The global context

The Alma-Ata Declaration in 1978, adopted in the International Conference on Primary Healthcare was conceptually a historical breakthrough to establish health as fundamental human right. The state was expected to play the primary role to ensure the right through universal health coverage adopting a health care system based on equity and social justice. Despite their commitments, most of the states failed to safeguard the health of people and surrendered before the tide of the market and increasing privatization of health, while the commitments of Alma-Ata gradually faded. Social justice, equity and rights of citizen to health were almost wiped out resulting in widening gaps between people living in different socioeconomic circumstances. Deprivation and marginalization of that section of people continued, which are reflected in unequal global and health indicators. In view of this, it is apparent that Universal Health Coverage based on equity is more relevant today than before, as we live in the most unequal world in the era of austerity. This relevance is well reflected in the notion of the comeback of the Alma-Ata commitments as Revitalization of Primary Health Care with people’s initiatives at the global level.

The Nepal Context

Nepal, a small in territory with less than thirty million people, a low income country, lies between two emerging powers – India and China with nearly two and half billion people. Experiencing a decade long armed conflict, Nepal faced series of political and economical hardships. Despite its size and development status, Nepal could not remain untouched from the global wave of privatization of health care. Soon after replacement of absolute monarchy by restoration of a multi-party political system in 1990, the country adopted neoliberal economic practices with massive privatization of health care services. Due to the weak state system and operating machinery to regulate the private sector, the market grew rapidly in a short span of time. More than half of the doctors and nurses, more than two third of the pharmacist are engaged in the private sector, more than half of the hospital beds in the country are owned by the private market [1]. Growth of the market not only dominated health services, it also influenced state policy and planning in its favor. This policy was based on the theory that people are willing and capable of paying for health services, Nepal introduced user’s fee in the public sector hospitals and healthcare in the name of cost recovery and sustainability. While the private market served the urban elites, even the public services were accessible for those with purchasing capacity. A vast majority of poor people, urban or rural, were deprived of health services. The deprivation of health services due to inability to purchase health services has been one of the determinants of disparity in health, which exists between the ethnic groups, people living in different ecological zones of the country and between the people living rural and urban settings [2].

Nepal enjoys an appreciation at the regional level for remarkable progress in implementing Millennium Development Goals (MDGs) 4 and 5 related to health indicators in terms of declining mortalities[3]. A brief snapshot of statistics in Table 1 reflects this change over the last two decades.

Table 1. Decline of mortality in Nepal

Reduction of mortality has resulted in visible increase of life expectancy which increased from 53 years in 1991 to 68 years in 2011. However, it is still short and there needs to be a serious review of the underlying causes. Contribution of critical awareness among the people and initiatives beyond the health sector are ignored and pushed aside while appraising these improvements. Even more important, progress in gross national average has masked the disparity in health across the country and people. Just taking these few mortality indicators into account, as mentioned above, discrepancy is considerable and sustained for many years.

Table 2 Disparity in mortality among the people

Struggle of Nepal to de-privatize health

It is well understood that strengthening the public sector is a pre-requisite to reduce the influence of the private market in health. Difficult topography, poor infrastructure development, inadequate human resources are major hurdles for Nepal to provide health care services to the people. Technical competencies, managerial efficiencies and governance are other dimensions of the problems that can never be ignored. Amidst these challenges, financing health is considered as the primary agenda of the struggle to meet the goal of Universal Health Coverage. Financing health is the primary agenda in view that it is interrelated to the fundamental aspects voiced since the Alma-Ata Declaration – equity and justice in health, health as a right of citizens and the role of the state.

A theoretical question ‘who pays for the health care services’ is irrelevant for Nepal, since the country has constitutionally accepted the capitalistic mode of production and distribution, where the cost of health services, like any other services, is borne by the citizen. Apparently, even so called free services are myths, as the cost of services is paid for by the citizens in different forms of tax. Therefore, ‘how to pay for the health services’ is the question and Nepal is struggling to seek the answer. Finding an appropriate answer is vital to replace the direct payment for services to the private market or to the public service facilities at the time of service consumption. Needless to mention that the market does not recognize equity and justice. Therefore, deprivation of services is the ultimate fate of people who cannot purchase these services.

Nepal’s alternative health financing approach

Nepal is in the initial phase of reforms for health financing approach. The reform is seen as a struggle for making a financing approach that will ensure Universal Health Coverage based on principles of equity and social justice. It aims to establish a system where citizen should pay for the health care services based on their ability to pay and will receive the services according to their needs; it is guided by the principles that consumption of health care services does not depend on the scale of their financial contribution to the system and the consumers do not pay for the services at the point of service consumption. Universal Health Coverage comprises of health care services of two categories – Basic Health Services (BHS) and beyond Basic Health Services.

Basic Health Services

It was an achievement of peoples’ struggle that Nepal abolished user’s fee in essential health services and declared these services free. Further, with a collaborative mobilization of civil society, professionals and academics, it was included in the Constitution. Thus the state defined Basic Health Service is guaranteed by the Constitution of Nepal as a fundamental right of citizen[4] and provided by the public health facilities at all levels free of cost . The fund for Basic Health Service is allocated by the state as a part of the national budget collected from general taxation based on the scale of income of the citizen. People do not pay tax particularly for health. Basic Health Service is equity based. As the scale of Basic Health Service depends on the size of the health budget, Nepal struggles to increase the state health budget and expand the package of Basic Health Services.

Beyond Basic Health Service

Financing beyond Basic Health Service is a challenge for Nepal, as the state cannot bear the cost of burden of health problems, which include a large portion of secondary care and nearly entire tertiary specialized care. People have to pay for services even in the public hospitals, where services are inadequate. Hence, people are largely dependent on the private market. These services are expensive. Poor Nepali people cannot afford the cost of services, which is catastrophic for many of them. Ensuring access to these services to the people is the epicenter of the struggle of Nepal to meet the goal of Universal Health Coverage. It includes sustainable financial provision and a structure with human and commodity resources. However, as mentioned above, financial provision remains the primary agenda.

Creation of public fund for beyond Basic Health Service

The Government of Nepal introduced the Health Insurance scheme in 2013 for creating a fund to cover costs for beyond Basic Health Service. The scheme raised the fund as premium in equal amount from families regardless of their economic status for enrollment in renewable health insurance schemes. The insured family could receive health services at a limited cost. It was a market model insurance – same price for all – and, therefore, did not comply with the principle of equity and justice. Paying the same amount of premium by poor and rich family for similar health services did not reflect the spirit of Universal Health Coverage.

The scheme was harshly criticized for its regressive nature since it marginalized the poor sector of the population further depriving them of access to health services. The need for a public fund to cover the cost of beyond Basic Health Care was undeniable. A strong public voice was raised for creating the fund guided by the principle of equity and justice. It was proposed that the contribution to the fund be based on the economic status and purchasing capacity of the family. There were reluctant views on such basis of contribution. There was also an argument on the capacity of the state to assess and monitor the ability of the family to pay.

As a response to the voice for people, despite objections, the parliament recently passed the Health Insurance Act 2017 with the provision of financial contribution to the fund by the family to be based on their income status. It is a legal indication that the fund for beyond Basic Health Services would be raised through the progressive taxation model in the coverage of health insurance. The Act also provides the legal provision that the government will pay the premium for families, who are below the poverty line as defined by the state[5]. This will ensure the inclusion of all citizens in the scheme regardless of their earning and economic status. It will provide the financial protection to the poorer section of the population and help to achieve the goal of Universal Health Coverage. It is note-worthy that people pay for health services based on their ability; for basic health services non-specifically as general tax, while people pay for beyond Basic Health Service specifically for health as premium.

Conclusion

Nepal has achieved a financing mechanism based on the principle of equity and social justice to ensure Universal Health Coverage to every Nepali citizen because of peoples movement and struggles. However, implementation remains the challenge and unfinished agenda. Despite the engagement of the private market in social health insurance schemes, it is expected to minimize the adverse impact of privatization of health services through the control of the state over the market. There is a reluctance regarding the progressive tax based health insurance, and there is widespread lack of trust about the ability of the state to implement the system. However, this is not the time to raise the question whether the state can provide basic health care not; it is rather a prime moment to ask whether the state must do it or not.

*** Sharad Onta, MD, MPH, PhD is a Professor of Community Medicine and Public Health at the Institute of Medicine, Tribhuvan University, Kathmandu Nepal, member of the Faculty Board (highest academic authority of the Institute). Sharad is also the author of several scientific papers and chapters of books on public health and health policies.

[1] High Level Commission on Health Profession Education 2015 Government of Nepal, Kathmandu

[2] Nepal Demography and Health Survey 2011 Ministry of Health, Government of Nepal, Kathmandu 2011

[3] National Health Policy 2014 Ministry of Health, Government of Nepal, Kathmandu 2014 *Analyzed from NDHS Report 2011(2)

[4] Constitution of Federal Republic of Nepal 20

[5] Health Insurance Act 2017, Government of Nepal