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Free Essential Health Service: Rhetoric or Reality?

Posted On: March 3, 2016

Free health service (FHS) program was implemented throughout the country by formulating, distributing and orienting FHS implementation guidelines (includes concept, implementation modality and responsibilities at facility level). The program has utilized regular structure of government (there is no cost addition) and the medicines are available to general public for free. There is less donor dependency since necessary drugs are being procured from government resources. The declaration has clearly demonstrated the commitment of Government of Nepal (GON) towards delivering free health services to all citizens, especially the poor, marginalized, elderly and disabled, and has acknowledged the provision of the Interim Constitution of 2007 on people’s right to primary health care.

A significant level of increase has been observed in the number of people visiting the health posts. Changes made in definition, scope and distribution of free health service delivery over the period can be considered encouraging in view of the quick expansion of the service, increasing level of government commitment in terms of budget, and the frequent updating of FHS Guidelines. A few national and local level Civil Society Organizations (CSOs), including Health Rights and Tobacco Control District Network (HRTCDN) are also involved in awareness raising to increase participation of poor and disadvantaged population. Persisting key issues: Despite the policy scope and visible improvement in few indicators, access, affordability and sufficiency to health services provided by health facilities remains a key issue particularly for the marginalized groups. Since HMIS information are not disaggregated by sex, caste/ethnicity and wealth category, there is problem in analyzing whether the improvement was equitable and inclusive. Low utilization of health facilities can be correlated with low health and nutrition status, which is the lowest among the least educated people, dalits, ethnic and religious minorities and the people in remote areas where key obstacles to utilization of health facilities include cost, transport and quality of services including drugs and staff.

In remote areas, resource crunch and inadequate supply of medicines in health institutions that are supposed to provide free health services has put the free health service scheme in jeopardy. The translation of spirit and concept of the central level policies/guidelines on EHCS in field level implementation is weak.

In some areas, health facilities are non-existent or non- functional since government has not been able to fulfill the required posting quota of health workers and arrange necessary facilities. At implementation level, there are gaps observed in terms of (i) understanding about FHS and dissemination of actual information to the field level, (ii) availability of human resources at health institutions, (iii) availability of resources in comparison to the demand and estimates at district level, and (iv) lack of an integrated approach and coordination between the sub-sectors. Although the formation of the Health Institution Management Committee (HIMC) was a positive step towards health decentralization, the committee has not been (i) provided with substantial roles/responsibilities related to free health service, (ii) oriented about the definition and scope of FHS, (iii) able to monitor the performance of health institutions and ensure availability of human resources. As sub-health post (SHP) management has been transferred to the VDC and there is a provision for the Village Development Committee (VDC) secretary being chairperson of the respective SHP management committee, the committee has not been functioning properly in the absence of elected representatives and has only added to the burden of the VDC secretary with his/her busy schedule. FHS Monitoring Committees, as prescribed by FHS Guidelines, are not formed, and are not functional even where they are formed. In constitution and other national level plan and policy documents, Government has shown its commitment towards people’s right to receive primary health care for free. However, the commitment merely is not enough. Government needs to translate its commitments into actions through legal provisions, programs and resource allocations.   There is a clearly observed financial and human resource gap. These resource constraints seem to be of chronic in nature and require shift in service delivery approach/mechanisms especially in relation to financing health services for poor and disadvantaged community. While the resources available are very limited, Government’s resource allocation to health sector is also not equitable and inclusive, in absence of acceptable and scientific targeting mechanism. The proportion of government resource allocated to EHCS is insufficient and is dominated by procurement of drugs. Necessary physical facilities (toilets, separate room for maternal care, electricity or another reliable source of light for night services, stretchers etc.) are not adequate enough to meet the increasing number of beneficiaries. Human resource gap exists at all levels of health facilities since Government has not created new posts to meet increasing demand, is not able to fill the sanctioned posts,  and many of the health workers in rural areas do not attend health facilities regularly. Moreover, FHS has anticipated limited role of Female Community Health Volunteers as people have to visit health facilities to get services for free. Though the declaration can be considered highly encouraging move by Government, there was inadequate preparation in managing the service. Field level stakeholders mentioned that free health service declaration has increased the morbidity and number of visits to health post for an individual. However, there were no efforts made in improving the existing management status of health facilities so as to meet the increased number of visits. Community monitoring and support remained sought for but undone activity. One of the common weaknesses observed in FHS implementation is lack of established and spontaneous community level monitoring and ownership. District and community level health facilities, though, are required to form a monitoring mechanism involving respective management committee, such committees are not functional because of various reasons which include lack of orientation, unclear provisions, and no resource allocation.     The commitment of GON in delivery EHCS is praiseworthy but require support and facilitative monitoring from CSOs and the general public to ensure proper functioning of health facilities with availability of necessary equipments and adequate human resources. There is a need for combined and synergetic efforts from state as well as non-state sector in enhancing accessibility, affordability and sufficiency of health care services to general public, especially to vulnerable and marginalized community. Efforts are necessary to strengthen supply side (health facilities, human resources, drug, and record keeping) to match demand side (awareness raising on scope and limitations of free EHCS). Even if the Government is making its efforts to improve supply side, its efforts are not enough. forming an independent section for monitoring and supervising FHS implementation under DOHS, (ii) identifying suitable modality and mobilizing CSOs for disseminating the message to wider public carrying out detailed and comprehensive cost analysis exercises to identify and resolve financial and human resource gaps, introducing and mainstreaming a social audit process at all implementation levels (SHP, HP, District Hospitals and other health facilities) to enhance transparency and accountability of the institution towards its beneficiaries, identifying and piloting ways to increase participation of local community (user groups) in exploring and mobilizing local level resources, localizing the drug procurement so as to ensure timely delivery of medicines to respective health facilities, strengthening the monitoring committee and ensuring regular reporting of the program, and inviting and involving donors in strengthening the EHCS and ensuring additional long-term predictable aid for health systems strengthening especially health workers and medicine supplies.

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