With provincial govern­ments coming into being in the past few days, fed­eralism is actually here. But it will be several years before all levers of devolved power structures are in place, as over 100 laws need to be written. Even in the best-case scenario—as examples from other countries suggest—it will take at least four years to fully phase-in a functioning federal structure. This waiting period may sound long and even appear frustrating, but it is in fact a perfect opportu­nity to enact sweeping reforms that do away with the dysfunction of erstwhile unitary system of governance. For clarity’s sake, let me dwell on one reform issue in each column.

Health, first. Under the devolved power arrangement in the new constitution, delivery of basic health services falls under the jurisdiction of the local gov­ernment. The provincial govern­ment, meanwhile, is responsible for overall health services—of course, leaving aside broader national policies and standards to the federal government. In the­ory, the provincial government is free to shape health policies within its jurisdiction so long as it complies with the broad contours of national policy.

But in reality, health system requires an integrated approach and should not be bracketed into different boxes with competing jurisdiction. Righting the wrongs of the current health system that perpetuates unequal treatment and preys upon patients’ vulner­ability requires substantial poli­cy reforms at the central level—backed by strict implementation and monitoring at the provincial and local levels.

The problem with Nepal’s health system is obvious: public health system suffers from short­ages of hospital beds in urban areas, while in rural areas there are inadequate doctors and shortfall of essential medicines and diagnostic facilities. There are also no financing priorities for different needs of different areas and sometimes global agenda (malaria and TB eradication, for instance) take precedence over local needs. This is the reason hospitals serving the Tharu com­munities, for example, have no stocks of drugs to treat sickle cell anemia—a common condition in this community.

Despite spending millions on public health system every year—roughly Rs 41 billion this year—poor patients still forced to seek basic services in the private system. That puts the per capita government health spending at approximately Rs 3,000 a year. But this number belies the much higher out-of- pocket spending by individuals. A complicated pregnancy can cost a family, on an average, half a million rupees in a private hospital.

Private health system is over­priced, highly exploitative and under-regulated. Anecdotal evidence points to a disturbing exploitation.

Last year, an acquaintance developed typhoid fever. Upon visiting Patan Hospital, she was referred to intensive care unit (ICU) in other hospitals, as there was no empty ICU bed in Patan Hospital. She ended up being admitted at a nearby pri­vate hospital. Five days later she was slapped with a bill of over Rs 100,000, including medicines. She was moved to the general ward after the hospital adminis­tration sensed she might not be able to pay.

Two days after being dis­charged, the fever came back, and she had to be rushed back to another private hospital. She came home after spending anoth­er Rs 35,000 and three days in treatment. In total, she spent a year’s worth of earning, not sav­ing, for the treatment of just one illness. That is a representative picture of our health system, which disproportionately affects the poor.

To address the problem in our health system, the incoming gov­ernment will have to revisit the flawed fundamentals while insti­tuting a mechanism to strictly monitor health services—both public and private. Instead of hav­ing hundreds of scattered health schemes, it should raise the cov­erage amount of the government insurance scheme and simultane­ously curb the runaway private healthcare costs.

Conditions have to be creat­ed such that government issued health insurance card is accred­ited in private hospitals so that patients aren’t refused treatment or forced out of hospital before the completion of treatment.

One of the signs of development is that poor families in the coun­try do not have to take out big loans to take care of their sick. I hope the incoming government with its agenda of shared prosper­ity will pay heed to this cause of recurring poverty.

 

The author is a Kathmandu-based journalist who tweets @johnparajuli