Nepal’s remarkable progress on health indicators, especially MDG5, has earned the country international recognition. This achievement, in spite of low levels of economic growth, a difficult geographical terrain as well as a prolonged political transition, is a lesson for other countries. The new national Constitution endorsed last year reiterates Nepal’s commitment to scaling-up these achievements, addressing persistent and future challenges towards universal health coverage.
Along with improvements in maternal mortality, Nepal has also reduced under-five and infant mortality. However, neonatal mortality has been stagnant at 33 per 1,000 live births since 2006—halting progress on MDG4 and reflecting a gap in health systems with respect to access to services. [break]
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Communicable diseases persist as a major public health problem—the incidence of diarrheal diseases and acute respiratory tract infection continue to be high; the emergence of dengue has added to the existing burden of vector borne diseases like malaria, visceral leishmaniasis, lymphatic filariasis and Japanese encephalitis. TB and HIV/AIDS also need to be tackled simultaneously for progress on MDG6. Then there are increasing incidents of lifestyle related non-communicable diseases including diabetes, hypertension, cardiovascular diseases and cancer.
The government of Nepal has undertaken a pragmatic, systematic approach to universal health coverage, committing to provide a basic benefit package of essential maternal and child health service to its entire population. An expanded benefit package is being explored through the National Social Health Insurance Scheme designed as a pooled fund mainly with public resources, supplemented by voluntary contributions from households. Based on a directive by the Prime Minister in 2012, this initiative provides an opportunity for Nepal to use international experience to strengthen its health system for universal health coverage.
There are three specific issues that need to be considered here: first, protecting vulnerable and hard to reach populations within the broader informal sector as a priority; second, garnering substantial contribution of community based civil society/NGOs to health; and, third, feasibly financing the scheme. Countries like Thailand, and more recently Ghana and Rwanda, have shown that in low income and resource constrained settings, both equity and efficiency may be improved through financing mechanisms that use an autonomous national agency to pool and/or manage resources in collaboration with district units.
This institutional arrangement allows subsidizing poorer households and districts to improve equity; it also supports the strategic purchasing of services from NGOs as well as private providers in a manner that helps contain costs.
Cost containment will be an important consideration for Nepal if it is to increase the benefit package for the next phase of universal health coverage, as additional resources for health may be difficult to raise in an economic environment of slow growth. Out of pocket health spending is already at 60 percent of total health expenditure and must be reduced to improve equity. As in India, a significant proportion of this household spending is on the purchase of medicines, and Nepal may consider the approach of free access to medicines adopted by some states in India as a ‘quick win’ on equity.
Importantly, as the free access to medicines initiative in India has highlighted, comprehensive health system strengthening is needed for universal health coverage, whatever the selected lead initiative. This implies simultaneous attention to health financing; procurement, pricing, distribution and dispensation of medicines; availability of adequately and appropriately skilled health worker supported by needed medical supplies; and, service organization and infrastructure development in the specific context of Nepal.
Further, there are areas of public health that require immediate multi-sectoral action to address social, economic, geographical and environmental influences on health in Nepal: food insecurity, especially among hard to reach hill and mountain populations, has left 47 percent of children under 5 stunted, 15 percent wasted, and 36 percent underweight. ARI and diarrheal diseases associated with water and sanitation are the two leading causes of child deaths.
Nepal is highly susceptible to climate change risks and ranks 11th in the world in terms of vulnerability to earthquakes with important implications for health and health infrastructure.
Beyond multi-sectoral action, Nepal’s universal health coverage efforts call for development partners to better align themselves with national policy and capacities, while strengthening them at the same time.
The prominence of health in the United Nations Development Assistance Framework 2013-17 provides a good opportunity for development partners to join other stakeholders to support Nepal on its journey toward universal health coverage.
The author is an International Public Health Specialist and Former Deputy Regional Director, WHO South East Asia region
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