I was talking to a relative. She said, "My daughter has a stone in her gall bladder. She was in a lot of pain, Veer took her to the hospital. If the doctor has to do an operation. Veer also said that if he wants to do it in the hospital, he will have to wait at least 6 months. What do I do now? I can't go to a private hospital, it's too expensive. That's it, I am waiting for the same time given by Veer Hospital.'

Hearing this, I fell from a cliff. Think - 6 months! A patient who needs treatment now, has to suffer for half a year? And, what a great injustice it is to stop someone's treatment due to lack of money! 

This kind of problem is not new in Nepal's public health. Lack of doctors, beds, equipment and long waiting times in government hospitals remain the same. However, many do not have the financial capacity to go to a private hospital. 

Recently I read the news that a woman gave birth on the way and died along with the newborn. They died because they could not be taken to the hospital in time.

Hospitals in rural areas of Nepal are far from the reach of patients. Not being able to travel on time, lack of convenient roads and no ambulance facility is the reality of our society. In such cases, the difference between life and death of a pregnant woman or patient is only time. Such cases also make it clear that the improvement in the statistics by reducing the death rate is not the only progress. Real progress is also about ensuring that people of all classes have access to timely treatment and the opportunity to save lives.

In a federal system of government, different levels of government (federal, provincial and local) can play a role in health service delivery. It can help in effective health policy formulation, budget management and service delivery through decentralization. Effective use of the federal system can definitely help in eradicating health problems.

If more powers are given to the provincial and local levels, it will be easier to deliver health services to villages, which will help citizens in rural and remote areas to get services. Similarly, local governments can independently formulate policies to improve the quality of health services in their areas. As they can plan according to the needs of their area, the effectiveness of the service will increase.

In this way, Nepal's federal structure can simultaneously contribute to increasing access to quality healthcare in a cost-effective manner, breaking the 'distant access' to healthcare.

It is true that no society has sufficient resources to provide all the health care that its citizens can use. The challenge of balancing limited resources with endless needs in the health care sector can be solved through a federal health system and can be understood through the concept of a triangle shape. The balance between these three aspects determines the success of an effective health system. Nepal's policy makers should adopt a strategy to balance the triangle in health care by strengthening the federal structure. This will help in ensuring quality, accessible and affordable healthcare for the people.

As it is increasingly recognized that the net expenditure on medicines in Nepal is the main cause of high out-of-pocket expenditure, the price adjustment of medicines has made the Department of Drug Administration  A

provides an opportunity to strengthen your regulatory efforts. The drug administration department can increase its efficiency by adjusting the price fluctuations in the international market appropriately. Similarly, since the government hospital is not able to provide necessary medicines and medicinal materials through its own pharmacy, complaints are also increasing about the health insurance of the service users. 

The government's inability to refund insurance money to hospitals raises serious questions about the sustainability of the insurance policy in Nepal. In such circumstances, increasing the sum assured from Rs 1 lakh to Rs 5 lakh remains an important question, as the government is already struggling to recover the sum assured to the hospitals.

Another concern is the maintenance and upkeep of medical equipment in public hospitals. For example, HDU and ICU services have not been able to operate due to manpower in Bardia Hospital and the structures and machines prepared with an investment of around 2.5 crores are deteriorating. This is just one example. In many public hospitals in Nepal, the equipment is old or not in working condition, due to which patients have to suffer due to service delays at critical stages of health check-up.

Increased public investment and institutional development of alternative financing mechanisms are essential for expanding universal health care. Individuals are forced to incur high out-of-pocket expenses due to poor public finances. As Nepal graduates from the list of least developed countries, the subsidy available to the health sector is likely to decrease, making it difficult to ensure adequate financial resources. Therefore, it is necessary to strengthen the functional coordination mechanism between the federal, provincial and local governments in order to achieve comprehensive health goals by promoting the coordination of policies and programs.

If Nepal's federal health system does not prioritize cost, quality and access, then the important concept of health economics cannot be broken, which means that the country will have to constantly struggle to balance these three important aspects. If healthcare is not affordable and accessible, especially low-income citizens cannot get the treatment they need. If the quality goes down, even those receiving treatment may not get effective results. If geographic, economic or systemic barriers to access remain, many Nepali citizens will be deprived of essential health services.