COPASAH HARPPS Workshop Nepal

Dr. Dhananjay

Pharmacy was all owned by the government at the end of 1990’s. Constitutional democracy was established in 90’s. Second long term health plan was from 1996 to 2016 to promote the private sector. Nepali people are willing and capable to pay for it. This assumption is a world bank language.

People don’t value free things, it’s a saying. The cost of the private health sector is very expensive. Irrational use of services and technology and the gap between rich and poor. Srilanka has a public health sector which is very strong.

Dr. Sharad

Private sector foot print in Nepal

The whole issue is very much focused on the private sector. Marketization in health in Nepal. In my generation when I was your age I never saw a private hospital in Nepal.

Everywhere you can see private hospitals in many other cities in nepal. How the private sector was settled in Nepal. Before Nepal shifted to a multiparty political system. In monarch time, Nepal was not open to the global market. We had health operative transport operative and collective health owned by the state even if the pharmacy were owned by the state. The service provided by the state was extremely limited. People used to go abroad for the services. A lot of people used to go to India, especially the Southern part. There were very few public facility institutions. There was no market and public escort was inadequate. Almost until the late 80 and the beginning of the 90s. Nepal was shifted and the monarch was brought in the constitution. The Constitution was active for the monarchy. We had political democracy liberty. Democracy in economy. The private sector was very active to establish themselves, this was the time to expand the international market. And that was the time when an NGO was allowed to establish in the company. Then we had to register for an NGO in the 90s. There was a huge massive growth of NGOs and the private sector. And the government very much promoted the private sector in health in Nepal. This was 20 years 2nd long term health plan. 1996 to 2016

was also the time to end MDG. These documents are very openly proved by the private sector.

How was the private sector justified in Nepal?

This is not the theory developed by one agency. The whole assumption and background was that Nepali people are willing and capable of purchasing health services. It has clearly prompted the private sector and this is a background on how private market health was established in the country. There was an interesting coincidence and internal Nepal was open to liberal economy, there was social, political and economic globalisation. Because technology was imported. There was one pharmaceutical industry owned by the public pharmacy. It produced medicine very cheap and powerful. In the mid 70s and late 80s diarrhoea was a problem and there was a debate about homemade med. They were almost trying to replace the market and this company produced a very powerful solution. It was 1rs per packet. Its name was jibanjal. Today we don’t know the number row pharmaceutical in Nepal. Market economy theory has taken the permission from the ministry and industrial sector like any industry. When the private sector is established the fundamental is that in Nepal the patients are converted into consumers. And health services are covered in commodities. The market does not recognize health right equity and social justice like any commodity health services are sold in the market to those who are capable of purchasing the services, those who cannot purchase the service they are not allowed to use the service and it has created the gap between rich and poor. The gap between urban and rural areas. It’s all because of market theory because the poor cannot afford it. State is not able to supply the demand of the people and that gap is filled by the market. Therefore, the market is increasing. The people have more fate in private compared to the public. There is increasingly consumerism. People go to the clinic and say prescribe me MRI. The death of people is increasing and this encourages the private sector to grow. The reason for that is the cost of services. Very high compared to the public sector, for delivery it cost 1 and 2 lakh or more. Dental is also expensive. Irrational use of services and technology. There is no standard protocol of treatment for any disease.

Open House Discussion

Expensive and overcharging during covid time
WHO has documented about South Asia it is written that in the health sector 4% are presumed to be below the poverty line in Nepal. About 11% of the health service users their expenditure in health is more than what they earn.
Private hospital refused to take the patient in the beginning of the covid.
The PCR test was overcharged.
People paid 4,5,6,7,8k just for the PCR test.
No oxygen in the second phase in the DELTA virus was not prepared; they did not have that facility.
In the government hospital no patient was referred for the hospital. Government hospitals provided oxygen but it was not the case in private hospitals.
Some of the private hospitals did not receive the permission from the government for pcr tests. they provide services with our achieving the permission from the government.
Government hospitals were not popular before the pandemic but over time government hospitals became far better and the care was really very nice .
One of the impacts of the pandemic is that people now prefer government hospitals as well.
In the beginning or middle state of the pandemic, the hospital was closed because of covid it was not only affected to the covid patient and it also affected to the patient of the non covid.
We cannot deny the role of the private sector. The private sector role is valuable, the question is not here to blame the private sector. The motive of the private sector is making profit no doubt.
There was a delay in reimbursement but there was not a case of non payment.
Scarcity of medicines, even vitamin c, d.
Government made quality service available.
Overcharging
Talking about outside of Kathmandu it was very hard during that time
The government said that we have been serious about the overcharging by the private hospital to the patient and if we find that then the private hospital will be punished.
Stock of cylinders by the rich people during the pandemic which also made the scarcity of cylinders.
All funerals were done by the army.
Has the Nepal court or judiciary played any active role for health rights?

Health rights are violated by the government and as well as the people of the country.

If people are still paying for the basic services because it’s a violation of human rights. I think the court is not active in this case.

Misbeliefs rise in the urban people during delivery. It’s a mix of gyno and astrology.
Does a private hospital have its own pharmacy and is it compulsory to take the medicine from the pharmacy of the hospital?

Regarding the medicine it’s not compulsory but they impose the trademark. They don’t prescribe from the general place. Those trademark medicines are only available in their company because of the trade mark of the company.

The internal market means even the government are now after a certain time they are privatised it means after 3 or 4 o clock they receive the patient and they charge differently. They call it extended hospital services. But they pay extra when they go after 3 o’clock. But in regular OPD there is no booking system. But in paying health services u can take appointments. This is what we call internal marketing. Even the government is privatising selling services.
One of the reasons for the shortage of human resources in the public sector is that we have to refine positions and that positions have to be created legally. Until we have the same positions we had 20-30 years back. The pressure and the services have increased so rapidly but the positions are the same.
The government will not provide the salary but the hospital will provide the salary. And they have to pay themselves if they are employing doctors who are not in position.

Date: 19th May 2023

Open House Discussion

3 things that the government of Nepal should apply to protect health rights?

What should be changed on policy level?

Government and private sector should coordinate to apply the health rights.
10%should be given to the poor from the private hospitals but it is not applied, it is in policy.
It should be done to 20% and should be applied and there should be monitoring.
Investigation should be done.
If there is complain they will go and check but it there is not complain then they won’t check,
In poor people’s name the government and officers are taking the Services.
Medical education should be provided by the government.
Bed charge of private and government hospitals had a huge difference.
We have policy guidelines and there is lack of implementation.
Categorised 4 type of hospital
15 bedded hospital
50 bedded hospital
200 bedded hospital
More than 200 bedded

If there is a complaint in these hospitals where do they go?

There is an authority team and they go to CDO. Another place is NMC (Nepal Medical Council).

CDO members will negotiate.