at least majority of local governments will work hard to realise those promises of social justice, accountability, good governance, transparency, prosperity and harmony. Sure enough, all of us agree that health is now a developmental agenda, which requires multi sectoral approach involving all stakeholders from community to local leaders to professionals from all fields of pure science, social science to economics. With the dawn of 21st century, we are sure to face lots of challenges that are related with increasing population density, environmental degradation, changing life styles and demographics. To our advantage, however, we are bestowed with limitless possibilities such that fast pace developments in biotechnology and Information Communication Technology (ICT) have profoundly changed our day to day livelihood especially with advent of internet and now artificial intelligence. In addition, the fast paced innovation and discoveries in biotechnology, immunology, vaccinology, virology, proteonomics, genetics have brought about so much advances in the field of medicine that we have been able to tame communicable diseases up to the point even eradicating some of the most dreaded infectious diseases. We can tell confidently that 20th century saw so much advances in the control and elimination of infectious diseases like TB, malaria, HIV & AIDS. Now, it is reported worldwide that the burden of communicable diseases is in decreasing trend, while the non communicable diseases as a result of change in lifestyles and modernity have increased in its burden. This change has brought about an epidemiological shift such that the countries like Nepal are facing double burden of communicable and non communicable diseases. In oder to provide relieves for our people in all walks of life with quality and affordable health care services, we need to built a health system that is both resilient and robust guided by evidence based decision as well as policy making in our ministries. We can see silver lining in the dark cloud that IT as well as our youths entering the job market will definitely displace outdated and feudal mindset, which is still prevailing in our work culture termed "babucracy". Importantly, we need to separate the public service oriented bureaucracy from political serfdom, which is practically destroying our public service in Nepal. One opinion that resounds in every sane mind is how can a public servant can be both a political activist using the government platform and a bureaucrate? This is in a simple words - conflict of interests. Hopefully, the new hope and political aspirations that have injected into our government service delivery will address this chronic infestation in the name of trade unions. Therefore, I would call this period of 5 years pre and post popular local election 2074 BC - the best of time or the worst of time ? it is up to us to evaluate 5 years later for sure. We are pretty sure that we will be a testimony to history in making towards prosperous Nepal.
Key words: federalism, governance, health care delivery
18 April, 2018
Dhangadi
