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