Strong regulatory system must come into force to strengthen the effect of monitoring
The health service sector in Nepal is surely expanding with the increment in numbers of hospitals and other health service institutions along with accessible network of essential health care service across the country. In past decades, the involvement of private sector in the health service has escalated and it appears that the private sector has taken the charge in broadening the scope of health services in Nepal. That said, benefiting from the weak presence of public health institutes, the private sector has been mainly focussing on quantity based deliverance of health service by neglecting the people centric approach and principles of equitable health service that does not differ in quality according to socio-economic status, geographical location and other personal characteristics. Therefore, a variation can be witnessed in the Nepali health care sector with the degrading state of public health service institutes and the booming private health industry with proliferating investment.
It is important that the health sector in the country is monitored and firmly regulated because it plays a pivotal role in the development process by contributing to various dimensions of human development such as life expectancy, solving infant mortality and improving the standard of living. But Nepal has failed to supervise the recent growth in health sector and it appears that the private faction in the health sector is pushing health care agendas in the country through various means. Incompetent government health service, irregularities and expensive services in private health institutions, disorganised public establishments, discontinuity of policy, political intervention in Institute of Medicine (IOM), commercialisation of medical education and other malpractices and irregularities are the major stumbling block that has cramped the much needed development in qualitative health service in equitable terms.
Department of Supply Management (DoSM) has found irregularities in charges and other services at many hospitals in Kathmandu during its inspection. As per the report of DoSM, hospitals such as Norvic Hospital, Grande Hospital, B&B hospital, Nepal Institute of Neurological and Allied Science, Ishan Children and Women’s Hospital have taken unnecessary charges from patients under different headings. DoSM has already sent all the files to Metropolitan Police Range to investigate on the matter and filed cases against the hospitals under fraud charge.
The inspection team visiting the Norvic Hospital found that the hospital has been collecting 13 per cent service charge on top of the five per cent health service tax to the bill. Besides that, it has also not renewed its operation permit and has been operating with more than 100 beds even though it has the permit for just 100. Meanwhile, the inspection team found Ishan Children and Women’s Hospital taking extra charge under similar headings and forcing patients to pay extra charges for the same service. Hospitals such as B&B hospital, Nepal Institute of Neurology and Allied Science and Grande Hospital have been found to have committed such irregular activities as per the report of DoSM. It has also stepped up its action against Kathmandu Valley Hospital at Sundhara for operating without a renewed license.
Many hospitals have also failed to justify the amount they have charged the patients. Laxman Shrestha, Spokesperson at DoSM says, “Majority of hospitals have taken service charges of 13 per cent on the top of five per cent health service tax as allocated by the government. Besides that, the hospitals seem to be taking different charges under similar headings and exploiting the general public. Such fraudulent practices in the hospitals have violated the people’s right to health service. So, we have forwarded the files to Metropolitan Police for further investigation under fraud charge.”
However, the hospitals have denied such allegations and defended its policy in the name of providing quality service. While providing explanation to the department, the hospital operators have justified their act by stating that the law does not prohibit them from charging patients under different headings. A highly placed source at DoSM says, “Many hospitals had started lobbying to defuse these issues. They tried to manipulate the officers at DoSM through different means but such efforts were to no avail as the matter is under police investigation and will proceed ahead under judicial jurisdiction.”
Not only hospitals but many clinics and pharmacies have been under inspection from DoSM as well. Majority of the clinics seem to operate without license and providing services to public in the absence of basic facilities. Bishnu Prasad Timilsina, Secretary at Forum for Protection of Consumers’ Rights says, “There is no guideline to regulate the quality of service provided to patients as financial per the financial expenses. People should have easy access to affordable health service but the scenario is quite different in Nepal. It’s important to address the loot committed against the public by hospitals under expensive charges through legal and judicial means.”
Strengthen the monitoring process
Another issue that needs to be tackled is the inefficient monitoring process and its inability to provide accessible justice to consumers. Even though the monitoring exercise from DoSM has gained some momentum in past months, it is important to note that such monitoring activities are yet to be institutionalised in every sector to create a larger impact. Furthermore, the monitoring process is not endorsed by judicial mechanism and it often fails to provide justice to the consumers.
The absence of consumer court is also one of the perennial problems affecting the application of consumers’ right. At present, there is District Compensation Committee consisting of five member tribunal lead by Chief District Officer which provides compensation to consumers after evaluating the evidences. However, the committee does not function like a consumer court and is limited to providing compensation to public. Furthermore, it would be wrong to assume that compensation provided to consumers equal to complete deliverance of justice. Timilsina says, “Consumers have no access to justice in the present judicial system because they are disorganised whereas the business community is organised. Even in the case of hospitals, all the hospitals and their investors will come together to boycott any punishment and continue their irregular business that prioritises financial value rather than people’s health. So, a fast track mechanism is needed in the form of a consumer court to safeguard consumers’ right and ensure that irregular business practices are penalised.” That said, it is important to note that the court in Nepal have been very efficient in providing speedy judicial services in some cases such as the Ncell profit reparation, arrest of Dr Govinda KC, settling the dispute in police rankings, et cetera.
Another problem that seems to weaken the monitoring process is the shortcomings in the existing acts. The Consumer Protection Act only covers the cases where the consumption of product and services have negative impact on health and also address the impurity, irregularities in billing but has no jurisdiction in the cases of hospitals’ irregular overcharging. Shrestha says, “The existing acts have to be amended to broaden the monitoring process and also to equip the monitoring agencies. It is hard to address all the fraudulent business practices under Consumer Protection Act and Black Marketing and Some Other Social Offences and Punishment Act. Furthermore, there is also confusion among other government agencies regarding the monitoring process. Only DoSM cannot take the charge of monitoring in all sectors because we lack enough manpower.”
Degrading state of public health services
The unguided commercialisation of public health care system in Nepal has a much larger implication when it comes to the overall progress of health care system. The private sector has been pouring large investment in the sector but the government often struggles to spend the allocated health budget. As a result, the health care infrastructures such as hospitals, health posts, and pharmacies are limited in urban setting only due to the active involvement of private sector. The unequal distribution of health care network in the country reflects the state’s inability in determining the priorities for health care system.
Poor housing condition, lack of health awareness, unsafe source of drinking water, lack of sanitation, exposure to environmental hazards and unavailability of basic health service are the major problems affecting a large section of livelihood in Nepal. As a result, diseases such as diarrhoea, fever, influenza, cholera takes epidemic turns and results in the loss of several lives. The ongoing spread of viral fever in Jajarkot which has resulted in the death of more than 13 people in the last two weeks shows how people in the rural setting are vulnerable risks due to the absence of basic health facility.
On the contrary, the scenario is quite different in urban centres like Kathmandu where one can witness exponential surge in the numbers of hospitals and other health care institutions. Stressing that the public health care system in Nepal has been heavily influenced by business interest rather than public interest, Dr Raamesh Koirala at Shahid Gangalal National Heart Centre shares, “In the past years, constant efforts have been made by the private sector to
weaken the state’s healthcare infrastructures and services in Nepal. Furthermore, various political establishments have also supported such endeavours instead of strengthening the state’s institutions. If only the government shifts its focus and prioritises up-gradation and reformation of its own institutes through policies and other financial incentives, it’s possible to change the health care system in Nepal in next five years.”
Besides the health care system, health education in Nepal is also in a deteriorating state. The frequently surfacing controversy in theappointments of Dean at IOM, the political lobbying in providing the permit for operation of medical colleges and the recent verdict by the court on the MBBS entrance exam paper leakage highlights the problems in the medical education system in Nepal. It is only fair to state that the inferior state of health education is responsible for the declining state of health care sector in Nepal.
At present, the Policy on Quality Assurance in Health Care Services 2007, the National Health Policy 2014, and the Nepal Health Sector Strategy 2015-2020 are in existence to guide the health care sector in Nepal. However, such policies seem to be ineffective in terms of guiding the health sector in Nepal to a positive path. It’s high time that government and other stakeholders associated with the health sector take ownership in the state’s vision for the improvement of health care system in Nepal.
A version of this article appears in print on January 14, 2018 of The Himalayan Times.