Free health care requires infrastructure development

In an attempt to ensure universal healthcare for its people, Nepal started with free health care to a select group of people  in the mid 2000s. The plan met much scepticism, especially from healthcare providers,  when it started out. Five years down the line, it has its fair share of believers.

The moral imperative to ensure healthcare to people disenfranchised by current health system (or rather the lack of one), was imminent. There was also an equally important sociopolitical and economic gain to be had by ensuring a common minimum set of health care gains. However, making a constitutional guarantee of health care as a fundamental right was the easier part. The larger challenge, has been in meeting the promise.

Lets leave the long-term requirement of resources out of the question here, for that is an issue for a separate discussion. By some means of clever management, that should be a doable thing. The issue for discussion, is how to create the physical and the intellectual infrastructure required to deal with such a gargantuan undertaking.

In the absence of such infrastructure, the free health care program has been rather languishing as free drug program for a select group of people. Not that free drugs are not welcome, but policy planners in the hallways of the health ministry  should know that a provision free essential drugs pedaled as free health care is either just a reminder of our lack of ideas and understanding or just plain moral hypocrisy in the face of such understanding. For healthcare involves a retinue of services and facilitation from prevention to end of life care, rather than just plain provision of a few free drugs. 

A basic public health infrastructure has been  available in Nepal for sometime now. However  if this public health system alone is to be used to deliver health care, it will prove to be woefully inadequate. Hospital beds available per person are well below global averages. In the city areas numerous health providers have sprung up; they could be co-opted to provide the required care; however in rural areas still experience a miserable shortfall of health care infrastructure.

Innovative ideas will be required in further expanding health infrastructure in the rural areas. Encouraging and co-opting private providers to provide services in the rural areas may be a good way forward. This has multiple benefits. First, it harnesses capital from the private investors, big and small to fund health care infrastructure expansion. This will be a welcome relief, especially when government sources of funding are already stretched to the limits. Second managing funds allocated to government health facilities has always been a challenge. Leaving the nitty-gritty of setting up and managing such facilities  will enhance efficiency at such institutions.

Of course involving the private sector in government sponsored health care services will be burdened with a monitoring mechanism. However when the services are provided out of a limited gamut, such problems should be manageable. Furthermore the benefit of farming out services in the private sector will outweigh the losses.  

The other thing that needs to be taken care of before health services can be expanded out for the masses is to standardise treatment delivery. The benefit of algorithmic approach to disease management has been validated extensively, both in Nepal and elsewhere. Management of TB, HIV and sexually transmitted infections are ready examples of the prudence of such an approach. Standard operating procedures for a major portion of services covered under free health care services will have to be developed. This will enable farming out service delivery to the private sector, as the quality of treatment delivery can thus be monitored and in the same time payment to such services can be standardised.

Furthermore standardising treatment protocols for the most commonly encountered conditions will enable learning within the system and improving service delivery based on such system.  It will also facilitate institutional learning; system based practices can then be developed to conditions in an effective and meaningful way.

Of course such standard operating procedures do not have to be restricted to the delivery of free health care; however the effective and affordable delivery of free health care  depends more than anything else on how well we can develop the intellectual capabilities on which to deliver such care.

Unless we can tackle come up innovative solutions to manage the requirement of physical and intellectual infrastructure, just mandating free health care into people’s right will not ensure such delivery; free health care will then be worth no more than the weight of the paper it was mandated on.

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