7-13 April 2017 #853

Policies for the people

Interview with Health Minister Gagan Thapa
Marty Logan

Health issues have been making headlines since Gagan Thapa became health minister seven months ago. He has promised to crack down on political leaders going abroad for treatment, expanded free coverage for serious illnesses and pledged to properly staff regional hospitals, including with specialists. But the minister says his preoccupation is making long-term policy changes.

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Nepali Times: Do you ever wonder if you’re being too ambitious, if you’ve bitten off more than you can chew?

Gagan Thapa: I don’t think so. What I feel is that the system here is not in sync with the speed at which I’m trying to move forward. Or I’m not fitting into the system. That is my observation in the last six months.

Sometimes it sounds very ambitious and people also feel that when we haven’t been able to fix basic things: getting medicine, basic services in hospitals, a number of other services. And when you talk about providing this and this it might sound ambitious and I accept it, but I are not just making these statements without any solid evidence or homework.

To give you an example: when I talk about ensuring specialist services in peripheral health facilities, particularly zonal hospitals, district hospitals, in the next 3-4 years, I’m making this statement on the basis that the ministry is going to start a post-graduation course in at least five zonal hospitals in the next three months, and we’re planning to go for the next 14 hospitals in the next year. The hospital is already there, the faculty is already there, demand is already there. The only thing we need to do is start this program.

I read you say in a recent interview that implementation is ‘very very weak’. So what do you do to fix that, rather than fix a single plan or program?

Yes, implementation is, I wouldn’t say weak – it is the most difficult and challenging part… But we need to start from the top. The first thing is the political will. I have that political will, and I am very lucky to have a very good back-up, to have a good young team who are full of enthusiasm and providing me all the evidence and support I need.

People here in the health ministry, I found them so scared. They think ‘If I do something wrong, there are a number of agencies to punish me. I’m all the time under scrutiny, the media is observing if I’m doing the right thing or not. But I don’t find them very scared about things like ‘What if I don’t finish the work that I’ve been given’?

We hear about the challenges, about the health posts that don’t have medicines, the doctors who didn’t apply for the jobs. It’s been seven months: what are some of the positive developments that you can point to?

The first thing is that we have been able to – not only the health ministry but people working in the health sector, our partners – we’ve been able to bring them on one page that preventive and curative, two sides of the coin, are not exclusive… It’s been an ignored sector for a long time, the curative sector, particularly the government hospitals.

Second, we’ve been able to start partnerships with a number of agencies: the Nepal Army, academic and teaching hospitals. Now we’re trying to reach out to private hospitals… So that way we ensure people will get the services that the Constitution has guaranteed – but we’ll not be the ones that provides the services directly. That can be private partners, that can be non-government organisations.

Also, a number of achievements in non-communicable diseases. We have started new regulations in smoking, alcohol policy, a number of things. And also not only awareness and promotional activities but clinical activities as well. When I came here as Health Minister at the time, the program was to take these ‘pain packages’ – essential, non-communicable disease diagnostic services – to 15 health posts. That was the target for this year. I’ve already taken it to 500, in the second stage I’m taking it to the next 500 so at the end of this fiscal year, 1,000 health posts will be able to provide these basic services. Previously it was planned for 50.

The biggest thing which I claim as an achievement is we’ve already introduced this Integrated Infrastructure Development Project. We’ve already started negotiating with the Finance Ministry. The idea is that within seven years, Nepal will finish construction of all its health facilities. This is the very first time we have brought all three dimensions: infrastructure, equipment and human resource on one page, and we have taken this holistic approach.

People are criticising me: ‘you’re not able to send doctors to Jajarkot’. Ok, fine, for the first time you noticed that Jajarkot Hospital is running without a doctor. And this is not the first time for Jajarkot Hospital… In fact, we have created a system so that each private health centre will be run by a doctor: we’re going to make it public on the first day of Baisakh. The names of all the doctors and where they are posted: people will have access to that. That gives us a kind of satisfaction.

These plans sound impressive, but the average Nepali will know that something has changed when they go to the health post and the medicines on that list of free drugs are all available. When will that happen?

From Day 1, I’ve put my work into three different categories: 1. I wanted this ministry to be well prepared for the 3-4 year transition after local elections. That was one of my priorities: we are all ready for this. 2. The ministry’s priority was to work on the policy regime. There are a number of policies that were redundant, a number of new policies which were needed… I consider that we’ve achieved a number of things in that area. Number 3: fix the basics. Not announcing new programs, not going for any stunts, but whatever is already on the list, let’s implement that. Let’s make people feel that – ‘we are getting what we deserved, what was promised to us’.

The first thing is medicine. There is already a list of free medicines, there is already a budget for that: 70 medicines at hospital level, 38 medicines at health post level. I tried to make sure that people are getting those 38 medicines at health post level, and when I started working at that I came to realise that I need to have a two-pronged strategy. One, how can I make sure that Nepal will not suffer again from the same old story of people not getting medicines?... We came to realise that there is a problem in our supply chain, in our public procurement. A number of partners – World Bank, USAID – have been working on this with the health ministry for the last five-six years and have made a number of recommendations but the ministry isn’t following them. We have started that, but we need some time to get results.

What about the immediate need? For the very first time, instead of procuring all the medicine from the centre, we gave almost half of this money to the district level, so now each district has the money it needs to buy medicines, at least for the next 3-4 months. We disbursed half of this money to district hospitals, regional hospitals, and things changed. Yes, there are still problems, I’m not claiming that this is fixed, but it’s not the same. If you compare today’s availability of medicine with three months back, things have changed dramatically.

It’s the same with doctors. We’re going to start post-graduate courses in a number of zonal hospitals, but it will take at least 4-5 years to get these doctors who we can send to the health facilities, so what about today’s need? We decided: let’s go and partner with private hospitals. We just had a huge camp partnering with the Nepal Army in Rautahat. Just yesterday we had a long meeting with the teaching hospitals. One hospital in Nepalgunj is now taking Bardiya hospital, Kathmandu Medical College is now taking Sindhuli hospital, I assume Chitwan Medical College is taking Nawalparasi Hospital. So now those private teaching hospitals will be providing specialist services in these hospitals, and we’ll be paying for that.

Now at least I can say in the next two or three months you will find that at least basic services will be assured at district hospitals.

Talking about resources. You’ve said you’re using sin taxes, mainly tobacco taxes, but will that be enough because you’re talking about universal health care, you’re adding items to the list of free services, such as dialysis?

Not at all. The sin tax is just one part of the whole health financing. On one hand, we have already approached the World Bank: we’d like their partnership on how we can fill this gap in health-care financing. It’s going to be more and more expensive. Another way is asking the Finance Minister. The amount we are spending on health is so low: on one hand we say in the Constitution that health is a fundamental right, people are entitled to this and this, but what are you spending? Less than four per cent. Previously it was almost eight percent. How can you, with less than four per cent spending, ensure that people are getting their entitlements? It’s not only about gaps, but overall spending is so low. Third is that we’re already working on insurance. We expect that in the next couple of days we’ll be able to submit this bill to Parliament. Already we have started to roll out this program in 13 districts. We are planning to go up to 45 districts by next year. We’ll be replacing a number of free services with insurance.

Will it work out to be cheaper with an insurance system?

Yes, if it attracts a large number of people. We’ve proposed making it mandatory but until and unless we strengthen the government health facilities’ quality and services, you can’t compel people to buy insurance schemes from the government. That will only happen if people trust in government facilities’ services, which is not the case at this point in time.

There is a gap, there is a huge gap when you talk about health services. Sometimes I find people getting worried about how the government can provide all the resources if we keep announcing – we have already announced – free dialysis, kidney transplant and this and this, but that is forgetting two facts: 1. Government spending is so low, 2. It’s not a luxury for any government; it’s mandated. No government can run from this basic responsibility to provide this kind of health services to the people.

The international community has been involved in a lot of the work of the health ministry. How would you like to see that evolve?

As Health Minister I have to acknowledge the role played by the partners. The things which we have achieved in public health, the things which we have achieved even in the curative sector to a large extent have been possible as we got their assistance, and we’ve been getting it for quite a long time – so we acknowledge that.

But now as the ministry is trying to go for long-term programs, long-term solutions, something very sustainable, there are a number of new things that we are trying to introduce in our upcoming policy and budget. That’s where we expect our partners to play a crucial role – instead of these fragmented programs, stand-alone efforts, scattering resources. We’re expecting that some new partners also, particularly those that want to help with construction and reconstruction of our health facilities, to get on-board as well.

People are saying that Nepal has a great nutrition plan, the Multi-sector Nutrition Plan, but it is failing for lack of implementation. Acute malnutrition was 11 per cent in 2001 and it’s 11 per cent now. Do you have any ideas about this?

Multi-sectoral sounds very fascinating: nutrition, eight ministries, 12 departments, this number of people involved, every ministry has its own separate program, these are the indicators. But whenever we look for someone who is responsible for any particular program, or who is accountable for some result, then we’ll find no one. That was the fate of all these kinds of multi-sectoral programs.

That’s why now we are proposing to let the health ministry take the lead… We have proposed that we need to have at least one nutrition officer in each district. Let the nutrition officer be in charge of all those activities, but let the other ministries implement their own programs. We don’t want to claim that agricultural ministry needs to submit this program to the health ministry – that is not our approach. But if we can’t get it and no one else feels the need, or comes out with a proposal, then things will remain the same.

Currently, the National Planning Commission has the lead?

Yes the National Planning Commission has the lead, there is a separate unit led by the Chief Secretary, there are a number of ministers involved, and so we all are lost.

You have incredible drive and ambition and enthusiasm. How much of that is coloured by your position in the coalition. Are you thinking ‘I have to get things done before the political situation changes and maybe my position changes’?

Two things. One, I’ve been very lucky that the Prime Minister, Finance Minister, Chief Secretary, my party president, from Day One, I’ve been getting all their support. Also, from all my other colleagues in cabinet. I’m the youngest minister there, by age also, so everyone treats me as kind of very near and dear to them, and I’ve find them very helpful. And also they’re all happy to see things happening in the health sector.

On the other hand, all the time there’s a constant pressure on me and my team… Everyone is given an assignment, and they work nearly 18 hours a day and there is constant pressure: we are here for some limited time, so we need to give some results. So I think that helps me. Otherwise, if we all had a kind of impression that we are here for four or five years, then I might not have been able to create that kind of constant pressure and excitement in my team.

Would you like to be here one year from now?

Yes, of course. Previously I was involved in water resources, agriculture, urban planning: that was my field, my area of interest. That’s why my choice was energy ministry, my second choice was urban planning. When I got the health ministry I was so so disappointed. I even wondered if I should go or not… But now what I feel is that I want to see some results from the policy steps that I have taken… Yes, I’ve given attention to immediate needs, but my priority is not just to get public attention or make some public statements. I have invested all my time and energy in these policy reforms, and I want to see the result, and I want to see the continuity for at least one year … But no one knows.

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