Free Health Services in Nepal

Background

The Human Development Report (HDR) 2010 has acknowledged Nepal as one of the top ten performers in human development across the world. According to the report, Nepal has shown significant progress in areas of health and education through effective public policy efforts. Making impressive progress in the non-income dimensions of Human Development Index (HDI), especially in health and education, in the last 40 years, Nepal has gained a position of one of the ‘top 10 movers’ in human development all the world over. Nepal is ranked third among the 135 countries making progress in last four decades.

Current Status of Health Service Delivery

Nepal has made various international commitments and has also formulated national level policies and plans to enhance the delivery of basic and essential health services to general public. Abiding by the Interim Constitution of Nepal, 2006 provision of primary health care as fundamental right, Government of Nepal introduced the provision of free health service program through district level health facilities on October, 2007 with the aim of bringing basic health services particularly within the reach of the poor and excluded groups. The policy came into implementation since January 2008 through existing health facilities financed by Government resources. Adoption of the free health care service policies is aimed at promoting utilization of essential health services to improve the health status of socially excluded and marginalised groups (women, Dalits, Janajatis) hitherto deprived of these services.

Based on analysis of the health sector budget in FY 2010/11, it can be clearly observed that there is higher proportion of recurrent budget than capital budget and this has led to the condition where donor grants and loans are utilized to cover the recurrent expenses. Among EHCS priorities, there are larger allocations on drugs/equipments and immunization program followed by expenses on child and maternal health related interventions.

MOHP has strong network of its sister institutions throughout the country. During 2008/09 period, basic health services were provided to general public through 100 government hospitals, 207 Primary Health Care Centers/Health Center (PHCCs/HC), 679 Health Posts (HPs) and 3,114 Sub Health Posts (SHPs). Primary health care was also provided by 14,366 Primary Health Care Outreach Clinic (PHC/ORC) sites. These services were further supported by 48,604 Female Community Health Volunteers (FCHVs) (CBS, 2008). Yet, the services are not being accessible, affordable and sufficient to target groups, especially poor, marginalized people and dalits.

Over the years, the number of health facilities has increased but their availability does not correspond the increase in population. The growth rate of government hospitals (1.67% annually) in last ten years is not very encouraging considering the population growth rate of 2.25 percent. The situation of the overall district level health facilities, which include health posts, sub health posts and primary health centres, is even appalling. The negative growth trend (-0.06) shows that there is high discrepancy between demand and supply. There is similar situation also in case of village level health workers (-0.80% in last nine years).

Under free health service scheme, GON provides up to 40 essential medicines for free through district level health facilities. The Logistic Management Division (LMD) under DOHS is responsible for procurement and distribution of drugs throughout the country through its service outlets. Currently, there are central and district level drug procurement and distribution arrangements. The drug availability in health facilities, especially of contraceptives, maternal and child health commodities, and selected essential drugs, have improved in last four years despite the reported increase in demand and consumption of essential drugs after the implementation of free health care policy. Though the stock out ratio for key category of drugs has decreased, it will be worthy to note here that the stock out ratio of essential drugs still remains high at 27 percent (DOHS, 2010).

Persistent Issues and Challenges

Limited and donor depended health financing: Health sector allocations depend heavily on donor funds: around 42 percent of the health sector budget is expected to be financed through donor sources in FY2010/11 which includes five percent of donor loan. Thirteen percent of recurrent expenses are financed through donor funds. The higher donor dependency for reform programs has also raised question in sustaining reform initiatives since large bulk of government budget goes to recurrent expenses.

Current free health provision/declaration is not sufficient to ensure universal access of health services with desired quality. Despite the policy scope and visible improvement in few indicators, access, affordability and sufficiency to health services provided by health facilities remains a key issue particularly for the marginalized groups. The service is limited only up to 40 drugs and a few services. In remote areas, resource crunch and inadequate supply of medicines in health institutions that are supposed to provide free health services has put the free health service scheme in jeopardy.

Human Resource crunch is limiting the service delivery. Though the provision of FHS increased the morbidity rate, the human resource level remained same as before FHS provisions. The sanctioned posts are not fulfilled. Currently, one doctor is available for around 21000 populations which is far above the WHO provision of 1:400. Around 12 percent of the sanctioned posts of health workers in government system are not fulfilled (NFHP & New Era, 2010).

Inadequate policy linkages between health facilities and communities. There is lack of an integrated approach and coordination between the sub-sectors. The provision of VDC linkage and lower participation of user group has resulted into irregularity of meeting; and the committee has not been functioning properly in the absence of elected representatives and has only added to the burden of the VDC secretary with his/her busy schedule. FHS Monitoring Committees, as prescribed by FHS Guidelines, are not formed, and are not functional even where they are formed.

Conclusion

Although the implementation of free health service has removed the barriers for poor there are questions on its sustainability and quality. There is a need of comprehensive health financing strategy along with continuation of free health service since the program suffered heavily due to financial and human resource constraints. Though the declaration can be considered highly encouraging move by Government, there was inadequate preparation in managing the service. Thus, the effective implementation of EHCS requires constructive donor support along with facilitative monitoring from CSOs and the general public to ensure proper functioning of health facilities with availability of necessary equipments and adequate human resources. There is a need for combined and synergetic efforts from state as well as non-state sector in enhancing accessibility, affordability and sufficiency of health care services to general public, especially to vulnerable and marginalized community.

References:

DOHS (Department of Health Services), (2010). Annual Report – Department of Health Services (2008/9). Kathmandu: DOHS.

UNDP (United Nations Development Programme), (2010). Human Development Report 2010. The Real Wealth of Nations: Pathways to Human Development. New York: UNDP.

Ministry of Finance (MOF). (2010). Red Book Fiscal Year 2010-2011. Kathmandu: MOF.

CBS (Central Bureau of Statistics), (2008). Nepal in Figures 2065. Kathmandu: CBS.

NFHP (Nepal Family Health Program II) and New ERA, (2010). Family Planning, Maternal, Newborn and Child Health Situation in Rural Nepal: A Mid-term Survey for NFHP II. Kathmandu: Nepal Family Health Program II and New ERA.

MoHP (Ministry of Health and Population). (2004). Nepal Health Sector Programme Implementation Plan (2004-2009). Kathmandu: HMG/MoHP.