Nepal has supported World Health Organization (WHO) and The United Nations Children’s Fund (UNICEF) to endorse the Declaration of Astana to strengthen primary health care around the globe. On 25th October 2018, our Deputy Prime Minister and Minister of Health, Upendra Yadav stood by the side of Director General of WHO, Dr. Tedros Adhanom Ghebreyesus and urged all stakeholders globally for the better comprehensive primary health care for universal health coverage (UHC).
The Astana Declaration is a commitment by WHO, UNICEF and Governments around the globe and is an urge that each government and stakeholders to make primary health care their priority which was declared on 26th October 2018 in Astana, Kazakhstan to celebrate the 40th Anniversary of Alma Ata Declaration. Alma Ata declaration aimed health for all by 2000 in 1978 which was not achieved. There is now global consensus on no universal health coverage (UHC) without strong primary health care.
In-spite of Nepal’s commitment to Alma Ata Declaration, people especially in rural areas do not even have access to high quality primary health care in their community. This is the bitter truth of Nepal.
Nepal has varieties of human resources for health system like Female Community Health Volunteer (FCHV), Auxiliary Nurse Midwife (ANM), Community Medical Assistant (CMA), Staff Nurse, Health Assistant (HA), Medical Officers (MBBS), Specialists, Sub-specialists, Ayurvedic Doctors and people who do not have formal medical education. According to World Bank, there are 81 % of Nepalese who live in rural areas of Nepal. Making quality primary health care accessible and affordable means working for the majority of people staying in rural areas.
Mental health is one of the most neglected areas of health services in Nepal. There is great role of psychosocial counselors (PSCs) in delivering mental health services. But PSCs are not staffed in government hospitals in our country.
The current scenarios of Nepal is there are not enough health workers and doctors in all areas to provide high quality primary health care. The staffing for health system designed more than 25 years ago is out of date and is unable to address and deal with the current health problems of expanding population. There is no robust system of referral chain between primary and secondary level hospitals.
The education system of nurses, paramedics, doctors and supporting services like laboratory, pharmacy etc are not competency based and need revision as well. Ministry of Education, ministry of health, Nepal Medical Council (NMC), Nepal Nursing Council (NNC) and Nepal Health Professional Council (NHPC) all need to work in collaboration to standardize and upgrade the knowledge, skills and attitudes of people working in health system. There needs to be ongoing professional development opportunities for those who are currently practicing.
FCHVs have done great contribution thus far, but it is a volunteer mechanism and is injustice for women for their service to their community, with lack of continuing professional training, high expectations to deliver so many public health programs and thus is unsustainable and unreliable for the country. The voluntary nature of FCHVs makes it more challenging for them to prioritize to work on health system as they may have their own social and family works. We need professionalized community health workers from their own community who get regular ongoing training and proper incentives for them for their work to ensure sustainability and reliability.
The physical infrastructure of health posts, most of the primary health centers and all district hospitals are not able to provide healthcare services in the community as per the need. The infrastructure for zonal, regional and central hospitals need re-design and analysis as per current trend of national burden of diseases. Adequate infrastructure is an essential element to provide high quality reliable health services. Nepal needs to review and plan seriously for the adequate infrastructure.
If a medical student passes MBBS from a reputed medical college, does she/he become a great doctor? Does anyone become great doctor after passing specialty exam from Nepal Medical Council (NMC)? Does anyone become great health worker after having Nepal Health Professional Council (NHPC) license? Nepal’s health system needs to find answers for these vital questions. It must and should have people whom patients can trust to give their body for proper management.
High quality health system is based on quality medical education. Nepal still lacks structured work and system for quality medical education which needs to be based on competency based education. This is one of the regular demands of Dr. Gobinda KC.
In the current scenario, each health facility lacks a continuous and persistent mechanism to upgrade and update health workers on recent national guidelines and evidence which are relevant to patient care. There needs to be a systematic way to update health workers on recent addition and change on clinical guidelines. Evidence has shown that daily continuous medical education system improves quality of health services.
Many rural areas currently face lack of supply chain of medicines and medical consumables. Persistent lack of even essential medicines in health facility has become regular news in the media. The supply chain management has completely failed in the public health system in Nepal. Nepal’s health system needs new reliable, trusted and tested way of supply chain management. Supply chain needs better digital design and improvement.
Nepal’s Health System is calling for complete reform as per the current need of the society. There is increasing Non-communicable diseases (NCDs), persistent high number of Communicable diseases, high Maternal and Child Mortality and inaccessible and inadequate clinical care for cancer and trauma patients.
Health System of Nepal needs reforms and can be done by the help of people who have experience working in rural areas for long time, public health professionals, policy makers, representatives of patients with strong higher level political commitment. Organizations having experience in delivering health care can also provide valuable help for the health system reform.
(Dr. Gauchan is the Medical Director of Bayalpata Hospital in Achham)