Three decades ago, when I was studying in grades 4 and 5, cholera broke out in two villages in what is now Sarkegad Rural Municipality of Humla district. The main cause was the open water of the Karnali River, near which people used to defecate.

There were no latrines in the village. Water of life, antibiotics, anti-diarrheal medicines and health workers were not available. More than 15 people in one settlement tragically died from cholera. Treatment in the village consisted of calling on the ancestral deity and building thorny gates at the entrances to the village as per the advice of the Dhamijhakri. It was a custom in a village where cholera did not occur, that village deity was considered strong. There was a superstition that cholera would worsen if you drank water. Such incidents made it a far cry from the state taking responsibility for treatment, and now you cannot even find records when you search.

41 years ago, I remember my mother telling me that I was born on the road. Giving birth on the road while going somewhere for work was a common occurrence in rural Nepal until a decade or two ago. Birthing centers were not even an idea. Regular prenatal check-ups were a distant subject. Because, there was a shortage of health workers, lack of public awareness, and lack of access to the health system. I have seen the bitter reality of many losing their limbs when village acquaintances tied bandages on their hands and feet due to lack of general public awareness. Vaccinations were not available in rural areas, thousands of people died from diseases that could not be prevented with vaccination. There was a similar epidemic of infectious diseases. Tuberculosis treatment was not available in hospitals. About 30 years ago, tuberculosis patients from all over western Nepal had to reach the Mission Hospital in Palpa.

MBBS doctors were not available in district hospitals in rural areas. When the National Academy of Medical Sciences (NAMS) was established at Bir Hospital, MBBS doctors started reaching the districts as they were assured of getting higher education (MD/MS) opportunities for serving in remote areas. According to a report published in 1990-2000, there was only one MBBS doctor in Jumla in the entire Karnali zone. The availability of health manpower was very low in remote areas of the country. Limited resources and means were available for specialized studies. About three decades ago, the Institute of Medical Studies, Maharajgunj (IOM) was the only educational institution offering MBBS, MD/MS studies.

For health management and good governance, ‘political appointments and direct politics-free health sector’ should become a permanent policy of every party and government. Nation-building requires collective sacrifice, penance and commitment rather than any one idea, class, or individual – which has been felt essential in the health sector.

Until about a decade and a half ago, the situation of all health indicators including access to treatment, level of public awareness, average life expectancy, etc. was pathetic. The proportion of women giving birth in hospitals or health institutions was only 9 percent in 2000. About 539 mothers died due to maternal and child birth complications per 100,000 live births. The average life expectancy of Nepalis was 58 years from 1995 to 2000. The rate of stunting (malnutrition) among Nepali children was 57 percent. The mortality rate among children under 5 years of age due to malnutrition and lack of treatment was 91 per 1,000. In 2000, the coverage index of universal health services in Nepal was 20 percent.

This means that about 80 percent of Nepalis were beyond easy access to general health services. The doctor-to-population ratio was 0.17 per 1,000 population. The status of preventive, promotive, curative, rehabilitative and palliative (palliative) services in health was in its infancy in Nepal a decade and a half ago. Public awareness to prevent disease was also lacking, and after contracting the disease, the patient either had to sell all his belongings and come to the capital for treatment, or else he had to die by the hands of a religious healer. Most of the rural population was not even aware of modern treatment methods.

As a signatory country to the 1998 World Flour Conference, Nepal has been strengthening primary health care. By formulating various acts, rules, policies, strategies and action plans in a cooperative manner in accordance with the Millennium Development Goals, Nepal has achieved many achievements by adhering to national and international health commitments and declarations. From 2000-2015, Nepal expanded safe maternity services for maternal and child health in accordance with the Millennium Development Goals. Significant achievements have been achieved through popular and effective programs such as the creation of women's health volunteers, the establishment of ANMs, birthing centers, national vaccination campaigns, provision of maternity allowance in health services, and the National Newborn Health Strategy, 2004.

Recently, the Constitution of Nepal (2072) has addressed health services as a fundamental right of the people. The provision of free basic health services, equal access to health, and non-deprivation of emergency health services has been constitutionally 'guaranteed'. In order to practically implement the constitutional provisions, specific acts, rules, and action plans have been implemented, including the Health Policy, 2076, the Public Health Act, 2075, and the Nepal Health Sector Strategic Plan (2023-2030). Not only is the country's health improved by the Sustainable Development Goals 2030, but health has also been given priority in the 17th Five-Year Plan.

Changes in health sector and manpower

Due to Nepal's all-out efforts, the maternal mortality rate, which was 639 per lakh in 2000, has now come down to 151. This can be considered a good achievement in the context of South Asia. Twenty years ago, the under-five mortality rate was 91 per 1000 live births, and now it is 28. The average life expectancy of a Nepali, which was 58 years two decades ago, has reached 71/72 years. Malnutrition, which was 57 percent, has now come down to 25 percent. Deadly diseases like smallpox and polio have been eradicated. Tetanus, leprosy, and trachoma have been eradicated. Tuberculosis, HIV/AIDS, measles, whooping cough, whooping cough, diarrhea, typhoid, kala-azar, elephantiasis, and Japanese encephalitis are under control.

Various public awareness and emergency trauma care arrangements have been made to prevent mental health and road accidents, which are silent epidemics. Nepal has also achieved historic and significant achievements in the production of quality human resources that are connected to every step of the prevention, promotion, treatment, and rehabilitation sectors in medical science. Nepal has become self-sufficient in teaching and learning in almost all subjects of medical science.

About 20 years ago, two government medical colleges, namely Maharajgunj Campus and BP Koirala Institute of Health Sciences, and limited private medical colleges including Manipal, Bharatpur, and Nepalgunj, were being established in the country. Till date, two dozen large institutions, namely 9 government-level medical colleges/institutions and 13 private-level medical colleges, have been established. In Jumla, Karnali, where one has to wait for a medical officer for a post-mortem, about 700 MBBS, MD/MS, nursing, pharmacy and public health students are currently studying, while more than 100 specialist doctors are working.

There is no such district hospital in Nepal today where at least 8-10 doctors and significant health workers, including specialist doctors, are not present. Emergency surgeries are being performed in many district hospitals, while even in the post-federal structure, treatment services are being provided through basic hospitals, health posts, primary health centers, district hospitals, provinces and central hospitals. There is a shortage of manpower in health, in remote and backward areas, but in Nepali society, where one has to wait for months for a doctor, there is no country in which it is difficult to get services through specialists. The most advanced hospitals in medical science are available in the country.

From kidney, liver, joint transplants to robotic surgery, everything is done in the country. Hundreds of 10, 15 and 25-bed earthquake-resistant hospitals are being built, while provincial and district hospitals are in the process of being upgraded. Even when the World Health Organization analyzes the six ‘pillars’ of the health system (service delivery, human resources, information, medicines, equipment, finance, leadership and governance), Nepal has achieved far-reaching achievements. Nepal has long practiced in the availability, accessibility, acceptability, quality and effective service access/delivery of health services and human resources. Nepal is considered a model country in the world in eye treatment.

Added challenges

Despite many challenges, from political and policy instability, post-conflict management, federalism, major earthquakes, COVID-19 to the Gen-G movement, despite significant progress in various dimensions of the health sector (prevention-treatment-rehabilitation, etc.) and the pillars of health, there are many areas where changes need to be made and can be made in the country’s health system. Even in the difficult situation of the country, there does not seem to be any significant work to produce, use, retain and motivate doctors and health workers who make an incomparable contribution to health services, education and research.

Although doctors are produced, more than half of them are leaving the country and going to Europe and America. There is a huge gap between rural and urban areas. A white paper is needed on how much manpower the country should produce and how doctors can be mobilized in the necessary places. Even when about 2,200 doctors are produced in the country and more than 500 doctors return to the country after studying abroad every year, it is difficult for us to retain specialists in rural areas and we should start a debate on creating a doctor and health worker-friendly environment that can prevent them from going abroad.

If there is no motivated and aware manpower, quality services will be affected. The expenditure incurred by patients for their own treatment was 50 percent 20 years ago, and has now reached 57 percent. This increase has brought about 20 percent of people below the poverty line annually. 10 percent of the population is the Nepali population that is most affected by catastrophic health expenses. To reduce ‘out-of-pocket expenditure’, there is a need not only to increase the accessibility of health institutions and access to services, but also to effectively implement health insurance. There is a need to comprehensively improve health insurance.

Although significant progress has been made in service delivery and ‘governance’ through digital means including HMIS, DHS, and telemedicine, the highest benefits of information and technology can be obtained in the health system by linking private and government hospitals and health institutions to the ‘electronic health record’ system. It is necessary to make the quality and level classification of service providers more scientific. Minimum service standards alone do not contribute to building quality health services and institutions, the level of satisfaction of health workers working there and the satisfaction of service recipients with the service should be measured.

The epidemic of non-communicable diseases is increasing. According to the Global Disease Burden Study, non-communicable diseases (mainly heart disease, diabetes, hypertension and chronic respiratory diseases) account for three out of every four deaths in the world. It seems that a specific action plan needs to be made and implemented to reduce the burden of non-communicable diseases due to changing lifestyles, pollution, etc. In our country, where the aging population is gradually increasing, it is too late to develop not only a national commitment for 'elderly health' but also an implementable action plan. Still, about half of the population seems to be out of reach of quality health services, a plan should be developed to connect it to the mainstream.

Despite the World Health Organization's suggestion that the revenue generated from alcohol should be increased to 75 percent for the development of self-reliant and self-reliant health finance, Nepal has not yet set more than 17 percent of the revenue that should be 75 percent on alcohol, cigarettes, foods high in sugar, junk food, etc. जनताको स्वास्थ्यमा प्रतिकूल असर पर्ने वस्तुहरूमा राजस्व दर वृद्धि गरी त्यसको केही प्रतिशत मात्र स्वास्थ्य सेवामा लगानी गर्न सक्ने हो भने कुल बजेटको ५ प्रतिशतबाट नबढेको हाम्रो स्वास्थ्यको बजेट वृद्धि गर्न सकिन्छ । कुल गार्हस्थ्य उत्पादनको कम्तीमा ६–७ प्रतिशत बजेट स्वास्थ्यमा व्यवस्था गर्नु अपरिहार्य सर्त बन्नुपर्छ । ‘स्वास्थ्यमा गरेको खर्च लगानी हो’ भन्ने कुरा राज्यले महसुस गरेमा जनशक्ति व्यवस्थापन र सेवा प्रवाहमा अझ विशेष कार्य गर्न सकिने देखिन्छ । 

स्वास्थ्य क्षेत्रको प्रशासन सञ्चालनमा राजनीतिक हस्तक्षेप र अतिराजनीतीकरण स्वास्थ्यका शैक्षिक संस्थाहरूको विभिन्न पदाधिकारीहरूमा राजनीतिक नियुक्तिले असक्षम र अमूकहरूले अवसर पाएर संस्थाहरू धराशायी हुने परिस्थिति बन्छ । अर्कोतर्फ, सक्षम, पारदर्शी र योग्य मान्छे जाँदा पनि कुनै न कुनै पार्टीको ट्याग लगाएर बदनाम गर्न खोजेर काम गर्ने वातावरण बन्न सक्दैन । तसर्थ, स्वास्थ्य व्यवस्थापन र सुशासनका लागि ‘राजनीतिक नियुक्ति र प्रत्यक्ष राजनीतिमुक्त स्वास्थ्य क्षेत्र’ प्रत्येक पार्टी र सरकारको स्थायी नीति बन्नुपर्छ । देश निर्माणमा कुनै एउटा विचार, कित्ता, व्यक्तिभन्दा सामूहिक त्याग, तपस्या र प्रतिबद्धताको आवश्यकता पर्दछ, जो स्वास्थ्य क्षेत्रमा अत्यावश्यक महसुस भएको छ ।