<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222f09c7e80680e0c0324jpeg.jpg" alt="" width="960" height="640"/><figcaption>Photo: POSSIBLE HEALTH</figcaption></figure>Ever since Finance Minister Janardan Sharma in his budget speech last month announced a plan to hand over management of Nepal’s national health insurance program to the private sector, experts are concerned that it will make medical treatment unaffordable for most people.Indeed, privatising health insurance is like the government abandoning its people, experts say, and it defeats the very purpose of the program — to provide affordable care for the most underserved communities who can neither access private plans nor expensive hospitals."Health insurance delivers the right of citizens to proper healthcare. As soon as it is implemented through a for-profit company, the social security aspect will be forgotten and serve purely as a business,” warns public health expert Sharad Onta.Private companies already provide health insurance schemes to those who can afford its expensive premium. The private sector therefore mainly serves the affluent, as public health experts Gaj B Gurung and Sushil Koirala <a href="https://www.nepalitimes.com/opinion/dangers-of-privatising-health-insurance-in-nepal/" target="_blank" rel="noopener noreferrer">argue in their op-ed</a> for Nepali Times:‘But can they really contribute to national public health security, understand equity, expand access to the poorest and the most marginalised population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?’Read also: <a href="https://www.nepalitimes.com/banner/sick-of-it/">Sick of it</a>, Sagar BudathokiIn 2017, then health minister Gagan Thapa introduced a national insurance scheme with a premium of Rs2,500 a year for a benefit package of Rs50,000 for a family of five. This was later increased to Rs3,500 premium and Rs100,000 payout. But this is still too low, and needs to be revised.Hospitals also complain of late reimbursement, and some are considering pulling out of the program. Dhulikhel Hospital alone is owed Rs250 million in reimbursements. Patients are not happy about the service either, and are dropping out.But it is too early to give up, says SP Kalaunee, former director of Nyaya Health Nepal which implements the national insurance scheme at its Bayalpata Hospital in Achham.“Nepal’s health insurance policy is fairly new and such challenges are to be expected,” he says, “But they can be and should be addressed within the existing structure.”He adds: “The goal of the program was to make healthcare accessible, affordable and equitable to all. The fact that we have an additional feature to the program to strengthen service providers means it was never just a financial mechanism.”Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health/">Taking wealth out of health</a>, Anita BhetwalA mandatory health insurance scheme where people pay the premium based on their per capita income could eventually include benefits that include treatment of chronic illnesses, say experts.Hiring competent staff with expertise in the field at the Health Insurance Board (HIB) might be a good start to improving the existing program. HIB should also be an autonomous body capable of making its own decisions without interference from the Health or Finance Ministry.Digitising reimbursement will also address some of the grievances, especially as the program should also look into signing up as many hospitals and care providers including the private establishments for the scheme. The private sector can be involved, but only in carrying out research on the sustainability of the program and for technical expertise.Nepal’s healthcare is divided into three levels:<ol><li>Primary health care (PHC) which is free in government hospitals</li> 	<li>Secondary care which is paid for by national health insurance and has waived premiums of the elderly, completely disabled, leprosy and Multi-Drug Resistant TB patients, people living with HIV, and the ultra-poor.</li> 	<li>Tertiary care that needs specialised treatment of chronic illnesses like cancers for which the government provides up to Rs100,000.</li></ol>Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, EditorialAll three aim to eliminate user fees at the point of care, but there are implementation challenges — the main one being the lack of government investment in the health sector and the limited understanding of what constitutes good health.“Health is more than just treatment and hospitals. A large part of it is prevention, from preventive measures against infection to building safer roads so that there are fewer road traffic accidents,” explains Sangeeta Kaushal Mishra of the Ministry of Health and Population.But health is not the priority of the government and there is not much investment in training medical personnel, making it incapable of meeting public demand. This gap is now being filled by the private sector.The government’s lack of capacity can be addressed to some measure by working with non-profits much like Nyaya Health Nepal and Nick Simons Institute which work with government hospitals to upgrade service.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeCommunity outreach is another crucial aspect in building a people-centric health system, and Nepal has a head start with its thousands of female community health volunteers across the country. They are primarily responsible for high childhood immunisation rates and reducing maternal mortality.  This now needs to expand to also include healthcare professionals at the grassroots, and retaining them.In the meantime, Nepal’s national health insurance policy also needs to address emerging problems like non-communicable diseases which with injuries make up two-thirds of death and disabilities in Nepal. The program must also include provisions for geriatric care and mental health conditions, all the while making sure the interests of the most vulnerable in the society are addressed."Private entrepreneurs will not fulfil the responsibility of the state. The access to the health care of the poor will be further weakened as soon as health insurance is privatised,” warns Damodar Basaula of the Health Insurance Board.Ensuring accessible and affordable health care for the people is the prerequisite of any government. Passing the buck to the private sector or any other group will further impoverish families unable to pay the medical cost of treating relatives.Says SP Kalaunee: “If you do not invest in the lives of people now it will cost much more tomorrow. The national health insurance program is set to become our biggest investment soon, and we must prepare the groundwork for it."Read more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

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Ensuring health insurance for all Nepalis

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ec9c7e80680e0c0322jpeg.jpg" alt="" width="269" height="642"/><ul><li style="font-weight: 400;" aria-level="1">Belamati Nepali of West Rukum was diagnosed with intestinal cancer and underwent surgery in Lalitpur. Her husband Khadke sold the family livestock to pay for his wife’s chemotherapy. He mortgaged his house to a local lender for Rs500,000, which he will lose if he doesn’t pay it back by October. But the money has run out. He says, "I am worried about losing my home, but I am now even more afraid of losing my wife.”</li> <li style="font-weight: 400;" aria-level="1">Aman Dhamala’s 23-year-old son was seriously injured in a landslide last year in Kalikot. A local hospital could not treat him, and he borrowed Rs250,000 to hire a helicopter which came seven hours later. His son died in the helicopter before reaching Kathmandu. "If we had a better equipped hospital in Kalikot, my son would be alive today. Now I am left with nothing but a huge debt.”</li> <li style="font-weight: 400;" aria-level="1">Suman Lamichhane broke his right leg in a fall 12 years ago in Gorkha, but because of improper treatment there, the National Trauma Centre in Kathmandu had to amputate it. Suman does not have a family. He had to sell everything he owned for treatment, but could not save his leg.</li> <li style="font-weight: 400;" aria-level="1">Punsiram Tharu’s son was diagnosed with retinoblastoma at Kanti Children’s Hospital this month. Treatment would have cost Rs300,000, and there was a 95% chance of recovery. But the Rs100,000 the government provides for cancer treatment was not enough, Punisram does not own any property, and no one back home will lend him money. The daily wage earner cannot afford his son’s treatment.</li></ul><ul><li>Six-year-old Roshan Tamang was taken home to Kavre by his parents midway through his cancer treatment in February because they could no longer afford his treatment. “I had to sell all my property for my son’s chemotherapy, but we were not sure he would get better, and we ran out of money. It broke my heart to take him back home,” Roshan’s father said. Roshan died at home three months ago.</li></ul>Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, EditorialNepalis are losing their lives and homes paying for expensive medical care. Others are living with life-long disabilities because they cannot afford treatment.Every year, the WHO estimates that 500,000 people across the country are pushed below the poverty line, and another three million face financial burden because of expensive medical care, and lack of insurance. That is over 10% of Nepal’s entire population.The cities have modern private hospitals which have made it possible for many Nepalis not to have to go abroad anymore for treatment. But these hospitals are out of reach of most Nepalis. The WHO recommends more than 10% of a nation’s total budget to be invested in health. This year’s budget allocates only 6.87%, which is even lower than other developing nations.Most of that money is allocated for construction and unnecessary equipment, there is not enough to train new doctors and nurses or retain them in rural hospitals.There was some hope with the introduction of the national health insurance policy, but the benefit amount of Rs100,000 per household is not enough for critical care.Instead of streamlining a national insurance scheme so healthcare is more equitable, the finance minister announced plans in his budget speech last month to privatise it.Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health/">Taking wealth out of health</a>, Anita Bhetwal<h2>Fix what is broken in Nepal's health system</h2><h2>Decentralised healthcare and a national insurance program can achieve equitable medical treatment for all Nepalis</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ee9c7e80680e0c0323jpeg.jpg" alt="" width="1024" height="683"><figcaption> </figcaption></figure>Ujjwal Thapa, the founding chair of Bibeksheel Sajha Party, died on 1 June last year due to complications from Covid-19.Thapa’s treatment, which cost Rs2.5 million, was crowdsourced after he was unable to put together enough money to pay mounting hospital bills. His family raised Rs6.8 million for the treatment of a young politician known for his integrity and vision for the country.Thapa needed financial support despite belonging to an upper middle class family with a house and business in Kathmandu.Covid-19 exposed the pre-existing failure of Nepal’s public health system and high cost of treatment at private facilities have forced many families into a vicious cycle of poverty, as well as countless preventable and premature deaths.Nepal’s healthcare mechanism is at odds with the constitutionally guaranteed fundamental rights of Nepalis, and needs a complete overhaul. Government hospitals cost less, but treatment is sub-standard and private care is too expensive.Read also: <a href="https://www.nepalitimes.com/opinion/dangers-of-privatising-health-insurance-in-nepal/">Dangers of privatising health insurance in Nepal</a>, Gaj B Gurung and Sushil KoiralaNepalis have had to sell property and livestock to pay hospital bills, and fall prey to loan sharks. Others have had to abandon treatment midway or entirely knowing that doing so would mean certain death.The government subsidises treatment for diseases including cancer, Alzheimer's and kidney failure, as well as for families of those who were killed or injured during the conflict. However, the amount does not even cover transportation for treatment in most cases. Bureaucratic red tape means not all patients receive the benefits.Arun Shahi, an oncologist at Patan Hospital says that cancer treatments might take up to five years, and cost as much as Rs20 million: “How much is the Rs100,000 government subsidy going to cover?”Particularly tragic are the stories of children whose parents have had to discontinue treatment for lack of money. Doctors at Kanti Children’s Hospital say they have seen at least five such cases from Achham, Sindhuli and Sarlahi districts in the last six months.“It is heart-breaking to be forced to send young children home, and we are very much aware that the lack of treatment will mean they will not live,” says Bishnurath Giri, a paediatric oncologist at Kanti.Read more: <a style="font-weight: 600;" href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudhathokiIn Nepal, medicine for chronic diseases like diabetes and high blood pressure cost about Rs1,000 per month. Kidney dialysis, required to be done thrice weekly, costs Rs2,500 per session. Cancer treatment cost a minimum of Rs300,000, while bone marrow transplants at private facilities cost up to Rs3 million. A brain surgery, which is not available at government hospitals, costs around Rs2 million at the Neuro Hospital in Bansbari.Meanwhile, the overall costs of a liver transplant could be as high as Rs3 million. Sagar Poudel, who sees up to 30 patients with liver disease at the Chitwan Medical College every day, says that at least five of those patients require liver transplants, but cannot afford it.For families in remote areas, even a fall from a tree or injury in a highway accident can sink them deeper into poverty. Many of Nepal’s migrant workers admit they seek overseas employment to pay debts incurred for medical treatment of family members.The average cost of treatment for an accident and surgery in private hospitals is Rs200,000. Just an ICU bed in a private institution in Kathmandu costs Rs20,000 per day, while the daily cost for patients needing ventilators is Rs100,000. Critical care at government hospitals is only about Rs15,000 cheaper.Additionally, the absence of a medical audit for treatment in Nepal, unlike in foreign countries, has led Nepali service providers to charge money arbitrarily by directing patients into unnecessary tests and treatments.Read also: <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">Health insurance must be an election agenda</a>, Gaj B GurungAnd since patients do not have technical knowledge of medical treatment, it is difficult for them to decide on the choice of service. "It is up to the patient to decide, but healthcare providers have taken the decision out of their hands," says Poudel, the liver transplant surgeon.And when families cannot afford treatment fees, hospitals are known to hold new mothers and babies, mentally ill patients, as well as bodies of deceased family members hostage.The over-saturation of private health institutions in Kathmandu has also led to unhealthy competition between private hospitals which have been known to pay ambulance drivers commissions for bringing patients to them. Tests performed in one hospital are not recognised by another, and a patient needs to take them all over again.Patients were already bearing the brunt of expensive medicines and over-prescription of unnecessary medications. Big pharma pays commissions to hospitals and doctors for prescribing drugs. Indeed, up to 75% of the total expenditure or medical treatment is spent on pharmaceuticals."While there is a big managerial weakness in the government health institutions, the private sector is engaged in unethical profiteering, and ordinary Nepalis are squeezed between those two problems,” explains physician Kiran Raj Pandey, author of Up is the Curve: A Genealogy of Healthcare in the Developing World.Read more: <a style="font-weight: 600; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeAccording to the National Health Accounts Report 2018, Nepalis spend 80% of their out-of-pocket expenses on private medical treatment. Nepal’s healthcare mechanism is not only causing people to spend a significant portion of their income on treatment, but also increasing indebtedness.Experts have time and again called for the elimination of out-of-pocket healthcare payments due to continued investment into an unregulated private medical sector.“The state has let hospitals and clinics charging arbitrary fees off the hook, this needs urgent fixing,” says public health expert Kedar Baral.The answer is a citizen-centric national health insurance program to reduce the burden of medical costs. Public health expert Sharad Onta says: “Healthcare cannot be a commodity, and patients are not customers."Meanwhile, Baburam Marasini, former director at the Epidemiology and Disease Control Division says that the treatment cost of 90% of patients will be reduced if health services are decentralised to primary health centres as well as local and provincial hospitals.Introducing a national health insurance scheme would then also mean sustainability for district hospitals and local primary health care centres.Read more: <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">This is how to upgrade Nepal’s rural health</a>, Sewa Bhattarai

Sick of it

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219c9c7e80680e0c02c6jpeg.jpg" alt="" width="1000" height="662"/>This year’s health budget kept the contribution to health insurance of the previous year's allocation of Rs7.5 billion. However, the plan to hand over the institutional management of health insurance programs to the private sector through the Ministry of Finance defeats the fundamental goal of the health security.This is not entirely surprising, of course, because the Health Ministry had passed a <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">narrow and poorly thought model of health security</a> for Nepal, and there were already concerns that it would eventually be handed over to the private sector and traded as a commodity.A private company can contribute to a health insurance program. But can they really contribute to national public health security, understand equity, expand <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">access to the poorest and the most marginalised</a> population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">National health insurance not as easy</a>, Sonia AwaleThe private sector has a role in contributing to achieving Universal Health Coverage by mainly serving the affluent. The poor neither can afford private health insurance nor access expensive private hospitals. Even if they are admitted to hospitals, they have to bear <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">catastrophic expenses</a> pushing them into the vicious cycle of poverty.The private insurance companies only pool the resource, they do not share the risk for those who cannot afford to pay the premium. It will be naïve to assume that such companies could be easily maneuvered to deliver services as a fair-price approach. There are around 20 registered private health insurance companies and 366 private hospitals in Nepal, and some are <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling health insurance at exorbitant premiums</a> many times higher than the current premium cap.There are six national health security indexes: prevent, detect, response, health, norms, and risk. During the pandemic, insurance companies got richer by <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling fake insurance schemes</a> while the hospital profits bulged through expensive Covid treatment. Very few hospitals treated Covid patients with a humanitarian approach. None of their technical advancements helped effectively prevent, detect, and respond to the pandemic.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219f9c7e80680e0c02c7jpeg.jpg" alt="" width="1641" height="1000"><figcaption> </figcaption></figure>The current health insurance program has identified the elderly, completely disabled, leprosy, Multi-Drug Resistant TB patients, people living with HIV, and ultra-poor as target populations to waive their premium. Though not adequate, this is an equity approach.But none of these target populations are <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">eligible for private health insurance</a>, or they will have to pay a much higher premium. It will be unwise to assume that these companies will change overnight and be equitable. They are powerful enough to influence government policy and have the power to bend them to suit their commercial interests.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, EditorialInstead, the government should <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">strengthen the Health Insurance Board</a> and explore ways to integrate health security with the broader social security scheme. In the short term, there are urgent but straightforward reforms like recruiting adequate and skilled human resources, strengthening the organisational systems, revising the design of service purchase strategy and equity, and gradually, having effective providers/purchasers split for better implementation.Ultimately, the program will benefit by forming a broader and more robust social security structure, co-incidentally introduced at the same time by the government. It would be able to absorb costs by pooling tax-based health care contributions and merging subsidies given to the treatment of cancer, renal failure, and other chorionic diseases under one integrated umbrella.But the current government does not appear serious about <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">reforming health insurance</a>, and simply does not understand the fundamental principles of health security. Health insurance is not just limited to providing health care, but is a part of broader health security.Read also:  <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe idea that health security can be strengthened by passing the buck to the private sector amounts to abandoning the constitutional commitment to provide health care, not as a service but as a citizen's fundamental right. The Nepal government is a signatory to achieving the health targets of the Sustainable Development Goals.As argued by Nepali Congress leader Gagan Thapa, who is one of the pioneers who <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">pushed health insurance</a> in Nepal, they contribute to strengthening the health system, strive for healthy populations, cushion the poor and provide them access to health services. It is a vehicle for mobilising adequate health resources, enhancing health security, and ultimately achieving Universal Health Coverage.These goals cannot be met by trading the people's health as mere commodities.Gaj Gurung has a PhD in public health from Chulalongkorn University and Sushil Koirala is a public health expert. Both are based in Bangkok.Read more: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee

Dangers of privatising health insurance in Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66739c7e80680e059980jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>There used to be a time when the main public health threat in Nepal was from infectious diseases like <a href="https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, encephalitis, <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a> and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener">renal failure</a> and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">poor health</a> is making Nepalis poorer.Read also:<a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37821&amp;preview_nonce=9ce6a7c55d&amp;preview=true" target="_blank" rel="noopener">Federalism leaves Nepal’s medical sector ailing,</a> Sewa BhattaraiAlso, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">stunting and wasting among children</a> due to malnutrition.In addition, <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">worsening air pollution</a> has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.Read also:<a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all of the change in world health"</a><a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialNepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a> or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.To meet these challenges, Nepal desperately needs <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">affordable and accessible medical care</a>. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance is not as easy as it looks</a>, Sonia Awale<a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa BhattaraiA survey last year showed that half of all <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical expenditure of Nepalis families</a> is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">commentary this week</a>, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.Parts of the scheme are being tried out in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a> (which last week <a href="https://www.nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award/" target="_blank" rel="noopener">won the Global Architecture Festival award</a> in Amsterdam for its design). Insurance reimbursement covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government  can no longer keep passing the buck on providing universal insurance for its citizens.<h2>10 years ago this week</h2>Nepali Times <a href="http://archive.nepalitimes.com/issue/480" target="_blank" rel="noopener">issue #480 of 11-17 December 2009</a> carried an <a href="http://archive.nepalitimes.com/news.php?id=16572#.XfId7ZMzaUk" target="_blank" rel="noopener">interview on page 1 with Baburam Bhattarai</a>, who was then vice-chair of the Maoist party.  Excerpts:‘From the very beginning, we have said that the basis of the federal system should be nationality. In Marxist terms, nationality means a common language, geography, economy and psychological make-up. A group of people that shares these qualities is called a nationality.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66769c7e80680e059981jpeg.jpg" alt="" width="392" height="600">On this basis we have proposed to constitute federal autonomous units in Nepal and we also practised this during the People’s War. Since the very beginning we have been consistent that federalism should be along the lines of nationality.’

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POOR HEALTH MAKES NEPALIS POORER

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108101144/636a257f9c7e80680e0439cfjpeg.jpg" alt="" width="1500" height="1115"/>In her recent article in this paper ‘<a href="https://www.nepalitimes.com/here-now/gurkha-grandparents/" target="_blank" rel="noopener">Gurkha Grandparents</a>’ (#944) Sikuma Rai movingly describes the plight of many elderly Nepalis now living in the UK, most of them <a href="https://www.nepalitimes.com/banner/a-military-migrant-economy/" target="_blank" rel="noopener">ex-Gurkhas</a> and their wives. The families get regular pension, heating allowances and rent support, free public transport, as well as access to the British National Health Service.But there are also costs, which include living away from their home country in a strange land among strangers, without the personal, social and cultural comforts of their villages. Many pine for Nepal, and <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/No-place-like-home,1123" target="_blank" rel="noopener">some decide to return home</a>. But women, particularly widows who speak little English, have few non-Nepali friends, and remain isolated in their homes in towns like in Salisbury or Aldershot. The weather does not help, and most remain house-bound or within a limited area of the city missing their children and grandchildren.Read also: <a href="https://www.nepalitimes.com/here-now/gurkha-grandparents/" target="_blank" rel="noopener">Gurkha Grandparents</a>, Sikuma Rai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.gwt.org.uk/" target="_blank" rel="noopener">The Gurkha Welfare Trust</a> runs advice centres which work closely with government bodies like the Royal British Legion to support army veterans. Numerous local charities unconnected with the army also help, as well as community services for older people, including mental health diagnosis, treatment and support, provided by the local council and by the health services.But much of this is cold comfort to elderly Nepali men and women who have settled in Britain, and who would, ideally, flock back to Nepal to be with their families and friends -- if only they could be assured of more financial support, including better and less costly health care.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108101144/636a259b9c7e80680e0439d0jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>The <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/need-to-prepare-for-ageing-society,3624" target="_blank" rel="noopener">elderly in Nepal</a> have traditionally been able to count on family support. But, as more older people live longer the financial burden on families has increased. Nepal’s average life span has increased from 35 for men and 37 for women in 1961, to 69 for men and 72 for women in 2014. By 2018, there were nearly 3 million people over 60 in Nepal. Family fragmentation has also resulted in physical separation between older grandparents and their children and grandchildren.Consequently, even back in Nepal, more elderly men and women are <a href="http://archive.nepalitimes.com/regular-columns/guest-editorial/guest-editorial-old-is-gold,876" target="_blank" rel="noopener">living apart from their closest family members</a> than ever before. Many are now suffering from the same problems as do those settled in the UK, but without pensions, allowances, and access to free medical services.Read also: <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/need-to-prepare-for-ageing-society,3624" target="_blank" rel="noopener">A much older tomorrow</a>, Sonia AwaleThere are relatively few specialised institutions for support and care of the elderly in Nepal. The Gurkha Welfare Trust cares for ex-<a href="http://archive.nepalitimes.com/page/the-gurkhas-an-interactive-timeline" target="_blank" rel="noopener">Gurkhas</a> and their families with Welfare Pensions to veterans and widows and medical treatment. But there are very few examples in Nepal of private ‘care homes’ and ‘retirement villages’ that exist in the UK.There is now some state support, but it remains pitifully limited. The non-contributory social pension scheme introduced in 1995 was intended to provide allowances to older people aged 70 and above, to older dalits and people living in the Karnali Zone aged 60 and above, and to poor widows aged 60 and above. The allowance was doubled to, Rs2000 and the age of eligibility reduced to 65, but scheme remains inadequately implemented.It is estimated by Pension Watch (Help Age International) that the number of people receiving an allowance is around 636,000, and 47% over 65 in Nepal receive a non-contributory pension, while 9% have a contributory pension. The total cost of the scheme is Rs15 billion, or 0.7% of GDP. By 2050, when the estimated number of Nepalis over 60 will be around 6.5 million, the cost will have more than doubled even if the same proportion of the budget is allocated to the scheme.Last year, Prime Minister Oli proposed a <a href="https://www.nepalitimes.com/here-now/social-insecurity/" target="_blank" rel="noopener">social security scheme</a> for private sector employees to provide for life-long pensions and reduce the fiscal burden by demanding that employers deposit 31% of the basic salary (20% from employers and 11% from employees) into a Social Security Fund. After 15 years, private sector employees would then be entitled to lifelong pensions, just like retired government employees.Read also:<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/social-insecurity/" target="_blank" rel="noopener">Social insecurity</a>, Om Astha Rai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/not-just-social-security/" target="_blank" rel="noopener">Not just social security</a>, Josh GloverBut even were this scheme to be introduced, it would still <a href="https://www.nepalitimes.com/latest/not-just-social-security/" target="_blank" rel="noopener">leave out millions working in the informal sector and agriculture</a>, and would be too late for those already of pensionable age.The Nepal government spends 6% of its budget on basic health care and in 2012, launched a pilot program for universal health insurance in five districts. This was followed up in 2017 by the National <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">Health Insurance</a> Act and in 2018 by the National Health Institution Quality Authority Act, providing the legal framework for a National Health Service.Although Nepal's 2015 Constitution guarantees basic health care as a fundamental right, however, access to high-quality care remains a privilege, and out of reach of most including elderly Nepalis who may want to come back home.<h2>Fighting for equality</h2>In May 2009, the Labour government under Tony Blair was obliged by public pressure to enable Gurkhaswho retired before 1 July 1997 with at least four years’ service to settle with their families in the UK, that being the date when the Gurkha Brigade headquarters moved from Hong Kong to Britain.Read also: <a href="https://www.nepalitimes.com/opinion/the-time-has-come-for-a-gurkha-peace-corps/" target="_blank" rel="noopener">Time has come for a Gurkha Peace Corps</a>, David SeddonEven before that, in March 2007, pay, pensions and terms of service of serving Gurkhas were equalised with those of regular British Army personnel and equal pensions were granted to those enlisted from 1 October 1993, but about 15,000 pensioners and 6,000 widow pensioners did not benefit.On 10 June 2011, the British Gurkha Welfare Society lodged a case with the European Court of Human Rights (ECHR) claiming that Gurkhas had been paid significantly lower pensions than their British counterparts. On 15 September 2016, the ECHR shattered the hopes of thousands of ex-Gurkhas for equal pensions.

Cold comfort

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110710110/6368c9ba9c7e80680e02f2cajpeg.jpg" alt="" width="225" height="224"/>Under the bank’s health insurance facility, Sunrise Bank has been providing savings account with a guarantee to compensate for the expenses, facilitating up to 25% of weighted average deposit of the last 365 days or the bill amount—whichever is lower—with a maximum limitation of Rs100,000.In the same line, the bank has handed over the cheque amounting Rs22,061.78 to the account holder of Bhaktapur Branch, Rajendra Kumar Sakhakarmi. The program was carried out on 4 April. The insurance facility is provided with an alliance of Shikhar Insurance Company Ltd.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110710110/6368c9bb9c7e80680e02f2cbjpeg.jpg" alt="" width="1000" height="407">

health-insurance

Ensuring health insurance for all Nepalis

Sick of it

Dangers of privatising health insurance in Nepal

POOR HEALTH MAKES NEPALIS POORER

Cold comfort

Sunrise insurance