National Health Insurance Program in Nepal, a low-income country’s quest for Universal Health Coverage.

 

 

 

Introduction:

As a continuum of its quest towards Universal Health Coverage (UHC), Government of Nepal launched the National Health Insurance Program (NHIP) 2013, followed by the Social Health Security Development (SHSD) Committee 2015 as a legal framework for the implementation. The pilot phase of this insurance program was launched from 3 districts, now in the second phase 2016 – 17, has expanded over 25 districts and has a final nationwide target of 75 districts by year 2021. This program has seen many hitches already and the pathway to complete successful implementation of this program seems more daunting.

Background:

Nepal has made significant progresses in improving the health of its citizens in recent years, with remarkable achievements in women and children health, the country is on track to achieve the Millennium Development Goals, however the aim of UHC and even the sustainability of current achievements appears grim with the frail health financing system. Health expenditure in Nepal has compromised of only about 6% of the total national GDP, with a meagre $40 per-capita expenditure on health, almost half of which is covered by the international aids. The public are at risk of catastrophic health expenditureƗ with 55% out of pocket payment as compared to 48% in other low-income countries.[1],[2]

 

 

 

Ɨ Catastrophic health expenditure is defined as out-of-pocket spending for health care that exceeds a certain proportion of a household’s income with the consequence that households suffer the burden of disease and poverty. (WHO Bulletin, 2017)

 

Country/Group

Per capita health Expenditure (US$) Total Health expenditure in GDP Public share of total health expenditures % Out-of- pocket share of total health expenditures %
Nepal 38.96 6.43 44 55
Low Income 27 5 42 48
Low Mid Income 81 4 42 53
High Income 4,618 11 61 14

Source: World Bank, 2010.

Table1: Health Financing in Nepal (2010).

 

Government of Nepal has declared health as a fundamental right with every citizen’s access to free basic health services. The Nepal Health Sector Strategy(NHSS) 2015- 2020 also outlines the strategies towards UHC consisting of delivery of this right while minimizing the associated the financial hardship for which the insurance program.[3] This new insurance program is based on comprehensive social contributory scheme with government subsidies for the poor (Table 2) ensuring access to quality health service while reducing out of pocket payments.

The national health insurance scheme relies on prepaid pooling of funds with later entitlement to health care benefits, reduced vulnerability to the expenses of care at times of illness or injury (financial risk protection). The current scheme aims at risk and contribution pooling in three forms- from low to high risk, from rich to poor and from productive to non-productive age group. The modus operandi, non-refundable, non-transferable social contributory scheme with annual contribution from households of NPR 2,500 (US$1 ~ NPR 100) for household of up to 5 members and additional NPR 425 per person for additional members, with subsidies for certain exempt groups as shown in Table 2.

 

 

 

Categories Subsidy
Ultra-poor 100%
Poor 75%
Vulnerable groups 50%
FCHV 50%

FCHV- Female Community Health Volunteers

 

Table 2: NHIP subsidy scheme.

 

 

The benefit package consists of coverage of medical costs amounting NPR 50,000 for a family of 5 members with additional NPR 10,000 for an additional member with maximum NPR 100,000 ($ 1,000) per year, per family.

 

Challenges ahead:

25% of 30 million people of Nepal live below the poverty line and 15% of them live below $ 1.90 per day.[4] Acquisition of matching fund for the subsidized enrollment of this group of the population, will be a huge setback for the aim of pooled fund collection, stern on the already exhausted health economy. Yet another issue of concern is the limitation and efficacy of protection provided by the insurance benefits, health service equivalent to $500 -$ 1,000 for the entire family. This upper ceiling is negligible compared to actual costs of health-related expenditures incurred by an average Nepali family today where 14 – 35 % catastrophic health related expenditures occur annually.[5],[6]

This program will also face the challenge in bringing about balance between pre- existing disparities in human resource distribution, gaps across wealth quintiles and geographic location. Nepal has an overall chronic shortage in health human resources, doctors, nurses, midwives with their density less than 7 per 10,000 population.[7] The prevalence of health facility is also scarce with less than 5 hospital beds per 1,000 population and most of which are in the major cities.[8],[9] Only 68% of the population reside in areas within 30 minutes access to health institutes, with a significant urban (86%) and rural (60%) incongruity.[10] The resulting burden of this discrepancy is, as expected disproportionately felt by the poorest households who have the limited recourse to purchase quality services from private providers.

Years of poor service both in terms of availability and quality has resulted in a very high degree of mistrust among people towards public health institutes. Private health sector in Nepal is a huge industry which received 90.4% of total out-of- pocket expenditures, amounting $540 million in 2011.[11] These private sectors are based upon highly unregulated fee-for-service business model and triumph over the public sector both in terms of number and patient turnover.[12] Contextually, incorporation of these for-profit private medical sector in the scheme will pose an immense challenge if not even threaten its very own existence. A very cautious outline should be put forward by the government for their amalgamation, probably building upon issues of their social accountability and responsibility.

 

Facility Number Available beds
Public Hospitals 95 7,637
Private for-profit Hospitals 105 4,621
Medical Colleges 20 10,576
Mission Hospitals 8 612
Total 228 23,446

Source: MOHP 2010

Table 3. Comparison of number of hospitals and beds.

In addition, chronic and Non-Communicable Diseases (NCDs) have become a huge global health challenge. The requirements in today’s personalized medicine era therefore cannot be limited to and by the mere 70 drugs of the National List of Essential Drugs. Suitable recourse to consider the costlier and effective noble treatment modalities to address the chronic illnesses, NCDs must also be periodically made.

 

 

 

 

 

The Silver lining:

 

NHIP aims to generate and distribute the limited financial resources to maximum number of its citizens when a backdrop of globally estimated 100 million people are pushed into poverty annually because of their health-related expenses.[13] Establishment of the constitutional health rights, programs and high-level committee for this insurance program demonstrates the dedication, which has been key to successes of similar kind of programs in countries like Thailand and China.

 

Thailand is a remarkable example of strong dedication from the leadership in bringing about changes at very affordable costs. In a span of 10 years, by 2011 the UHC program was successfully expanded from less than one third coverage to over 98% of the 68 million population. Costs of their health scheme averages $80 per person, double to the existing $40 expenditure of Nepal. China on the other hand has the largest known expansion of insurance coverage in history. In the span of 5 years (2005 to 2011), the coverage expanded over a billion population from less than 50% to 95% citizens. Though, Nepal’s population is nowhere compared to China, however Nepal can pick up on the role of political and socio-economic backup, importance of public support, and commitment demonstrated from top leaders for such a gigantic maneuver. [14]

Nepal also needs to be meticulous on their financing strategies. The government needs to seek for options in increasing revenue, perhaps by appealing more international support or increasing tax rates. On a better approach, the government should also take steps towards the spill reduction by corruption control as in Indonesia, where the government took on policy for zero tolerance against corruption and were able to raise tax related revenue from 9.9% to 11% in just over four years.[15]  Much can be achieved in the arena of economic transparency in Nepal, where reports of Transparency International show stable corruption perception index of around 30 in the last decade, 0 being very corrupt and 100 very clean.[16]

Nepal also has different pre-existing free health benefits covering the major health issues of the country and will eventually come under the remit of this program. The government already provides free 70 essential drugs, basic laboratory services, maternal and neonatal health care at public health facilities. Ongoing public health programs for immunization, family planning, community-based integrated management of neonatal and childhood illness (CB-IMNCI), essential therapeutics for Tuberculosis, Malaria, Kala-azar, Leprosy, HIV prevention and treatment program are being distributed free of cost.

Lastly, Nepal needs to set up a clear realistic idea, aim for practically achievable targets. The program in China, for instance where the annual premium is only around $20, almost equal to $25 of Nepal, the coverage in return is merely sufficient and hence the benefits of which are often questioned. [17]

 

 

Conclusion:

 

Successful implementation of the health insurance will not only have the well-known benefit of financial protection but also health related benefits. Experiences in Costa Rica, China and Peru have demonstrated that consumers with protection against health-related financial risks have better health seeking behavior as well as service providers have a positive difference in behaviors of the towards them.[18] This scheme will again, also provide an opportunity for improvement of the existing public institutes both in terms of quality and quantity.

To conclude, merely formatting a policy and distribution of health insurance cards will not suffice this low-income nation to achieve its health targets. This health insurance policy should be taken as a nation’s top priority health policy and convert all its challenges to opportunities. Nepal must learn from other countries, examine experiences of both successes and failures, make necessary policy innovations, timely amendments and with a multi sectoral approach implement them, make this National Health Insurance Program implementation a story of success worth remembering .

References:

[1] Ministry of Health and Population Nepal, Partnership for Maternal, Newborn & Child Health, WHO, World Bank and Alliance for Health Policy and Systems Research. Success factors for women’s and children’s health: Nepal. Geneva: World Health Organization; 2014.

 

[2] World Bank. 2010. Nepal – Second Health Nutrition and Population (HNP) and HIV/AIDS Project. Washington, DC: World Bank. http://documents.worldbank.org/curated/en/964991468291002895/Nepal-Second-Health-Nutrition-and-Population-HNP-and-HIV-AIDS-Project (Accessed November 22, 2017)

 

[3] Government of Nepal. Ministry of Health and Population. Nepal Health Sector Strategy 2015-2020: Unofficial translation. Kathmandu: MoHP; 2015

http://nhsp.org.np/wp-content/uploads/2016/03/NHSS-English-Book-Insidefinal.pdf

(Accessed November 25, 2017)

 

[4] UNDP. Human Development Report Nepal 2016. http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/NPL.pdf (Accessed November 25, 2017)

 

[5] Eiko et al. Catastrophic household expenditure on health in Nepal: a cross-sectional survey.World Health Organ 2014;92:760–767 | doi: http://dx.doi.org/10.2471/BLT.13.126615

 

[6] Sanjay et al. Multidimensional poverty and catastrophic health spending in the mountainous regions of Myanmar, Nepal and India. The International Journal for Equity in Health.https://doi.org/10.1186/s12939-016-0514-6

 

[7] WHO Global Atlas of the Health Workforce, 2010. http://apps.who.int/globalatlas/dataQuery/default.asp (Accessed November 25, 2017)

 

[8]The world bank data.  https://data.worldbank.org/indicator/SH.MED.BEDS.ZS?end=2006&locations=NP&start=1960&view=chart (Accessed November 15, 2017)

 

[9] Global Health Workforce Alliance. Towards building a comprehensive and costed HRH plan through the CCF process in Nepal http://www.who.int/workforcealliance/countries/ccf/CCF_poster_Nepal.pdf

(Accessed November 15, 2017)

 

[10] CBS Nepal, 2006. Nepal living standards survey (1995/96 and 2003/04). Government of Nepal. National Planning Commission Secretariat. Central Bureau of Statistics. March 2006.

 

[11] World Bank Development Indicators database, accessed in November 2017.

 

[12] MOHP- DoHS 2010. Annual report.

http://dohs.gov.np/wp-content/uploads/2014/04/Annual_report_2067_68_final.pdf (Accessed November 25, 2017)

 

[13] WHO. WHO Global Health Expenditure Atlas September 2014.

http://www.who.int/health-accounts/atlas2014.pdf (Accessed November 25, 2017)

 

[14] Simone et al. Fair choices in universal health coverage in Thailand. The Lancet.

DOI: http://dx.doi.org/10.1016/S0140-6736(16)31608-7

 

[15] Hao Yu. Universal health insurance coverage for 1.3 billion people: What accounts for China’s success? http://dx.doi.org/10.1016/j.healthpol.2015.07.008

[16] Corruption Perceptions Index 2016. Transparency International. http://www.transparency.org/cpi2016 (Accessed November 30, 2017)

 

[17] Hao Yu. Universal health insurance coverage for 1.3 billion people: What accounts for China’s success? http://dx.doi.org/10.1016/j.healthpol.2015.07.008

 

[18] Maria et al. Impact of health insurance in low- and middle-income countries. Brookings Institution Press

Washington, DC. https://www.brookings.edu/wp-content/uploads/2016/07/theimpactofhealthinsurance_fulltext.pdf (Accessed on November 16, 2017)

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Please contact me through roshankhatri@gmail.com

Shifting hospital from tents to indoors.

Shifting hospital from tents to indoors..

Shifting hospital from tents to indoors.

This is the story of a doctors experience in the worst case disaster situation. In here I will try to narrate the story of what happened, the stories of unsung bravery and courage staffs at Jiri Hospital displayed during and after the disaster. In the latter part I will try to cover the transition from tents to indoors.

A rural doctors tale on earthquake experience.

The strike

We had just finished examining new cases on that day, May 12th, and were following up with investigation results in our patient examination room when the earth beneath us began to beat the drums. Our team and patients along aware of the unique nature violent shakes from April 25th massive quake, which came along with noise of massive drums being beaten deep underneath, were aware of what was about to happen next so soon cleared the room and were running in all directions.  The only word anyone uttered and thought of was “ayo ayo, bhuichalo ayo, bhaga bhaga” ( Earthquake, earthquake, run,  run).

It took some time for me to gather my consciousness, some time to mentally assemble my next step based on my knowledge of things to do and not to do In cases of earthquakes.  I remembered running in cases of earthquakes is a big no rather find a table, a bed, a door frame and save your head.
However, I was sitting on a chair, had my arms on a table and a bed just a few steps away. But no this time it was big, the shakes were violent enough to make me realize that my walls won’t be able to with stand it any further. I had to run, flee for a safe ground.

IMG_0283
Our pharmacy building turning into rubbles just as the earthquake was happening.

As I stepped outdoors, clouds of dust was rising from all directions and my hospital staffs, patients were running in all possible directions searching for an open ground. It was the busiest moment of the day for our nursing staffs and indoors, so I tried to run towards the indoor block. When suddenly one of our laboratory staff who was panic-stricken and so shaken from the quakes emerged out from the lab and collided with me that she fell flat on the ground. She was totally blank and wasn’t able to respond. I helped her up and had to take care to the open ground, where I saw almost  all the patients and staffs were already there.

Up in the nearby town all we could see was clouds of dust and smoke. We could hear loud thuds of houses turning into piles of stone and woods. I felt that in any moment flocks of injured will be rushed into the hospital and we should be ready to receive them.  But our story was no better.

Our store, our inpatient ward building all were like ticking time bombs ready to drop flat with big piles of rocks.
All the hospital staffs were panic-stricken. Everyone was trying to make futile contacts with their families; with telephone networks long gone, local staffs had already rushed to locate their families.

I tried to gather all the possible staffs around. Everyone was shaken; scared, with turmoil of thought processes in head, it was a situation where your senses and brain decide to give up on you, there was a unique combination of fear, confusion, anxiety and emotions. I had to shout at the top of my lungs to gather their attention. I grabbed each of the shaky ones, consoled them that this was our moment. It is us now who should be brave and be prepared for the worst case scenario.

IMG_0304
Counselling room for patients and discussion room for doctors and sisters.
IMG_0319
Pharmacy and guest room.

Then we decided to use our badminton court as emergency arena, while the bigger challenge lied in gathering our medical and emergency supplies from piles of stones, earth beneath us still shaking. Time was of essence so I made a call that all the men will rush inside the building one by one, grab the first thing they can see and walk out as soon as possible. Surprisingly the ladies staff took part in this drill as much as the men did, if not more.

So in no time, we were all able to set up our emergency triage center, gather adequate medical supplies, be prepared for the emergency management of all cases about to come within few minutes of the disaster.

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Our makeshift hospital. Sincere gratitude to all the donor agencies for the tents and supplies. In this picture is our OPDs, Inpatient ward with 18 beds, Post op tent with 3 beds, and a Emergency tent plus a duty room.

The Rebuidling

With the harsh monsoons knocking at our front door, all we lack is the pleasure of time! We have gathered all the resources possible and have started rebuilding!

Our target for now is to shift all the patients, outpatient clinics and the quarters indoors within one month.

IMG_8954

Our first priority was to provide safe and clean drinking water to all our patients, staffs and the public, hence we have setup an electrical water purification plant near our tents.

Open to all patients, visitors, staffs and the public.

IMG_8959

Strange but true, number of regular surgical cases increased drastically after the quake. It was a very difficult time for us, more for the new mothers. a very strange world indeed to welcome our new borns. We had to conduct 7 C-sections within a period of one month since the first quake in April; 20 deliveries. Five of the deliveries were conducted in the open since the patient and the family didn’t approve of going indoors.

11295566_10155498677125315_6766557645840913663_n
First time mother of one day along with her baby leaves the hospital early morn on a bamboo basket carried by the father. Their home is six hours away for a normal person without a bagpack. I wonder how and when they might have made home.

3 thoughts on “Shifting hospital from tents to indoors.”

  1. Please contact us for 10 by 14 temporary shelters good enough to last at least a year or two. It’s very live able safe and sound

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Jiri Hospital

DSC_2724The Institution

Jiri Hospital was established in the year 1957 AD (2014 BS) with the support of Swiss Government as a part of holistic support to the people of Dolakha along with a technical school, now know as Jiri Technical School and Animal Development Farm, in Jiri. It was later handed over to the government of Nepal in the year 1972 AD (2029 BS). Under the model of Public Private Partnership (PPP) government handed it to the community in the year 2064 BS.

This hospital still runs under the PPP model and is operated by an operational committee compromising of 17 members from different public related sectors, and is among total of only 4 different institutions running in the same model throughout the country.

Jiri Hospital currently as 15 beds sanctioned by the government, however more than 30 beds are available to the patients to address the increasing inflow. Its services range from Outpatient department open on week days, Inpatient, 24 hours emergency services, Dental services, fully functional operation theater, Pharmacy services, Maternity and Child health care programs, Ambulance services. It also conducts all the preventive, promotive health programs as per guidelines of government of Nepal, Ministry of Population and Health.  In addition to this, the hospital has been conducting regular health camps both in the hospital and in its different catchment areas to address varying health needs.

IMG_1456 Strength

A successful example of Public Private Partnership can be observed in the hospital. This model has been able to build a strong sense of ownership in people of this area. The operational committee has been addressing immediate and has been planning for all the long term issues to come. The operational committee is created under inclusive ideology hence it is highly representative of the population here further strengthening the sense of ownership.

IMG_1459

Clinical Aspects

This institution serves as the referral center for all PHCs, Health Posts and Sub health posts of this region. It primarily receives patients from Dolakha, Ramechap, Solukhumbu and Okhaldhunga regions. Daily about 100 patients receive treatment in the Out patient department. This hospital also provides in patient services, Comprehensive Emergency Obstetric Care (CEOC), minor and major surgical procedures, Dental services, 24 hours emergency care.Regular health camps are also being organized as a part of the medical facility. This hospital conducts monthly outreach health camps to the inaccessible people at their doorsteps while more specialized health camps are being conducted in the hospital.

IMG_0384 IMG_0368 20141108_093636 20141108_085324 IMG_0435

My experiments with health camps:

I had only one mission when I entered Jiri Hospital to increase the patient flow. On my way to Jiri, one socially active Jirel started giving me of what I was to expect next. All the people did was compare the hearsay of Jiri Hospital when the hospital operated under Swiss management. What they do not understand is why would our nation be in this chaos if we were Swiss?

Bringing the hospital service to the standards which was 40 years ago, seemed to be a very high set benchmark. Inspite, afte spending few days in the hospital, talking to few made me realize there is another important if not bigger issue needed to be tackled, ie hospital management.

The hospital seemed to be highly understaffed, staffs present also spend most of their time at their homes, weeks and weeks of absentese. There were few who had been lost from the office, still employed however for years. My skills as a leader was in doubt, I questioned my self as I was very naive to the Neapli health system, running a district hospital with more than 30 employee was a holy grail chase to me.