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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 2  |  Page : 123-127  

Assessing Nepal's health policies and programs from a human rights perspective


1 Associate Professor, Department of Economics, Patan Multiple Campus, Tribhuvan University, Patan, Nepal
2 Senior Researcher, Department of Research, Institute of Nepal Environment and Health System Development, Kathmandu, Nepal

Date of Web Publication14-Jun-2018

Correspondence Address:
Sanjaya Aryal
P.O. Box: 14423, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_308_16

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   Abstract 


Background: The right to health is a fundamental part of human rights. Ensuring right to health is not straightforward; there are several challenges. Factors such as capacity of right holders and duty-bearers and practices of providing and utilizing services among others determine to ensure health rights for the whole population. Objective: The objective of this paper is to analyze whether the health policies and programs follow a human rights-based approach (HRBA) and assess the situation of rights to health among the poor and vulnerable population. Methods: The study assessed domestic instruments against human rights policies and analyzed the implementation status of the policies and programs. An analytical case study method is used by utilizing qualitative and quantitative data. Results: Around 90% medicines are available in the facilities; however, 22% of health worker posts are vacant. Persistence of unequal distribution of health facilities, high out-of-pocket payment, and cultural and language barriers does not ensure accessibility of health services. Acceptability of health-care services in terms of utilization rate and client satisfaction is improved after introduction of new policy. Nepal has made significant progress in improving maternal mortality ratio, infant/child mortality, immunization rates, and life expectancy at birth. Conclusions: Although a progressive realization of the right to health is being achieved, more efforts are still needed to follow HRBA so as to achieve quality and equity in health-care services.

Keywords: Health policy, human rights, Nepal


How to cite this article:
Adhikari SR, Aryal S. Assessing Nepal's health policies and programs from a human rights perspective. Indian J Public Health 2018;62:123-7

How to cite this URL:
Adhikari SR, Aryal S. Assessing Nepal's health policies and programs from a human rights perspective. Indian J Public Health [serial online] 2018 [cited 2019 Dec 6];62:123-7. Available from: http://www.ijph.in/text.asp?2018/62/2/123/234502




   Introduction Top


The right to health does not only mean we have a right to be healthy. It requires immediate and targeted steps to be taken to progressively ensure that health services, goods, and facilities are available, accessible, acceptable, and of quality. However, right to nondiscrimination, including on the grounds of social and health status, should be immediately enforced rather than realized progressively. Moreover, all human rights to be realized depend on each other and all rights form a whole and no rights are more important than other rights.[1]

Ensuring right to health is not straightforward; there are several challenges such as fiscal space of the country, capacity of rights-holders (individuals and communities) and the duty-bearers (states),[2] lack of exercises, and appropriate indicators to measure the violation and realization (progressive or stagnant or retrogressive) of rights to health among others. Development and health indicators are often used as proxy indicators to measure the situation of rights to health;[3] however, these indicators do not provide sufficient information while measuring the health rights.[4] For example, increased percent of utilization of health-care services does not ensure the increase in utilization of the services by the vulnerable groups and the consumption of health-care services without violation of rights to health.[2] Health policy-making and programming are to be guided by human rights standards, principles, and national as well as international commitment and aim at developing capacity of duty-bearers to meet their obligations and empowering rights-holders to effectively claim their health rights.[5]

The Constitution of Nepal ensures free basic health services to its citizen by making it a fundamental human right. There are a number of human rights in the Constitution of Nepal that is closely connected to the right to health, such as rights to education, right to equality, right to access to information, and right to participation among others. The Ministry of Health has been implementing policies and programs to provide free essential health-care services to all citizens, whether poor or not, at below district-level health facilities since 2008.

However, out-of-pocket (OOP) expenditure contributes almost 55% of total health expenditure with the cost of medicines alone accounting for 50% of OOP expenditure.[6] O'Donnell et al.[7] points out that Nepal's health-care subsidy is pro-rich because of several constraints, such as problem of identification of poor.

Therefore, the paper has twofold objectives: To provide the status on progressive realization of the right to health and other health-related human rights in Nepal and to assess the situation of rights to health among the poor and vulnerable population particularly analyzing availability, accessibility, acceptability, and quality by utilizing a human rights-based approach (HRBA).


   Materials and Methods Top


Research design

We used a HRBA as a framework to measure the implementation status of international human rights standards in promoting and protecting human rights in a national context. In order to assess and analyze the human rights claims of rights-holders and the corresponding human rights obligations of duty-bearers related to health policy and programs, we used qualitative approach in collecting data and analyzing variables derived from human rights principles, namely, availability, accessibility, acceptability, and quality of health services.

Sources of data

Publicly available recent documents relating to health policy and programs and right to health were collected for desk review and in-depth analysis. A total of 10 expert interviews were conducted with senior policy-makers. The total number of interviews was determined by the principle of data saturation. Focus group discussion (FGD) with the community people, i.e., the representatives of health management committees, civil society, human right activist, and service users among others were carried out. The discussions were guided by a trained moderator and took place with seven to ten participants. Two FGDs were undertaken in the rural and urban community in a district. The paper adopts a HRBA to meet the aforementioned research objectives by combining and triangulating: (i) policy document review, (ii) secondary sources of information, (iii) in-depth discussions with key stakeholders, and (iv) FGD in the community. Standard guidelines, as proposed by Stewart and Shamdasani [8] and Ritchie and Lewis,[9] were followed during the data collection process.

Data analysis

The paper tried to measure the progressive realization of human rights over the time. Qualitative method that focused on people's perceptions and values was mainly used to assess health policies and programs from health rights perspective.

Coding of focus group interviews, memos, information collected from in-depth interviews, and other relevant documents were used for analysis of emerging themes and presentation of data in the form of narratives. Memos were prepared independently by researchers and iteration was done at many levels to ensure validity and credibility of collected data. Data were reduced and narrowed to certain themes based on inductive approach which were finalized with rigorous discussion among study teams. Final themes were generated through discussions between the authors on the basis of their independent initial analysis. Data analysis was an iterative process, whereby themes were continuously generated, revised, and re-examined.


   Results Top


Progressive realization of the right to health and other health-related human rights

The state has duty to maintain comprehensive arrangements to promote health, prevent sickness and accident, and provide medical care. Nepal's Constitution, 2015, addresses health as a fundamental right. The new health policy, 2014, has devised different strategies to effectively implement universal health coverage and made provision of free basic health services. Free health-care program (FHCP) includes essential health-care services free of charge to all users at primary health-care centers, health posts, and subhealth posts. Other plan that acknowledges health, nutrition, and population as one of the major thematic areas of human rights includes the fourth National Human Rights Action Plan (2014–2019). Some of its objectives are to provide essential health services through establishing additional primary health-care centers at village level and strengthen health service centers.

Legal provisions

Nepal has ratified seven core United Nations conventions out of nine (The ratified conventions include: International Covenant on Civil and Political Rights, 1966; International Covenant on Economic, Social and Cultural Rights, 1966; International Convention on the Elimination of All Forms of Racial Discrimination, 1965; Convention on the Elimination of All Forms of Discrimination against Women, 1979; Convention on the Rights of the Child, 1989; Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 1984; and Convention on the Rights of Persons with Disabilities, 2006). It respects the provisions laid by ratified international treaties as good as law (Nepal Treaty Act, 1990, Section 9) and further domesticates international human rights instruments through enactment of constitution, legislations, policies, and programs and establishes and mobilizes institutional structures and mechanisms. The Constitution of Nepal, 2015, guarantees health as fundamental rights (Article 35 of the Constitution). To materialize the constitutional provisions, new act, rules, and regulations are being developed.

Health-care policies and programs

The FHCP introduced in 2008 was targeted to poor and vulnerable citizens attending primary health-care centers, health post, and subhealth post. The FHCP interacts with demand-side financing for maternal health-care and free delivery services (jointly Aama Program), free curative services for tropical diseases such as kala-azar and malaria, and free preventive services. FHCP is playing a leading role in the Nepalese health system to increase access to and utilization of maternal health care, child health care, and tropical disease care among others.

Assessing availability

We used the indicators or proxy variables to show the current status of functionality of health-care facilities, availability of services and human resources, and availability of essential medicine by utilizing the secondary and primary sources of information while analyzing the availability. The services should have been functional with 100% availability of human resources, equipment, and medicines. Although state can progressively realize rights, <100% functionality of health-care services and availability of equipment/medicines in the real situation mean the deviation from the minimum standards set by the instruments.

According to the Department of Health Services,[10] demand and consumption of essential drugs have increased drastically after the implementation of the FHCP, and at the same time, the stock-out of selected drugs has reduced. Likewise, the average availability of essential drugs and other commodities has increased in health facilities in comparison to previous years.

Although the GoN has provisioned for free distribution of medicines, all the “free medicines” are not available at the public facilities. A survey of public facilities in 2014 revealed that only around 90% medicines are available in the facilities.[11] Comparing the availability in terms of ecological region, the hilly region had availability of 87.60%, the mountainous region had 84%, and the Terai had 82.40%. It includes 93% available in primary health centers, 88.20% in health posts, 82.80% in subhealth posts, and 90.80% in warehouse and 79.80% in private retail pharmacies.

A data presented by the Ministry of Health suggested that 22% of health worker posts are vacant/not fulfilled; procurement and supply of commodities, drugs, equipment, and services are generally “delayed” for some reasons.[12] It shows that the health workers are not recruited in full capacity nor minimum standard/number of drugs; equipment and services are made available to fulfill the programs/activities envisioned by the government.

“…Because of the programme (the FHCP)…., the availability of free medicines is increased at the local level….”

–A male, storekeeper at the health facility

“……Sick people come here but we only have 35 items of medicines so they have to go to private shops to buy other medicines……”

–A male, medical officer

“…. People are bound to visit private service providers as health professionals are not available at the public health facilities….”

–A male, NGO worker, Kaski

Although the government has been putting its efforts toward the full realization of the right to health and heading toward positive direction, still the basic health-care services, medicines, and treatment technology are not fully available at the local level. The poor and vulnerable people are particularly affected by the less availability of drugs and services at the local level public facilities. It shows the gaps between the government plans and real implementation.

Assessing accessibility

Accessibility of health-care services can be measured by the (equal) distribution of health-care service. Health facilities, goods, and services should be accessible to everyone without discrimination. Discrimination can be presented in terms of geographical discrimination (facilities are not equally distributed among the geographical regions or physical accessibility); financial discrimination (services are not affordable, particularly for the poor people); and information discrimination (sufficient information is not provided in their language, their culture, and appropriate places).

“……. Some of the Health care services is not accessible to Muslim women because of language and cultural barriers……”

–A female, Muslim woman activist

“……None of the public services [buildings] are accessible to persons with disabilities….”

–A male, representative of organization working with persons with disabilities

Results show that access to free health-care services has increased. The proportion of clients receiving free care at public health facilities increased from 29% in 2009 to 82% in 2011.[13] However, there is still rural–urban divide in access to services, and equity has not been ensured for the people living in the rural areas. Because of the top-down approach and lack of localized health sector plans and policies, local or contextual need is not addressed properly. Special need of marginalized and vulnerable is not given due consideration as the definition of poor and disadvantaged is not clear.[11]

Assessing acceptability

Acceptability of health-care services can be measured using utilization rate and client satisfaction. Increasing utilization rate of health-care services indicates growing acceptability of services. Higher satisfaction of client indicates that services are responsive and sensitive to client needs and culturally appropriate and respectful.

According to the Department of Health Services,[10] the number of persons utilizing free health services among total number of outpatient department (OPD) morbidity was 71.4%. The number of persons utilizing free health OPD services was 98%. A report pointed out that Dalits were recorded as benefitting the most from free outpatient services and over two-third of the total number of patients reported being satisfied with free health-care services.[13]

“I went to health centre for ANC check-up,…… I was comfortable while health workers were proving services…….I decided that I will go there next time ……….”

–Female, FGD participant

“……. Free medicine does not cure when I am ill, I have to take medicine from private to get cured when I am sick……”

–Elderly female service user

There has been a mixed finding regarding the acceptability of health-care services. In some instances, the utilization of services has increased with increased number of marginalized. Moreover, the programs have not focused in making the services more acceptable to the marginalized population.

Assessing quality

One of the key principles of the right to health is the right to quality health-care services that affect their health. The paper used improvement of health status at aggregate level as the indicators of quality of care of the national health programs.

The performance of the health sector in Nepal has improved steadily over the past two decades. The health performance indicators including life expectancy at birth, infant/child mortality, immunization rates, and maternal mortality among others are improving over the years. The life expectancy at birth now is almost 70 years; it was never reached this level before. Under-five mortality has been reduced by more than 50% from 1996 to 2011. Immunization coverage for all vaccines has been doubled from 1996 (43%) to 2011 (87%).[14]

“……. There is some problem in quality so medicines purchased by government for supply should be monitored strictly……. Such news is coming on newspaper and TV….”

–A male service provider

“………Our primary health care centre has such a good infrastructure but here is no doctor …. only 5 or 6 patients visit per day …….”

–A male social worker

While there has been a significant overall improvement in health indicators, this hides serious geographic and socioeconomic disparities that are demonstrated by large variations in health indicators between the development regions and rich and poor. Child mortality rate among Dalit, Muslim and Janajatis, is twice as high as among Newars and Brahmins.[15]


   Discussion Top


Nepal has been heading toward positive direction in progressive realization of the right to health. Domestic provisions, namely, constitutional provisions are at par with the international human rights instruments with minimum gaps. This shows that health and other economic and social entitlements have been increasingly recognized as right in line with the international commitments to human rights instruments and standards as in the case of global scenario.[16],[17] However, progressive realization of the right to health is necessary condition but not sufficient.

As articulated by Gruskin et al.[1] on the use of FGDs to assess the status on availability, accessibility, acceptability, and quality of services, the FGDs with local communities revealed the status as well as implementation challenges. Health-care services and medicines are not available evenly in different ecological and administrative regions and communities. Although the introduction of FHCP has increased the availability of human resources and medicines at the public health facilities, patients are still bound to get services and medicines from private sector, which depicts the gap between the government plans and real implementation. Major issues related to accessibility of health-care services are existing geographical discrimination, financial discrimination, and information discrimination. Poor, marginalized, and disadvantaged people and communities have less access to quality health-care services. People have less trust and ownership on government health services/facilities, which have been a major drawback toward increasing acceptability.

The health policy and programs should be guided by the human rights principles of entitlement of rights, empowerment of the rights-holders to claim the rights, and duty-bearers to respect protect and fulfill the rights. However, in practice, it focuses on fulfilling the interest of the government in power rather than following the human rights standards and principles. It is not designed toward developing the capacity of people (the right holders) to claim their rights; thus, even in principle, human rights impact assessment is meant to empower both the rights-holders and duty-bearers.[16],[17] Although the existing policies are targeted in providing health services to all citizen, reaching out to the poorest of the poor and the most vulnerable groups has still been a challenge. Likewise, the right to health is not based on proper indicators and disaggregated data to monitor the achievement targets. Similar difficulties have been experienced by governments and other entities around the world in its proper implementation, and in some instances, earlier models of development have just been given new name as HRBA without framing the policies and programs by human rights principles.[1]

Therefore, we can make a conclusion that the human rights standards and principles are yet to be mainstreamed or integrated while developing and implementing health policy and programs. Despite achieving progress in health indicators, reaching the poor and marginalized, and addressing inequality in access to quality health care among people of different ethnic groups and geographical areas still remains a challenge in Nepal. OOP expenditure is the principal means of financing health care in Nepal, and high OOP payment is creating discrimination in utilization of health-care services.


   Conclusions Top


The constitution, legislations, and policies guarantee health as fundamental rights and provide provisions for progressive realization of the right to health. Nepal has made significant progress in improving maternal mortality ratio, infant/child mortality, immunization rates, and life expectancy at birth. Acceptability of health-care services in terms of utilization rate and client satisfaction is improved after introduction of free health-care policy. However, conflicting results related to availability of services are still found. For examples, data from public facility survey revealed that 22% of health worker posts are vacant and only around 90% of medicines are available in the facilities. Accessibility of health-care services among certain section of society is further exacerbated by unequal distribution of health facilities sustained through geographical, financial, cultural, and language barriers and high OOP payment. Therefore, to achieve quality and equity in health-care services along with a progressive realization of the right to health, more efforts are still needed to follow HRBA.

Financial support and sponsorship

This study was financially supported by the World Health Organization

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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