The United Nations World Summit on Social Development (1995) defines poverty as: lack of income and productive resources to ensure sustainable livelihoods; hunger and malnutrition; ill health; limited or lack of access to education and other basic services; increased morbidity and mortality from illness; homelessness and inadequate housing; unsafe environments and social discrimination and exclusion. It is also characterized by lack of participation in decision-making and in civil, social and cultural life.
Nepal’s health care problems largely stem from the centralization of political power and resources in the capital, contributing to social exclusion of other parts of the country. Democracy in the 90’s emerged as a more objective, “scientific” form of government that would expose human rights violations and lead to better opportunities for the poor.
But as a result of political patronage the high caste elite classes still managed to exploit hidden advantages built into the system. Nepal has a history of systematic discrimination along ethnic and caste lines in allocation of state resources, which has produced disparate outcomes in health. Over the last 22 years messages such as “Health for All by the year 2000 AD through primary health care approach” remained confined to rhetoric in spite of billions of dollars from external development partners for better services.
In 2000, the government funding for health was approximately US $2.30 per person which by 2007 rose to US $ 4.06 per person. The general level of medical technology and services are fairly good in Nepal, but most of them are located at urban centers and are accessible only if one has deep pockets. Private affluence has contrasted with public squalor. It is no secret that many people in Nepal commit suicide because of their inability to pay for medical expenses. In view of the fact, the Interim Constitution emphasized that “every citizen shall have the rights to basic health services free of costs as provided by the law.” Therefore, attention should now be directed to reduce inequality and minimize its adverse effects on health.
It wasn’t way too long ago when a diarrhea epidemic (which was easily preventable) broke out in Rukum resulting in 140 deaths (52 percent of them dalits) and financial catastrophe for many families. The visual evidence we gathered not long after landing at Aathbiskot, Rukum (April, 2011) was enough to tell the story. The Rukum district headquarters, Mushikot, was 7-8 hour drive from Aathbiskot on a four-wheeler. In Aathbiskot, medical stores run by local health workers and others had dominated the tiny area where we lived. Over the course of the next few days we noticed women washing clothes with intravenous cannula in situ, men on the street playing carom-board with intravenous cannula and even women breaking stones with intravenous cannula.
It was also alarming to see many quacks fearlessly practicing medicine. Out of curiosity, we asked a lady what she was getting treated for. She responded “Well, the doctor
[could have been anyone] examined my urine and told me that I have 10 big stones in my kidney, so I should get 2-3 bottles of these”. Infact, everyone was getting treated with 5 percent dextrose injection with vitamin B or Sodium Chloride. There were approximately 10-15 illegal medical stores providing such treatments to 50-60 people each day. The location was also suitable for treating villagers and animal herders from Jajarkot and Dolpa.
Nepal’s health care problems largely stem from the centralization of political power and resources in the capital, contributing to social exclusion of other parts of the country.
Such incidents are representative of general health situation in Nepal because majority of Nepalis living in the rural areas suffer double disadvantage: first though the exclusionary policy of the state and second from hands of quacks. However, the problem doesn’t end here; when it comes to reducing inequality, health services on their own have only a marginal role.
By the time sick people get to hospital, the medical damage would have been done by inadequate education and other factors outside the influence of the health service. Although the idea of universal health insurance has recently come up, it is not a one-size-fits-all concept, nor does it address the cumulative effects of exclusion on health over one’s lifetime. Moreover, skewed insurance coverage benefitting the well off more than the extremely poor has already been documented from recent studies in countries like the US and China. Such a situation will continue to prevail unless social justice is provided by addressing socio-economic inequities for a long-term health pay off.
The author is a PhD student in Preventive Medicine and Epidemiology, University of Oslo