Coronavirus and Nepal: Federated healthcare system a bad idea for Nepal

Kamal Dev Bhattarai

Kamal Dev Bhattarai

Coronavirus and Nepal: Federated healthcare system a bad idea for Nepal

Dr. Sushil Nath Pyakurel is former Director General of the Department of Health Services under the Ministry of Health and Population. Kamal Dev Bhattarai talked to the veteran healthcare expert with over 30 years of experience in Nepal’s healthcare to discuss the country’s federated healthcare system and its ability to deal with pandemics like the novel coronavirus.

How would you evaluate Nepal’s healthcare system in the new federal set-up?

Previously, we had a central ministry under which various department and offices functioned. There were five regional centers overseeing district health offices. At the grassroots level, there were health post and sub-health posts. Then there were health volunteers and Aama Samuha (‘mother's groups’) at the grassroots to deal with general health issues. We used those entities for both preventive and curative measures, and there was a lot of coordination among them. We have now adopted a federal structure, which is good in principle. Yet we have failed to ensure robust health structures under it.

How has Nepal’s healthcare system changed in the new set-up?

Earlier, district health offices directly supervised health posts and sub-health posts. Regional health offices supervised and monitored district health offices. The Ministry of Health and Population and its departments in turn monitored the regional health offices. There was a robust chain of command from the center to the grassroots. This helped maintain order in the healthcare system. In the federal set-up, we have a three-tier government. Health posts, PHCs and hospitals with fewer than 15 beds are now under the local government. Under the federal government, there are just big 6-7 hospitals. 

Are you suggesting Nepal’s healthcare system has been facing problems since the country was declared a federation?

A couple of things have created problems. First, the federal government has failed to properly manage human resources. The adjustment of civil servants has not been completed even in over three years; there is either over- or under-staffing. In rural areas, human resources are scant. In a centralized system, we could have forced staff to go to rural areas. We are allocating more and more budget to the provinces, but they are unable to instruct local units to work. That’s the crux of the problem. There is no coordination between provincial and local units. This weakness was also evident during the Dengue fever outbreak last year. 

Second, management of logistics and infrastructure has been faulty. For example, we gave provincial governments budget to buy necessary vaccines and medicines. Of the seven provinces, only Sudur Paschim was able to buy Vitamin A capsules for children. Finally, the federal government had to itself purchase Vitamin A and provided them to other provinces. The bodies authorized to buy vaccines—provincial social development ministries—cannot even make such simple purchases. There is no proper supply-chain for it. Provincial governments have failed to buy and manage other medicines also. There are instances of corruption while purchasing medicines. At the same time, provincial and local units are unable to spend their health budget. And when they spend, they do it unnecessarily.

What about management of information on various diseases? 

The management of information related to diseases is also problematic. Previously, there was a system of proper reporting to the ministry and Department of Health when there was even a minor outbreak of a disease at the grassroots. This reporting process has been disrupted in the federal structure. Local units are not reporting to the upper levels about diseases and health problems in their areas. If we fail to pass the information to the concerned agencies, we cannot handle new diseases. Again, we saw such problems during the outbreak of Dengue in Kathmandu last year. But we seemed to have learned little from our experience.

What could have been done to avoid such problems? 

When I was the Acting Secretary at the Ministry of Health and Population in 2018, we had recommended establishing testing labs in each of the seven provinces because we have only one lab for infectious diseases in Teku, Kathmandu. Labs are needed to immediately test suspected patients at local levels. They also minimize overload at the center. If there were labs in all seven provinces, testing for Covid-19 could have been much easier. But the provincial governments did not take any initiative towards this end. We see coronavirus samples of suspected patients being sent to Kathmandu for a test. There are qualified people outside the government. We can hire them for the provincial labs. 

Do we need a specialized body to tackle epidemics and pandemics? 

Yes. There has been a lot of discussion on it but no progress. We should immediately set up a Center for Disease Control (CDC). We see such entities in countries like the US and India.  Such a body at the central and provincial levels can do research on how to deal with new viruses like corona, as well as train healthcare workers, and inform the public. Additionally, they will empower health workers in dealing with new viruses. Such centers can also conduct research on future pandemics.

Nepal may become an epicenter of other infectious diseases in the future. Before the coronavirus, there was an outbreak of common cold in Humla and Jajarkot districts but we failed to study them. The diseases may also be different in the mountains, hills and plains. A center like the CDC can help prepare us. We are now totally dependent on the World Health Organization since we don’t have an independent research center. After the outbreak of Dengue, we had prepared a plan of action about the CDC. 

Are you suggesting that even in the federal structure, the healthcare system should be centralized? 

Certainly. There should be some sort of centralized system in public health. When we deal with an epidemic or pandemic, there should be a proper chain of command because qualified professionals are concentrated in Kathmandu. We can hand over the duties to provincial levels once they get qualified manpower. But unless provincial and local governments are capable, a proper chain of command should be maintained. Currently, there is a lack of coordination among the three tiers of government. 

Health is a fundamental right of every citizen. There should be universal health coverage. All governments shoulder equal responsibility to provide health services to the people. But the performance of local bodies in health services is dismal; even the health workers are deprived of basic facilities. Our federal structure has failed to ensure the constitutional provision of mandatory healthcare to all citizens. 

Can you share the experience of other countries with federated healthcare systems? 

Different countries have different systems so there cannot be a perfect comparison. But we can learn from others. Consider Pakistan, whose federal model is similar to Nepal’s. They had to centralize some of their health systems when their federally administered programs failed. The provinces of developed countries are resourceful so they can make their own infrastructure. But that is not the case in Nepal. For instance, the Kathmandu Metropolitan City has far more resources than a rural municipality. In some places, there is a lack of technical manpower, while in other places logistics are missing.

We adopted federal health structures without sufficient homework and thinking. There was a hurry. The problem is that non-medical people dominate provinces and local units. Instead of having provincial social development ministries look after health-related issues, we need separate health ministries at the provincial level. You cannot expect good output when you break the chain of command. 

So the existing healthcare system should be totally revamped? 

Definitely. First, all systems should be centrally commanded. Instead of social development ministries at the provincial level, there should be health ministries. There should be CDC in all seven provinces. There should be well-equipped labs in all seven. For this, we need political commitment. All political parties should understand the flaws in our current system. If these flaws are not corrected immediately, we can neither guarantee universal health coverage nor ensure health as a fundamental right. We have to make federal and provincial structures coordinate effectively. 

Why was the federal healthcare system botched even though there was a lot of time to get it right?

There was a lot of discussion about the healthcare system suited for a federal set-up. To be frank, higher authorities of other ministries were dominant in decision-making. The constitution allows deployment of necessary manpower to provide health services. But this did not happen because people who were in decision-making process did not take strong stand when it was needed.  

Nepal also seems to have learned little from the experiences of other countries.

You are correct. We shared the experiences of other countries with our bosses. We prepared a blueprint of the healthcare system suitable for Nepal. However, certain people acted like they knew everything and ignored our suggestions. There was dissatisfaction with the new structure, and some health workers threatened to protest. But people in decision-making simply ignored them.

How do improve communication and coordination between the three tiers of government?

There is coordination in some places but only due to individual efforts. The system as a whole is not working properly. There is a sort of vacuum but no one is paying attention. Until we have separate health ministries at the provincial level, there will continue to be a void. The current provincial health departments cannot give orders to peripheral health posts under local units. You see that both local units and provincial governments are now building corona quarantine centers and temporary hospitals on their own. There is no coordination. It would be more efficient for the two tiers of government to combine their efforts and resources.