In a healthy state

Every year, half a million Nepalis fall below the poverty line paying for expensive medical care. Another three million face financial burden, unable to pay hospital bills even after selling their assets. This is over 10% of Nepal’s population.

Nepal might have taken dramatic strides in reducing maternal mortality and childhood malnutrition in the last decades, but it is lagging behind in assuring accessible and affordable healthcare for its people.

This is a crime, it goes against the Constitution which guarantees basic health care for all Nepalis. Like other social sectors including education, healthcare is either over-commercialised or offers substandard service.

Public health is just not the priority of the government, especially when it comes to the poorest and most neglected sections of society. The state’s investment in healthcare is inadequate, and the budget allocation for the health sector is considerably lower than the global average of 10% of GDP, and is less than most developing countries.

Read more: Grassroots democracy promotes good health, Sagar Budhathoki

Even the budget that is set aside for healthcare is mostly spent on shoddy infrastructure, or procuring unnecessary and expensive equipment that is never used. There is little left for trained medical personnel and retaining them in remote area hospitals.

Nepalis are sick because they are poor, and they are getting poorer because they are sicker. Most families that cannot afford treatment in private institutions have to sell property or borrow from loan sharks to pay medical bills.

Private hospitals and clinics operate on free market principles, and need a return on investment. The most lucrative business in Nepal today is medical education, and the sky high fees in those colleges perpetuate the cycle of over-priced medical treatment.

Read more: Do hospitals have to be so expensive? Elipha Pradhananga

Healthcare should not be guided by the free market, and as long as the state does not take responsibility for the wellbeing of its citizens we will never achieve equity.

Medical care cannot be a commodity, patients are not customers.

Primary health care (PCH) is free in government hospitals in Nepal, and is paid for through taxes. Specialised medical care is best covered by insurance so the cost is not passed on to patients and their families. But in Nepal, primary health care is too basic, government hospitals are crowded and understaffed, and private hospitals are out of reach of most.

A welfare state with a social safety net pays for free healthcare through taxes, or insurance. Tax revenue goes for other sectors besides health, but medical insurance is targeted for specifically for health.

Countries like Bhutan, Cuba and Sri Lanka show that it is indeed possible to achieve free universal healthcare. Nepal itself has public-private partnership models like Bayalpata Hospital. Replicating these examples requires political will, and a national vision.

Read more: This is how to upgrade Nepal’s rural health, Sewa Bhattarai

Our salvation may lie in national health insurance that is mandatory and where the premium is based on a family’s capacity to pay. Nepal introduced its national insurance scheme in 2017, and the premium is now Rs3,500 per year per family for a benefit package of Rs100,000. But this does not even pay for an ambulance to a city hospital.

Late reimbursement to care providers is chronic, and hospitals now want to pull out from the national insurance program. Patients are cannot access timely treatment, and  are dropping out.

To correct this mistake, the government is making another blunder: hand over management of health insurance programs to the private sector.

The state is giving up on health insurance without even trying, abandoning citizens and leaving them at the mercy of profiteers.

Letting the private sector manage health insurance defeats its very purpose: providing equitable and affordable medical care for those most in need and to prevent them from falling into the poverty trap.

A better alternative is to work within the existing health insurance program by upgrading its features including the revaluation of the premium and benefits, bringing in private institutions for research and technical know-how, and digitisation of reimbursement for care providers.

There are ways the Nepali state can fulfil its constitutional obligation to ensure healthcare for all, and deliver on promises not kept. It just has not tried hard enough.

Read more: Is free health care possible in Nepal? S P Kalaunee

Sonia Awale