Strengthening Health Systems: From the Election Manifestos of Political Parties of Nepal

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Original Article

Every citizen is excited about the first election of the parliament and federal states after promulgating the new constitution. More than seventy percent of population has enthusiastically voted in the local election, and now citizens are witnessing another historical event of Nepal, the Federal Democratic Republic. It is routine phenomena that every political party presents their vision and goals in the election manifesto. Usually, most of these manifestos demonstrate parties’ political principles and philosophies guiding them since their inception. The recent local election has shown that there are four to five major political parties in the country.

The purpose of this article is to critically summarize health-related vision and commitments of these political parties regarding principles of health system developments, and how they will address the way forward on some of the missing elements. I describe health systems as a “Tree Model” as depicted in the picture, where strong roots are the six building blocks of the health system (Governance & Leadership, Financing, Health Workforce, Health Services, Medical Products, and Technologies and Information) where fruits of the health system are improved responsiveness, efficiency, and equity and financial protection. The ‘Tree’ growth depends on various external factors like research, quality, education, economy, access, collaboration, and different principles and characteristics.

Before going into details based on each of these building blocks, all political parties have emphasized health as basic human rights and put together with education, food security, shelter, employment etc. or described as part of social security. Typically, populist goals and vision have dominated these manifestos and lack vision and mission of overall health development when the country is devolving to seven federal states. Health insurance and free health services remained at the top on the agenda for all. However, no one has addressed how to generate funds when the country’s health budget is still dependent on external development assistance and out of pocket expenditures. Nepal has achieved significantly over 2-3 decades on health despite various odds like decade-long insurgency, long-term political instability, a mega earthquake and major border blockade. Though, these achievements are well delineated but failed to refer any strategies to maintain them in manifestos.

Governance and Leadership: Health service is considered as state business and described as an integral part of socio-economic reform or social security nets, which is very promising.  However, parties have not mentioned how this reform or social security nets will be expanded at the state level. There must be policy guidance at the national level, which can be implemented in the states. All political parties seem to believe in the pluralism of health delivery and emphasized collaboration with non-government or private sectors and ensured the development of standards of the care and monitoring of the quality of care.

Financing: This is one of the areas that has taken most of the section of manifestos. The apparent reason is the national health insurance bill and the provision of free health services. Parties have delineated their covering insurance mechanism to vulnerable groups like poor, disabled, orphans, single mother, elderly and cases of some serious diseases. Social security nets ensuring treatment and health protection of the labour workforce and armies are well recognised. These all sound perfect and achievable when the country has adequate financial resources. However, parties have not indicated how the funding will be ensured to achieve these goals. Control of tobacco and alcohol market is on the agenda and capitalising through taxation can fill some of the funding gaps for health insurance, and at the same time reduces risk factors.

Health Workforce: This is one of the poorly delineated components in the manifestos of all parties. Other than increasing salaries, allowances and benefits of health care workers and restricting government doctors for private practices and policy to recruit doctors who studied medicine with a scholarship to village hospitals and centres, there is nothing on human resource strategies like recruitment, mobilization to remote and rural areas, retention of health care workers at the facility levels, and needs-based training and education etc. The amount of infrastructure development mentioned in manifestos for health is so massive that throughout 5-10 years, Nepal will require additional millions of healthcare workers. Whichever political party wins the election and forms a government would need to develop a clear human resources strategy and plan based on the need proportionate to the infrastructure development.

Health Services: Another area covered everywhere in every parties’ manifesto is health services or service deliveries. Despite that, this is too focused on curative care rather than preventive care. This section can be divided into subsections like infrastructure development; curative care and disease control; maternal, child and reproductive health; and emergency preparedness and response for better analysis.

  • Infrastructure development: Infrastructure development is vital to any development. These manifestos are going to build 15-50 beds hospitals in every villages and municipality. This is clearly one of the most populist expressions and is in no way achievable and doesn’t depend on any scientific rationale or needs. Some political parties are too prescriptive on infrastructure development. Even the most developed countries don’t have or need such level of infrastructure. This should be developed based on the density of population and accessibility of the villages and municipalities. For instance, surrounding village committees of the metropolis may not need hospitals and resources can be mobilized on institutional strengthening.
  • Curative Care and disease control: All manifestos have ensured free health care services for serious non-communicable diseases like heart diseases, diabetes, kidney diseases, lung diseases, cancer from testing and treatment. Some have included the provision of testing of cervical cancer at the local level. Implementation of health insurance can help in achieving these goals. Despite the heavy focus on curative care, some delineation has been made on effective disease control of infectious diseases, mental illnesses and non-communicable diseases by addressing risk factors and lifestyle modification.
  • Maternal, Child and Reproductive Health: Nepal has made significant achievements on Millennium Development Goals regarding maternal and child health. Sustaining these achievements are difficult challenges. Most of the aspects of maternal and child health is addressed with regular monitoring and service provision, providing allowances to ensure nutrition to child and mother. Additionally, manifestos have ensured the provision of adolescent, sexual, and reproductive health to the population with monthly nursing care and an opening of every hospital’s social service centre.
  • Emergency preparedness and response: This is one of the weakest sections of these manifestos. Manifestos don’t have clear vision or goals in emergency preparedness and response in a country that faces emergencies quite frequently. Except for providing free health services for those affected by the disaster, nothing is mentioned. In collaboration with other sectors, parties need to work together and have a clear policy addressing emergencies by having robust preparedness and response strategies.

Medical Products and technologies: Few lines are mentioned about providing free essential medicines and developing infrastructure with modern technologies and conserving herbal products and industries. Strengthening this area would increase efficiency and save many resources, for example, modernizing and establishing government drug companies can ensure effective and quality essential drugs to all health facilities. This should be a priority for the upcoming government to achieve universal health coverage and health for all of Nepal’s citizens.

Information: Information is the backbone of any systems and development. Except for vital registration of children and free access to internet provision in health facilities nothing has been mentioned on information system development and utilization. This links with disease surveillance, monitoring, and evaluation of universal health coverage, health programs/interventions and health governance. This ensures the credibility and accountability of the political parties or government and assists in informed decision making.

Some elements of external factors of the wellbeing of the ’Tree’ has been mentioned in the manifestos like a collaboration with the animal health sector, research development and health education, provision of access to health services in a remote part of the country, door to door services for public health and provision of access to safe water and sanitation. However, after the election in their multiyear implementation plan, whoever forms the government should ensure collaboration and coordination with other sectors as health is multisector; strategizing accessibility to people of the remote area, ensuring research and development on health and preventing commercialization of health education.

Country’s primary source of income has remained the tourism industry and health sector, and can contribute to economic development through medical tourism. One of the political parties has emphasised developing Nepal as a medical tourism destination. However, to achieve this goal, the upcoming government needs to establish internationally accredited hospitals and ensure quality care. Thailand and India among the few countries with medical tourism contributing to their overall economic development.

In conclusion, none of these manifestos is either perfect or bad. In aggregate, these manifestos cover most of the elements of health system development. Thus whoever forms the future government should review and analyse these manifestos when developing a multiyear plan for the government. There is always something to learn from different groups or views that could benefit societies and Nepal.

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