| Summary, etc. |
SUMMARY: The ministry of Health and population of Nepal Government took several steps towards universal access to essential free health care services to all Nepalese from government health facilities since 2008. Initially, an exemption policy was offered to the public in 2006. This decision was driven by political ideology rather than based on research evidence and recommendation. Neither the government made any consultation with social experts of diverse field nor did any feasibility study prior to its announcement. Though the concept seemed important at policy level, there might have been a challenge to implement at ground level within the context of limited capacity and resources of the nation, International evidences have also shown the weakness in the implementation level. Social science approach not only attempts to promote the health and prevent the disease but also attempts to understand the way health and disease make sense to the lay people from their social and cultural context. Using this outlook this study approached to look factors that determine the health of family members and health service utilization patterns for different social groups in the society. In essence, did public get the free health care they need? Was the care accessible and effective when they received it as mentioned in policy, including whether or what the impact of this policy has been on the society? The study highlights the landscape of implemented policy and experience of health providers, users and other public from different social groups in the community. A cross-sectional descriptive cum exploratory study based on purposive sampling, both qualitative and quantitative information has been carried out. The data has been collected by semi-structure questionnaire for household survey, FGD, Key Information Interview with public and health service providers, case studies and observation of availability of medicines at health facility level, case studies and other records and secondary information from study district. This study has been undertaken during the period of 10 months (from October-2010 to July -2011), based on field work of rural and urban geographical setting of Myagdi district. In both of the study places, from 2064/065 to 2066/067 fiscal year; the number of attendance of patients increased by just over two-times. It is interestingly to note that, there has been a high flow of patient from Dalit groups after free health care policy's endorsement. Similarly, the tendency of service utilization by different ethnic groups has increased gradually. However, the proportion of service utilization by Disadvantaged Janajatis Groups found to have been lower in compared to other ethnic groups even if the majority of the population of this group is very high in this district. However, there was a reverse trend in use of private hospital; it is seen while reviewing one year's data of private hospital at district level. Of total respondents, 37(74%) had made health facility visit for seeking free health services in urban (Beni) Whereas it was 41(87%) respondents for rural area. On the basis of attendance, it has also been found that 21(56.5%) of the respondents reported that they didn't get listed drugs at district hospital whilst it was 6(14.64%) for the Gurja sub- health post of rural area. The data also reveals that the majority 41 (82%) of the respondents could reach to district hospital by walking 30-60 minutes from their location even though it is located to urban place (nearby district headquarter) while they have to walk more than 2 days for receiving such an access to district hospital for the rural people; however, the majority 42 (89.36%) of the respondent could visit to the nearest located health facility at their village within 30 minutes. With respect to satisfaction level, about just over 25 (50%) of the respondents were somewhat satisfied with the service provision at Sub- health post (rural area) Whereas nearly one-third of the respondents preferred to express their satisfaction level to somewhat satisfied category from respondents preferred to express their satisfaction level to somewhat satisfied category from urban area. There was no one found to be fully satisfied with the existing service provided health service by District Hospital; however, the majority of the respondents were only satisfied somewhat with the existing service. Interesting to note that there was only 1 out of 13 clients found to be fully satisfied at district hospital. The majority of the respondents 57 (58.76%) of the total 97 expressed their view on 2nd (middle) category that the free Health care Policy to be important for them. Likewise, 8(62%) of the 13 clients also assessed this program to be important (middle). However, on average 29 (29.89%) percentages of the household respondents responded that the program is not being good as such though it was 23 percentage of the clients (3 out of 13 exit clients) judgment to this category. On average, about just over one third of the respondents (36%) suggested that the free health care policy has yielded economic benefit while 14.43% put their view on social welfare of FHCP. The policies design weakness include targeting criteria to differentiate between poor and ultra poor and lack standard tool for cross-verification for the drug supply, properly management and preventing of from being leakage. Second weakness of the policy was the poor situation of monitoring and supervision. The policy implementation weakness include poor implementation capacity, insufficient supply of listed drug, problem of transportation cost to remote area for drug supply; lack of coordination to involve other local stakeholders and community in supporting to this program from other stakeholders. Failure to set up management committee for free health care program separately as recommended in the policy guidelines. However, there are some advantages with cross-cutting benefit of this policy like health, economic and other social welfare. Notably among respondents; it has been addressed the health problem of poor people and targeted groups to some extent. There are, however, some inconsistencies at health facility level where people many times compelled to take medicines from outside from hospital even to listed drug when that should not be. The major barriers to basic health service are not only due to fees health facilities, but are attributed to many other factors such as transportation, a shortage of medicines, understaffing, social relationship, waiting time, economic status, behavior of health staff and social inequality in staff management, quality of service. Moreover, the health status of district is low in terms of service and health indicators. On the other side, still there seems a strong tradition of pursuing traditional healers (Dhami and Jhankris) for the treatment in rural part of the study area than urban setting. This result seems similar to the findings of Manandhar, 2000:''the continued belief in the traditional healers, with the notion that they are ''community owned'' and not '' government owned'' their appeal is complex and involves their proximity and accessibility as their history and compatible ''illness model of historical spiritual cause for most ailments.'' The key message to the respective institution of government include: health policy should be effectively implemented addressing the constraints and issues identified, clear directive should be sent with considering the reality of grass-root level. Training, supervision, monitoring, and management systems need improvement; participation of the other stakeholders and community need to be encouraged through enabling environment. Most important point is that separate section need to be established in the district level to implement this free health care program more efficiently to ensure the better service in the community. The concerns and potential problems listed above indicate importance of focusing attention to the process of policy implementation and health system capacity within the different social structure of Nepal. It can also be said that on the basis of data community social capital is associated with the better health service utilization when social network, interpersonal communication, involvement in community and mutual benefit what they shared; that influence status of service utilization. |
| Summary, etc. |
Some social changes have occurred over time into the society in terms of level of education, health seeking behavior, sanitation and economic and political aspects via empowerment. The differences observed on gender and caste differences in the community are still in existence and it has directly influenced the service utilization and accessibility of the provided services. Mainly service is being influenced with the personal and organizational relation. Thus, it can be concluded that the offered health services and its relation with the community is directly associated with the structure of the society i.e. social unit family, organization, and its network. Free health services also should not be influenced by relation, nepotism and by the political relation; all patients should get the equal services as per the policy of Nepal Government There is a wide space to be undertaken an academic research in the days to come for the students and researchers being focus on the issues of social determinants of health like equity, equality, gender and traditional practices in terms of health services. |
