Free health service: A rhetoric or reality?

Research Report.

SUMMARY: Resource Center for Primary Health Care ( RECPHEC) with support of Oxfam GB carried out a case study on the effectiveness of free health services. Objectives of the study were to (i) document and analyze the extent to which the free health service policies of the government have actually addressed the health issues of poor and marginalized people, (ii) identify the policy gaps and capacity needs, (iii) identify delivery gaps and assess the existing delivery, (iv) assess the role, contribution and capacity of CSO activists vis-à-vis effective delivery of health services, (v) provide an evidence-based picture of the effectiveness of the free health service scheme in terms of the extent to which it has benefited the poor and marginalized communities, and (vi) document lessons learnt and derive recommendations. The study was based on literature review, central level discussions, field-based survey and field visits ( in four districts: Bardiya, surkhet, Dailekh and Dadeldhura). The history of formal health services in Nepal dates back more than six decades. The commitment of the government of Nepal (GON) towards the health sector started with the fight against malaria followed by similar effort against various other mass-communicable diseases. The government has been focusing more on primary health care while encouraging the participation of the private sector in tertiary level health service delivery. Nepal , as a signatory of the Alma Ata Declaration, has been involved in delivery of health services (basically primary health services) with motto of Health for All (HFA). The government has formulated various plans and policies to reinforce the commitment made in the declaration and the idea was again endorsed in the Three Year interim plan (TYIP, 2007-2009).The interim constitution of Nepal, 2007 was a landmark in defining and ensuring the people's right to basic health services. The declaration therein of access to basic health services as a fundamental right of each and every Nepali citizen laid the ground for the government's declaration of free health services. GON declared all basic health services provided by health posts and sub-health posts free by Magh 1, 2064. Similarly, GON declared its commitment to providing health services and a list of medicines free for the general public at primary health care centres by Mangsir 1, 2065 and for a target group at 25-bed hospitals by Magh 1, 2065. The declaration has also shown commitment to delivering free health services even at central, regional, sub-regional and zonal hospitals by making specific budget allocations. Similarly, the government has tried to develop a strong reporting mechanism in line with the Health Management Information System (HMIS) for strengthening the areas of FHS. The declaration has clearly demonstrated the commitment of GNO towards delivering free health services to all citizens, especially the poor, marginalized, elderly and disabled. The declaration has acknowledged the provision in the Interim Constitution of 2007 regarding free health services and recognized and respected the people's right to health. A significant level of increase has been observed in the number of people visiting the health posts. The program got high priority even within the Ministry of Health and population since there is a provision for a National Levels Steering Committee led by the Minister. The government has developed Free Health Services Programme Implementation Guidelines to strengthen and accelerate the implementation process. The improvements made in the areas of definition, scope and distribution of free health service delivery 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. However, the sprit and concept of the central level declaration have not been reflected at the field level. The infrastructure and the service delivery mechanisms at district and field levels are inadequate for the implementation of FHS. 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 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 VDC secretary being chairperson of the respective SHP management committee, the committee has not been functioning property 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. The overall implementation of FHS is satisfactory. The commitment and efforts shown by GON are praiseworthy and require support and facilitative monitoring from CSOs and the general public. However, there are various areas of FHS that need to be improved, reinforced and strengthened. The major recommendations of the study for the short-term include (i) strengthening monitoring and accountability including by forming a specific and independent section for monitoring and supervising FHS implementation, (ii) improving information communication for all stakeholders about the policy including by declaring and celebrating a national day on FHS and establishing it as a national movement, (iii) carrying out detailed and comprehensive cost analysis exercises to identify financial and human resource gaps (iv) increasing resources to strengthen the delivery mechanism, (v) strengthening the monitoring committee and ensuring regular reporting of the program, (vi) introducing and mainstreaming a social audit process at all implementation levels to maintain transparency, (vii) increased resource commitment from Ministry of Finance to strengthen the health system, (viii) developing a joint planning mechanism with DDCs and VDCs to fill resource gaps, (ix) inviting and involving donors in strengthening the FHS programme including by providing addition long-term predictable aid for health systems strengthening especially health workers and medicine supplies, and (x) reconsider the targeting mechanism in place. The recommendations for the long term include (i) designing, developing and initiating improvement of the service delivery mechanism through exploration of successes achieved in other countries, including through the development of public -public partnerships to improve service delivery performance (ii) explore and introduce improvements in tax revenue raising and allocation of health resources to extend the possibility of free health care for everybody, (iii) identifying and introducing scientific mechanism to target poor, if in case the service is made available only to poor people by giving ad-hoc criteria, and (iv) improve the salaries and working conditions for health workers including a comprehensive incentive package to tackle absenteeism and ensure vacancies at rural health posts are filled.