On June 6th, the Ministry of Health and Population (MoHP) of Nepal and Public Policy Pathshala hosted the launch of the report of The Lancet Global Health Commission on High Quality Health Systems in the SDG Era in Kathmandu, Nepal. The report was officially launched by Hon. Upendra Yadav, Deputy Prime Minister and Minister of Health and Population. Hosted by HQSS Commissioner Hon. MP Gagan Thapa and his team, HQSS Co-Chair Margaret Kruk attended the launch to share findings from the Commission and to help establish action steps towards improving health system quality in Nepal. Secretariat researcher Todd Lewis was also in attendance. Together, the HQSS team met with an array of policymakers, researchers, government officials, and other advocates and stakeholders in health system quality to take a deeper look at Nepal’s health care system, share insights and recommendations from the Commission, and to build momentum for health system quality in Nepal.
Nepal has made great strides in certain health domains in recent years, such as in maternal and child health. However, significant challenges for the Nepali health system remain, including poor facility management, health worker absenteeism, medicine stock outs, long wait times, unresponsiveness to patient concerns, and overall low quality of care. Further, health inequities by income and place of residence remain entrenched, while expectations of the health system continue to grow. In response to these challenges, Dr. Kruk provided an overview of Commission findings and their application to the context in Nepal, describing how health system inputs alone, such as the building of health facilities, are insufficient to ensure health outcomes and how health system quality is largely a political problem, rather than a technical one. Sharing findings from Commission research, Dr. Kruk stated that clinical quality is low in Nepal, with both physicians and nurses completing only 39% of essential clinical actions in primary care across the country. She described how confidence in the Nepali health system is similarly low, with 43% of respondents to a survey indicating that the health system needs major changes and 27% reporting the health system needs to be completely rebuilt. Dr. Bhagawan Koirala, Co-Chair of The Lancet NCDI Poverty Commission for Nepal, discussed the need for a strategy to bridge the “center-local disconnect” and emphasized the importance of system building across the country. These sentiments were echoed by the Deputy Prime Minister, who stated: “Too often our citizens cannot navigate between levels of care; we need to improve the connection from primary health care to hospitals.” In his remarks, Mr. Thapa recalled his own personal experience as a patient, an experience that convinced him that “business as usual will not work” to improve health system quality. He described the need to think differently about the health system level at which services are delivered and to create demand for quality care at the grassroots level across Nepal.
A second day of meetings focused on the proposal of a social movement for health in Nepal in response to many of the aforementioned challenges. The event aimed to explore people’s experiences of and expectations for their health care, and identify opportunities for building a broader popular movement for high quality care at all levels of the health system. Formally announced by Mr. Thapa, the launch of the social movement included voices from civil society describing their experiences as users of the Nepali health system and a panel of health and human rights activists helping to spur the movement onward. Attendees at the launch called for a greater focus on health system inequities, especially those between Nepal’s geographic regions, and for stakeholders in both the public and private sectors to join the movement for higher quality care.
The importance of addressing geographic inequities and fostering inter-sectoral collaboration were persistent themes during the launch and throughout the visit. This was particularly evident during the HQSS team’s visit to a small health post in the Himalayan foothills. Reaching the health post required use of an unfinished road that turned from asphalt to gravel to dirt with increasing altitude. The team’s small car became a liability about halfway through the journey, and a larger truck was required for the remaining climb. Near the end of the journey, it became clear that even the more rugged truck would not be able to safely scale the final heights, so the remainder was traversed by foot. Upon reaching the health post, the HQSS team was able to speak with health workers, tour the facility, and learn about the community’s experiences at the facility. After the visit, the team’s descent was impeded by construction vehicles in the process of building the road. A large truck was lodged in a rut in the road, sandwiched precariously between the mountain slopes and a many-meter drop. The team watched for over an hour as a group of locals sought the best way to dislodge the truck without sending it toppling over the side. Eventually, the truck was cleared from the road with the helpful push of a front loader. As the team sat delayed, they could not help but wonder who else was delayed, perhaps on their way to the health post—A pregnant woman? A mother with a sick child? This was the sole route to the post and the road was nearly impassable (in the dry season, no less). The experience inspired Commissioner Thapa’s remarks at the launch, when he said: “Don’t ask to improve the local birth center. Improve the road instead.” This precarious journey became a touchstone of the visit, both a true challenge and a metaphor. Timely, high quality care is an inter-sectoral challenge that will require (among other things) better roads and infrastructure; however, the road to high quality care is already under construction by a contingent of passionate Nepalis seeking solutions, a group of policymakers, clinicians, researchers, and civil society members paving the way to a stronger health system.