And needless to say, public health policies formulated under such a purview, though well-intentioned, will neither be effective in addressing immediate health challenges nor will they be sustainable in future scenarios.
Not just in Nepal, but if one examines statistics from any low-, middle-, or high-income country, there is a clear increase in cases of non-communicable diseases in the last two decades. However, this alone is not sufficient to infer that people are suffering less from communicable diseases and more from non-communicable ones like cardiovascular diseases, diabetes, cancer and blood pressure. The observed increase does not mean that communicable diseases no longer pose an urgent threat to health security; it simple indicates that more cases of non-communicable diseases are being diagnosed due to advances in health care surveillance and delivery.
World Health Organization’s Global Burden of Diseases study indicates that lower respiratory infections, diarrheal diseases, HIV/AIDS, Malaria, Tuberculosis, prematurity and low birth weight, birth asphyxia, birth trauma and neonatal infections, are still the ten leading causes of death in low-income countries. Nepal is no exception. Surely, non-communicable diseases pose a huge challenge to our present health-care policy and practice but we are still not at a juncture of “paradigm shift” where we should divert our attention from communicable diseases and focus more on “new diseases.”
In Nepal, as per WHO data (2008), each year, of every 1,000 live births, at least 48 children die before their fifth year, of which 17 percent die due to diarrhea. The country’s maternal mortality ratio continues to be as high as 380 per 100,000 live births. We are certainly not at a stage where communicable diseases cease to pose and therefore no longer constitute a grave public health challenge.
New health policies should stem from evidence-based research and expert knowledge. But the past and existing policies should be properly assessed before moving on.
Undoubtedly there is an urgent need for national health policy revision and reformulation. But before the government launches a new initiative to address “new challenges” and introduces new solutions, it is essential to rethink through the existing public health landscape. Policymakers should not forget that unlike non-communicable diseases, every case of communicable disease is an agent for spreading that disease. As such, in a resource-limited setting like Nepal, the public health threat (from a potential epidemic) due to communicable diseases continue to be larger than that posed by non-communicable diseases.
Communicable and infectious diseases are still widely prevalent in Nepal and their impact is most severely felt by the poorest members of society, who have limited resources and minimal or no access to even primary healthcare. Surely, non-communicable and chronic diseases pose a serious threat and demand effective attention from public health authorities, but they should not divert resources away from combating communicable diseases.
Formulating new public health policies based on assumptions about changing trends in disease incidence might in fact prove counter-productive to the goals of the Ministry of Health and Population. New policy needs to be formulated, but it should stem from evidence-based research and expert calibrated knowledge. The strengths and weaknesses of past and existing policies should be properly assessed before moving forward with policy reformulation. Policy changes should be brought forward only after evaluating the potential effectiveness and feasibility of such policy implementation. Otherwise it will be yet another case of poor resource allocation and management.
While Nepal Health Sector Programme (NHSP-2) is in its formative stages, policymakers should not forget to address the structural and systemic inequities in health service utilization and mortality. WHO’s World Health Statistics (2011) shows that the under-five mortality rate in rural Nepal is 84 deaths per 1,000 live births whereas that for urban Nepal is 47 deaths per 1,000 live births. Under-five mortality rate for poorest 20 percent is 98 deaths compared to 47 deaths per 1,000 live births for the wealthiest 20 percent. Health service utilization follows a similar trend.
Even for basic healthcare, such as health professional assisted deliveries, there is a substantial disparity between urban versus rural and poor versus rich. Where skilled health personnel attend 58 percent of births for the wealthiest 20 percent, only five percent are attended for the poorest 20 percent. Likewise, skilled health professionals attend 52 percent of urban births when a mere 19 percent of those in rural areas receive skilled medical attention. It is indeed alarming that there is such a sharp difference in the profiles of people who live and who die.
Nepal has witnessed an unanticipated but promising growth in number of medical care facilities and institutions for medical training in the past 15 years. Yet, healthcare facilities remain centralized and people continue to suffer in rural areas. Even in urban areas, healthcare is not an option available to all. Is there something lacking in the training of health professionals in Nepal? What incentives could be offered to health practitioners to extend their services to rural and poorer communities? Are there enough functional healthcare sites (hospitals, health centers, clinics) with capacity to meet the demand of the local population? Are such facilities evenly distributed throughout the nation?
NHSP-2 can bring vital changes to the present status of health in Nepal. Establishing yet another governmental body or an affiliated council of advisors to make recommendations to the prime minister will not improve the country’s overall health condition. Instead, giving more responsibility, credibility and partnership opportunities to existing organizations would contribute to effective decision-making. Providing a platform for dialogue between healthcare policy makers, practitioners, and most importantly the people, is critical.
There is a missing link in the chain of healthcare delivery in Nepal. This lacunae needs to be identified and corrected. Good health depends on healthcare, but it also depends on lifestyle, nutrition, education, women’s empowerment, economic security, and equity and equality in society. Policy-making and health reform should emphasize structural reform and decentralization. More than blindly following “trends” and replicating models that worked in other nations, the solution should be engineered such that it is relevant, sustainable and plausible. Public health policies should be scientifically grounded, economically effective and in tandem with societal realities. A new comprehensive national health policy should approach the future with cautious optimism.
The writer is a graduate student at the Department of Epidemiology, Biostatistics and Occupational Health at McGill University, Canada
jigyasa.sharma@mail.mcgill.ca
Related story
Pharmacy owner arrested for mixing various narcotic drugs and s...
