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

Orginal Article

Every citizen is excited with the first election of the parliament and federal states after the promulgation of the new constitution. More than seventy per cent of populations have enthusiastically voted in the local election, and now citizen is witnessing another historic event of the Federal Democratic Republic of Nepal. It is routine phenomena that every political party presents their vision and goals in the form of the election manifesto. Usually, most of these manifestos demonstrate parties’ political principles and philosophies which is guiding them since their inception. The result of 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 summarise health-related vision and commitments of these political parties regarding principles of health system developments and will try to address way forward on some of the missing elements. I describe health systems as a “Tree Model” as depicted in picture, where strong roots are the six building blocks of health system (Governance & Leadership, Financing, Health Workforce, Health Services, Medical Products and Technologies and Information) where fruits of health system is improved responsiveness, efficiency and equity and financial protection. The growth of the ‘Tree’ 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 emphasised 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 at a time when the country is devolving to seven federal states. Health insurance and free health services remained at the top on the agenda for all, but no one has addressed on 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, 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 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 on the pluralism of health delivery and emphasized on collaboration with non-government or private sectors and ensured on the development of standards of the care and monitoring of quality of care.

Financing: This is one of the areas, which has taken a majority 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 mechanism of covering insurance 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 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 scholarship to village hospitals and centers, there are 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 and proportionate to the infrastructure development.

Health Services: Another area, which is 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 municipalities. This is clearly one of the very populist expressions and no way achievable and doesn’t base 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 infrastructures. 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 the provision of 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 the control of risk factors and lifestyle modification.
  • Maternal, Child and Reproductive Health: Nepal has made significant achievements on Millennium Development Goals in terms of maternal and child health. Sustaining these achievements are difficult challenges. Most of the aspect of maternal and child health is addressed with regular monitoring and service provision, provision of allowances to ensure nutrition to child and mother. Additionally, manifestos have ensured the provision of adolescent, sexual and reproductive health to the population with a provision of monthly nursing care and an opening of the social service center in every hospital.
  • Emergency preparedness and response: This is one of the weakest sections of these manifestos. Manifestos don-t have clear vision or goals in terms of emergency preparedness and response in a country that faces emergencies quite frequently. Except for the provision of free health services for those who are affected by disaster nothing is mentioned. In collaboration with other sectors, parties need to work together and should have a clear policy, strategy of addressing emergencies by having robust preparedness and response strategies.

Medical Products and technologies: Few lines are mentioned on the provision of free essential medicines and developing infrastructure with modern technologies and conserving herbal products and industries. Strengthening this area would increase efficiency and saves a lot of 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 in order to achieve universal health coverage and health for all of every citizen of Nepal.

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 credibility and accountability of the political parties or government and assists in informed decision making.

Some elements of external factors of wellbeing of the ’Tree’ has been mentioned in the manifestos like collaboration with animal health sector, research development and health education, provision of access to health services in remote part of the country, door to door services for public health and provision of access to safe water and sanitation. However, whoever forms the government after the election in their multiyear implementation plan should ensure collaboration and coordination with other sectors as health is multisectoral; 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 the 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 need to establish internationally accredited hospitals and ensuring quality of care. Thailand and India are few medical tourism destinations and contributing to their overall economic development. Finally, none of these manifestos is either perfect or bad. In aggregate, these manifestos covers most of the elements of health systems development. Thus whoever forms the future government should review and analyse these manifestos when they are developing a multiyear plan for the government.  There is always something to learn from different groups or views which could be beneficial for societies and Nepal.