Only the governments that have made public health their priority and invested in people-centric systems have best achieved overall well-being of their people.
Despite taking dramatic strides in reducing maternal mortality and childhood malnutrition in the last few decades, Nepal is lagging far behind in affordable and accessible healthcare for all.
Half a million Nepalis every year are being pushed below the poverty line paying for expensive medical care. Another three million more face financial burdens unable to pay the bills.
It is past time that our government and policymakers learn lessons for equitable healthcare from some of the exemplary models out there.
The Indian state of Kerala is often cited among those with the best healthcare in the world. During the pandemic the ‘Kerala Model’ was praised for its robust Covid-19 surveillance and recovery.
Kerala has strong emphasis and investment from the state on public health and primary health care, health infrastructure, decentralised governance, financial planning, girls’ education, and community participation and a willingness to improve the existing practices.
Kerala invested in a multilayered health system designed to provide first-contact access to essential services at the community level and diversified integrated primary health care (PHC) coverage to people to access a range of preventive and curative care.
Additionally, Kerala rapidly expanded the number of medical facilities, hospital beds, and doctors. This increase in the number of PHC centres and doctors allowed for the provision of the proper care in the right place, reduced patient care costs, and lowered the burden on secondary and tertiary care facilities.
Other public health and social development initiatives like safe drinking water in the state’s capital, Trivandrum, and primary education for men and women helped create the environment for a robust primary care system.
Read also: Health insurance must be an election agenda, Gaj B Gurung
Rwanda in Central Africa is another notable example for its resilient primary and community health care which it achieved by investing in infrastructure, human resources and supply chains.
It is also proof that investment in the health workforce from community to hospitals is critical in improving the country’s overall progress in medical care.
With national health insurance and its privatisation generating healthy debate in the Nepali cybersphere, it might be a good time to review Thailand’s much-lauded health scheme primarily funded by general income tax.
By doing this, this southeast Asian country has successfully managed to reduce mortality rates, workers’ absence and medical-financial burden on the families.
The achievement of universal health coverage in Thailand is one of the examples which relies on social insurance mechanisms and is popularly known as the ‘30 Bhat scheme’. Here the driving factor is a dedicated leadership set on improving healthcare affordability.
Sri Lanka might be crashing economically but its healthcare is among the most envied in this part of the world for its dominant tax-funded public system supplemented by a fee-for-service private sector, the most notable feature being that it offers services on a walk-in basis with no charges at points of use.
In all these three countries and states, what has worked is leadership and accountability at all levels, the key to a people-centric healthcare system.
In Sri Lanka, the central Ministry of Health and nine provincial health departments manage public healthcare services. The central Ministry oversees referral centres, runs disease control, provides technical guidance, and undertakes policymaking, human resources training and recruitment, purchasing and distributing drugs and medical supplies, and research and development.
Apart from a small share of primary care services administered by municipal authorities, the provincial health departments manage all other healthcare facilities, including the bulk of preventive care.
Read also: Step by step for rural health care in Nepal, Aryan Sitaula
Preventive service delivery n Sri Lanka is decentralised to the provincial departments of health. Community Health Workers (CHWs) are the backbone of PHC systems. Evidence highlights the effectiveness of CHWs in delivering a range of preventive, promotive and curative services related to reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases, and neglected tropical diseases.
This is true for Nepal as well where its Female Community Health Volunteers (FCHVs) have been credited for the country’s high childhood immunisation rates, and reduction in maternal and infant mortality.
In the case of Kerala, it underwent a significant overhaul when the state government implemented the People’s Campaign for Decentralised Planning through which it relinquished a substantial amount of power.
The campaign emphasised improving care and access, regardless of income level, caste, ethnicity, or gender, reflecting a goal of not just effective but also equitable coverage.
Kerala is also planning ahead of the rest. The proportion of the population of adults over the age of 60 is expected to double by 2050, and Kerala is already developing geriatric care wards and geriatric-friendly facilities in preparation.
In Rwanda, local to national governments can gather the political will to unite behind a shared goal. To hold public officials accountable, the Rwanda government adopted the idea of performance contracts as a traditional practice of setting and achieving goals called IMIHIGO. First implemented with district mayors, it was later expanded across government ministries and agencies.
The increased focus on the performance of public officials helped Rwanda achieve impressive rates of economic growth, infrastructure, and increased health and education outcomes for its citizens.
The above examples are references for some of the best practices. Copying them does not necessarily change the system and services. However, reviewing and understanding the mechanism and contextualising it according to local needs is the best way to strengthen health care delivery.
It is important to invest in health services, including interdependencies like education, safe drinking water and sanitation. The services should be people-centered and equitable irrespective of income. Accountability of the leadership at all levels is key to sustaining the health goals.
Read also: Healthcare moving from hospitals to homes, Bishal Raj Paudyal
Nirmal Kandel is a public health scientist based in Geneva. kandeln@gmail.com
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