Nepali Times
Guest Column
10+2 for public health


Nepal is on track to achieve and even exceed a few of the Millennium Development Goals, such as reduction of child mortality, maternal mortality, fertility, access to drinking water supply, and basic education.

In the past half century, Nepal reduced its under-5 mortality by 80 per cent, from 250 to 50 deaths per 1000 live births. Most European countries took two centuries to achieve such a reduction.

Some of the greatest public health success stories in Nepal are the eradication of smallpox, virtual eradication of polio, and significant reduction in iodine, Vitamin A and iron deficiency anemia affecting large numbers of women and children. Our national network of 50,000 female community health volunteers deserves credit.

The children of Nepal today are healthier, more educated, and more knowledgeable about the world than any previous generation. There has also been good progress in women's health, education, and their overall status in society.

But there are huge inequalities and disparities among various population groups. Some of our historically marginalised communities and population groups lag seriously behind, not least in terms of child and maternal mortality rates, and access to health facilities.

In the light of this mixed picture, a 10+2 agenda should govern public health in the coming decade in Nepal:

1. Scale up essential health care
We have to substantially increase the number and quality of trained health workers, ensure there is no stock-out of essential medicines, upgrade health facilities, and offer conditional cash grants for vulnerable populations to ensure universal access to basic health services.

2. Focus on equity
The elimination of user fees for certain basic health services has progressively reduced barriers to access by the poor, marginalised communities. But more effort must be made to implement the National Health Systems Plan (NHSP-II), which contains specific objectives to reduce cultural and economic barriers to accessing health care services by the poor, Dalits, Janjatis, Muslims and deprived Madhesi communities.

3. Tackle malnutrition
Nepal has unacceptably high maternal and child malnutrition. A key strategy to improve nutrition is to ensure household food security. But beyond food, control of infections and good caring practices are equally important. Pilot schemes initiated to improve maternal and child nutrition should be scaled-up.

4. Prioritise non-communicable diseases
Nepal is going through an 'epidemiological transition' to non-communicable diseases such as heart and kidney ailments, cancer, asthma, diabetes, obesity, and strokes, as well as accidents, injuries and mental health problems. The main response to these is behaviour change and adoption of healthy lifestyles.

5. Prevent accidents, injuries and disabilities
Besides prevention, much more needs to be done to expand treatment, rehabilitation and special education, and counter the alarming rise of traffic accidents.

6. Promote environmental health
Safe water, clean air, basic sanitation and hygiene are of critical importance with respiratory infections and diarrhoea, the leading preventable causes of mortality and morbidity in the country. Our children should be taught good environmental citizenship.

7. Harness the power of educawation for behaviour change
The more we can do to empower parents with knowledge and skills in child care, the better the health outcomes. Teachers, and children themselves, are potential health workers, and we should harness the power of radio, TV, newspapers, and mobile phones to spread public health messages.

8. Strengthen health systems
To back up the health-seeking efforts of people themselves, we have to strengthen our health systems to make them more effective, including in emergencies.

9. Foster public-private partnerships
We need to foster a more productive partnership among the public, philanthropic and for-profit private sectors. Urgent action is needed to enact and enforce clearer norms and regulations, while avoiding excessive government interference or micro-management.

10. Capitalise on international health partnerships
Nepal enjoys strong international support in health programs, but there is room to ensure greater aid effectiveness to produce even better results.

Additional +2 elements are needed to ensure a peaceful and healthy national body politic to further advance Nepal's public health:

1. Institutionalise a culture of non-violence
The 'structural violence' of poverty, inequality, exclusion and marginalisation has long existed in Nepal, but widespread physical violence in public life is a recent phenomena. We must reject this cancer of violence as an acceptable means for achieving any worthy goals, and inculcate non-violence in the minds and hearts of our children.

2. Consolidate genuine democracy
The WHO defines health as being "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". Such well-being is only possible in a full-fledged democracy with a thriving economy in which people can live a long, healthy, productive and creative life.

This article summarises the keynote address at the inaugural conference of the Nepal Public Health Foundation in Kathmandu, 30 June 2010

Green hunt, PUBLISHER's NOTE
Conflict of coverage, CK LAL
Stuff of dreams, INDU NEPAL
What's sticky?, ASHUTOSH TIWARI

1. Agya
I believe the focus should be on a 2+10 approach.
Without institutionalizing a strong culture of non-violence and consolidating genuine democracy, the ten agendas presented here are most likely to remain as paper-agendas. 

2. Daniel Gajaraj

Kul Gautam's emphasis on rejecting violence is very very timely.  starting from ,inculcating non-violence in the heart and minds of children.May I take the liberty of going one step forward?

3. Shyam Sharma

These are remedies cited in the article are applicable to all developing countries. Writing to shun violence is very easy, but putting into practice is an uphill task since the culture in Nepal is the use of this to come to power or become a politician. Without inciting the general public to declare strikes and bandhs you cannot become a neta jee. That is the way of life in the country today. Democracy in developing countries have taken another form of meaning - that is buy the people instead of "by", off the people instead of  "of", and far the people instead of "for". For a general layman in the country who spends 12 hours a day working and thinking of how to arrange the next meal for the family, democracy has no meaning. Such people comprise of the majority in the nation and they need good income, in fact disposable income, so that they can spend the money in health care, education, and basic needs of the family. The increase in population has undermined the development efforts of the country; so the country must prepare another strategy to offset these deterrents.  


4. koji
#7. What is 'educawation'?

5. Satya Nepali

Two thumbs up for Shyam Sharma #3!

#4 Koji: "educawation" is the education system of Nepal that produces student, union and national leaders who "caw-caw-caw" from khula-manch platforms and can do nothing else!

6. Om Pd. Gautam

Thanks for the health sector comprehensive column! I am pretty much happy that, you brought-up the issues of "Equity and Environmental Health" under 10+2 for public health. This is important to look into 10+2 points equally however needs immediate priority for certain issues including equity, environmental health from which health can significantly reduce their financial as well as programmatic burden and also disparities in health outcomes for overall human development. The main crux of the problems in the current system lies under these two arena due to lack of institutional priority, governing system and willingness. Since NHSP-II talks about both the arena as cross-cutting theme, hope health sector in Nepal will be able to look into these issues in coming 5 years. Environmental Health is important; it is because Nepal made significant progress on reducing the infant and child mortality, however WASH related infectious diseases are still being the most common causes of morbidity and mortality. Broadly WASH associated diseases including Cholera, Diarrhoea, Skin diseases, Typhoid, Trachoma, Hep-A etc are the leading preventable diseases reported in Nepal. The ARI and diarrhoeal diseases remains the leading causes of child mortality (10,500 diarrhoeal deaths among <5yrs children per year) however, health sector initiatives for reducing WASH associated diseases are pretty much limited with curative interventions not through prevention despite of the availability of cost effective public health interventions. Diarrhoeal outbreak in 20 districts of mid and far western part of the country during the year 2009 killed more than 346 people are the prominent examples of WASH associated diseases burden in the country. Health Sector Institutional priority for 10+2 with deliberate empahsis on certain theme will certainly meet the people's expectation!!!. Once again, thanks for bringing the issues into table for wider dedate and internalization. 

7. bibek
#5 I disagree with your argument about the education system of Nepal. It is  producing  more netajee than good intellectual people but you can not deny the fact that the teachers calling for student going home to home in Manang and Dolpa, engineers surveying the road in leks of Jajarkot and Myagdi, doctors at least going to the hospitals of Baglung (although they may not in Bajhang), most of the bureaucrats who keep running  the country  on this fragile condition are the product of Nepali education. You have known ratio of college going student is more in Nepal than many developed country. The technical education is well known as one of the best in Asia. What those people not educated in Nepal did till today for this country in spite of barking at the moon from New York, London, Geneva or Sydney.
Yes, we did more in few decades than European did in centuries but we have to pave a long road ahead. We can have did more if we had focused on work than politicking every matter and gossiping. Institutionalizing nonviolence and democracy, controlling population explosion, provision of health,safety and equity definitely materialize the rays of hope. It's easy to utter all these good words but we do not have a good leader who can understand this and implement it in better way.

8. Jiwan

Kul Gautam's article proves that we have no dearth of theoriticians who are good to preach using the language of a roving consultant who are good at making numerous recommendations. In the last two decades, it cannot be denied that certain gains have been made in the area of child and maternal mortality. However, it will be a misleading statement in any way to assume or attribute it to such results to a good planning by GON and effective implementation and leadership by the Ministry of Health. Health care needs have been felt by the people due to awareness and rising in literacy rate. The question is: has the government stepped up to meet the needs as per the rising needs? The answer is resounding NO. The Ministry of Health has a worst bureaucracy in place and in practice and planners and top implementing officials are busy in doing the tours around the globe. WHO, UNFPA, UNICEF, World Bank and many other donor agencies are responsible for funding the junket trips for MOH officials. MOH, instead of becoming a public health ministry, it has become just a public ministry, minus health. It does everything but health. To quantify further, top ministry, including Directorate of Health Services, are interested in travelling abroad in one pretext or the other and therefore, any given time, 80% of top Ministry beaurocrats and public officials are either on travel abroad or busy in planning for another travel abroad 90% of time. What were the accomplishments of the Health Minister travelling, with wife,  to the USA three times just in last one year? Are doing playing with each other or the Minister playing with donors in the travel game? Should the Secretary and Director General visit more to health posts and health facilities within country rather than going to numerous junket trips that bear no results for the country?

Is anyone concerned when 80% of child survival vaccines go to waste? Is anyone worried when government funds are used to procure items, for personal gains, that are already plentyful and create only redundancy?

If you see how many foreign advisers and consultants connected to health were already in Nepal or travelled to Nepal in the last two years, you will be astonished to find out. There are over 600 foreigners in Nepal at any given time who are either in Nepal or travelling to Nepal in the name of provision of assistance in the area of health. Just take a look at the aiport entry form and visa applications. One will wonder what this army of advisers and consultants may be doing in Nepal? What is the Ministry of Health doing then if all projects are being run and managed by foreigners or through foreign funded? Mind you, it is over 600 in number. MOH has no idea where they are and what they are doing. When the MOH itself in disarray, how could they know who is doing what? Do we really need two Secretaries in the Ministry? If you survey physically the health posts and subhealth posts, you will find that most of them are out of stock of essential supplies, medicines and contraceptive devices. Can the donor take some responsbilities for this mess created over the years? Could some health economists give us some figures as to how much money Nepal has spent in health care in few years which includes the amount reportedly spent by various donor funded projects? You can then weigh the related advantages of gains vs the amount put in in health sector. Experience has shown that various donors have limitations and certain priorities which are not unbiased in terms of funding and choosing areas. Even within donors, certain donor representatives have their own bias and inefficiencies which complicate the priority further as it does not jell with the national priorities. In such a situation, MOH with its mind not in the wellbeing of the people but only on personal training and tour abroad, is clearly not positioned to provide proper guidance and coordination.

Any proud Nepali who visits our premier public hospitals in the heart of capital, Bir, Teku, etc., should hang their heads in shame by seeing the sheer unhygienic conditions and practices.

Taking a cue from Mr. Gautam's article, my recommendation is that a comprehensive and a thorough assessment of MOH be conducted by a team of carefully selected individuals which should not only look into the capacity of the Ministry's current human resources but its operational procedures and future needs in terms of human resources and how the Ministry could position itself better in a areas of policy, implementation and coordination roles. If MOH is to be the key government ministry and there are no radical changes in the thinking and practices of the top officials along with its operational procedures, we can go on prescribing 10 plus 2 or 100 plus 20, none of these will make any difference. Last but the least, while the provision of health services to its people is the responsibility of the government of Nepal, donors have played a key role in it. Donors also must change their behaviour radically in terms of their dealing and supporting the health sector. It should be more of people centered rather than the Ministry or certain individuals centered. May I say that World Bank, UNICEF, UNFPA, WHO are few donors/stakeholders who have shown time and often that they are notorious in pleasing the individuals by ignoring the larger interest of the country. These so called experts are quick to blame the corrupt, lazy, lethargic and incompetent government and its officials but as the saying goes in Nepali, afno aangmaa bhainsi hideko dekhdain, aruko aangmaa jumraa dekhne.


9. Hom Nath
what's up with this laundry list of things to do? kul chandra gautam's 'bikashe jhola' has nothing to offer but another boring development-speak prescriptions only. besides i doubt the data to back up his claims about Nepal being on track to meet any of the MDGs are reliable. of course, the whole development world has not choice but to show that MDGs project has been somewhat of a success - and they will cook up the book, if they have to,  to show just that. all we're gonna get is yet another self fulfilling prophecy!

10. manisha
Kul chandra gautam articles is compelling but yet not convincing.Action speaks louder than word, so its high time that we stop making strategies and policies when the already existing ones are not implemented properly.The writer talks about increasing the number and quality of trained health workers but lets not forget the fact that government health staffs are the ones who actually receives the maximum number of training.Users fees is a history i guess as government has already ensured free health services for basic health services.The international agencies are providing with a lot of fund in health sector but what is the question is have we been able to utilize those fund effectively and bring about the impact it is ought to bring.i believe the article provides yet another opportunity to study the public health realted article which we all already know and nothing else.

(11 JAN 2013 - 17 JAN 2013)