Lessons from NHS relevance to Nepal

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Lessons from NHS- relevance to Nepal

• Dr Prasanna Chandra Gautam FRCPE

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Topics

• Background
• How was UK at the inception of NHS
• How is Nepal today
• Important lessons from NHS
• Current thinking in Nepal for planning,
  establishment and management of health service
• Relevance to Nepal.
• Ways forward- suggestions

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Architects of NHS

• Concept of a NHS was being thought of in the
  early 1930s.
• Aneurin Bevan was one of the most important
  ministers of the post-war Labour government and
  the chief architect of the National Health
  Service.
• On 5 July 1948 the government took over
  responsibility for all medical services.

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NHS

• The NHS Act, May 1948, established a
• comprehensive health service to secure the
  improvement in the physical and mental health of
  the people . . . and the prevention, diagnosis
  and treatment of illness.
• NHS was established on 5 July 1948.

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NHS will be

• A service comprehensive in scope, including
  medical and allied services of every kind
• A service available to all -- a health service
  funded largely from central taxation
• A service free at the time of need.
•  A pattern of medical remuneration reflecting
  doctors wishes.
• A hospital service administered by centrally
  appointed, not elected, bodies and the officers

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NHS will be Contd.

• There should have been one more distinctive
  feature
• Co-operative general practice from
• shared purpose-built health centres.
• This is the trend now.

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DGH for a population of 100,000--120,000

• Three general surgeons and physicians of senior
  grade (half-time).
• Three general surgeons and physicians of junior
  grade (half-time).
• No fewer than three surgical and three medical
  registrars (whole-time).

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NHS Funding

• Traditionally, the funding of the NHS had three
  characteristics,
• It was low by international standards, 5.6-6.0
  of GDP, ( 7 Europe, 15 USA)
• 89 dependent on public finances,
• 3. A reliance on general taxation (rather than
  insurance or employers' contributions

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Ethical ConsiderationsTavistock Principles

• Cooperation Health care succeeds only if we
  cooperate with those i. we serve, ii. each
  other, and iii. those in other sectors
• Improvement Improving health care is a serious
  and continuing responsibility
• Safety Do no harm  
• Openness Being open, honest, and trustworthy is
  vital in health care

• Rights People have a right to health and
  health care  
• Balance Care of individual patients is central,
  but the
• health of populations is also our concern  
• Comprehensiveness we also have an obligation
  to ease suffering, minimise disability, prevent
  disease, and promote health  

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Medical education Goodenough report

• medical education was the essential foundation of
  a comprehensive health service.
• the spirit of education must permeate the whole
  health service, professionals and public alike
• A principal aim of national policy should be the
  encouragement of the promotion of health
• developing the teaching
• staff and the facilities could not happen
  overnight
•  Greatly increased public funding needed to
  provide the research and education for the NHS

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Summary

• NHS is about the interaction of the three main
  parties involved
• 1. those needing care,
• 2. those who deliver skilled care, and
• 3. those whose task it is to raise the money and
  see it properly spent.
• The peculiarly difficult triangular
  relationship between these interested parties has
  to be satisfactory if the health service is to
  function to the benefit of society.

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Conclusions

• NHS succeeded
• because
• 1. It is one component of Welfare State
• 2. It is expensive but state has been able
• to support it
• 3. Every part of the country is accessible
• and the infrastructure is established
• 4. Only now it has become self sufficient
• in medical manpower. 40 are IMGs

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Lessons learnt (1)

• Patient expectations continue to rise and
  media coverage of health affairs to increase. 
• Bottomless pit
• Expenditure on health will continue to
  escalate due to scientific advancement, new
  diseases, increasing expectations and longevity.

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Lessons learnt (2)

• Health is a Human Rights issue- associated
  ethical dimensions are very complex.
• It is impossible for the service to stand still
  when advances are international.
• The introduction of new technologies is driven by
  
• the spirit of enquiry, commercial gain,
• competitiveness and globalisation.

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Lessons learnt (3)

• The concept of value for money is not for
  disease prevention but for the efficiency of
  service delivery and its quality.
• Coordinated efforts between the suppliers of
  trained manpower, agents of service delivery,
  researchers and entrepreneurs are essential

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Lessons learnt (4)

• that the NHS has been too centralised
• that patients should have more choice and be
  treated as consumers rather than passive
  recipients

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Social inequality and health (5)

• The down trodden, the underprivileged,
• the uneducated, the uninformed have always
  suffered from poverty (viz Janjatis, Dalits and
  Tamangs in Nepal)
• Their diseases may be treated but their health
  cannot be restored by medications- high morbidity
  and mortality
• A progressive government must make legislation
  to protect and promote this section of society.
• They must be targeted for overall improvement,
  not health, which will automatically follow.
• eg poverty in children, inner cities, travellers,
  addiction
• unemployment,

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Relevance to Nepal

• ..some thought they stood on the brink of the
  abyss, others of the millennium. The problem was
  to geld a mass of often conflicting institutions,
  keep them working and then get them to work
  better.
• The existing components were to be united into a
  new system for delivering care to everyone,
  redistributing staff and facilities...

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Over the last 5 years, Nepal has received 785
Millions in aid DFID gave 273 M

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Reminding NepalDFID report Oct 2007

• Poorest country in SE Asia, per capita 418, 31
  live on less than 1/day
• 1.18 of GDP 115M, is spent on health
• Estimated expenditure on health is 14/person,
  10 from private and 4 from govt,

• 50 of Nepalese children suffer from malnutrition
• 46 Dalits and 61 Tamangs live below the poverty
  line of average 31 Nepalese.
• 17/100 Dalit children die within 5 years,
  national average is 8/100

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Relevant facts about Nepal WHO Oct 2004 Country
Case study , Nepal

• 1 nurse for 4,000 people
• 1 health assistant per 4,500
• 1 village health worker for 6,000
• 1 MCH worker for 7,500

• Only 29 of the population can reach a health
  facility within half hour.
• 1 hospital bed / 200 people
• 1 doctor /18,500 people

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Social status

• ----Working class people did not expect to be
  comfortable.
• Most went hungry and their undernourished
  children showed evidence of rickets until vitamin
  D supplements, provided by welfare clinics,
  controlled it.
• Many were miserably cold in winter unless they
  were roasting in front of the coal fire in the
  kitchen----.

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Social status 1948From Cradle to Grave history
of NHS

• ----the waiting room with rows of seats for
  about 60 patients who sat facing a high bench
  like a bank counter.
• Behind stood the three doctors and behind them
  the dispenser. The doctor called the next patient
  to come forward.
• Having listened to the complaint, he turned to
  the dispenser to order the appropriate remedy.
• There was rarely any attempt at examination----.

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Summary of problem analysis on MOHP site (1)

• The mortality and morbidity rates among women and
  children are alarmingly high
• Acute, preventable childhood diseases,
  complications of child birth, nutritional
  disorders, and endemic diseases such as malaria,
  tuberculosis, leprosy, STDs, rabies and vector
  borne diseases continue to prevail at high rate.

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Summary, contd (2)

• Determinants of such conditions are associated
  with pervasive poverty, low literacy rate, poor
  mass education, rough terrain, and difficult
  communications, low levels of hygiene and
  sanitary facilities, and limited availability of
  safe drinking water.
• These problems are further exacerbated by
  under-utilisation of resources, shortage of
  adequately trained personnel, underdeveloped
  infrastructure poor public sector management,
  and weak intra and inter -sectoral coordination.

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Partners in Planning and plans

• 10th development plan
• Nepal Health Sector programme- Implementation
  Plan
• Millenium development Goals
• Ministry of Finance
• National Planning Commission
• Parliament
• External Development partners WHO/DFID etc
• NGOs
• Tribhubana University

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Strategic thinking by GON and donors (1)

• Commission for Macroeconomics and Health
• Disease creates poverty
• Health will create economic growth
• Investing in health will result in high economic
  growth
• Especially, when investment is
• targeted at the poor.
• Maria Palman, WHO Country Case Study, Nepal Oct
  2004

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Strategic thinking, contd (2)

• M C H focuses on
• Achieving better health for the poor, thereby
  reducing poverty and stimulating economic growth
• Eliminating financial constraints by increasing
  domestic and external investments in health
• Eliminating non-financial constraints to
  providing a package of essential intervention to
  the poor.

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Top ten diseases in NepalMOHP website Dec 2007
poverty, lack of clean water and poor
hygieneovercrowding and poor environment

• 1. Skin disease
• 2. Diarrhoeal diseases
• 3. Acute respiratory
• infection
• 4. Intestinal worms
• 5. Pyrexia of unknown
• origin

• 6. Gastritis
• 7. Ear infection
• 8. Chronic bronchitis
• 9. Abdominal pain
• 10. Sore eyes and
• related complaints

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Problems with assumptions

• No evidence that Britain was poor in the
  beginning of 20th century.
• The diseases prevalent at that time were due to
• 1. poverty among the underprivileged
• sections of the society and
• 2. lack of education.

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Comparative figures on spending

• UK average per person 14 per annum
• Sub-saharan Africa 5 per annum
• Nepal 1 per annum
• WHO recommendation minimum 17

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Reality and aspirations

• Dynamism is an intrinsic characteristic of
  health care.  Challenges are changing and never
  ending for as one problem is handled, others
  emerge.
• Nepalese are also demanding the benefit of latest
  technology and advancements e.g
• IVF, anti cancer and HIV treatments,
  transplantation, gene therapy etc etc.

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Lets face the facts- learn from others experience

• Fundamental facts (1)
• It is is the other way around
• Poverty breeds poor health
• The top ten diseases in Nepal are caused by poor
  living conditions due to dire poverty.
• These can be mostly eradicated by improving water
  supply, overcrowding and balanced diet.

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Way forward

• Fundamental fact. 2
• Infrastructure development leads to
• economic development-
• not symptomatic treatment of morbidity
• Transportation, electricity, communication will
  improve access to health care , among other
  things.

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Way forward

• Use monies to develop infrastructure, energy and
  information systems.
• This will help to minimise poverty and cause
  economic growth.

• Accept that without a fully developed Welfare
  State ,
• MOH is unable to provide a comprehensive health
  service and cope with increasing demands on
  resources for it

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Vision of a good Health system in Nepal

• Government- provides basic minimum primary
• care and health
  education
• Legislation and improve access for
• i. abolishing discrimination and
  exploitation
• ii. Health insurance for all employees
  and
• their dependents.
• Private sector provides all facilities for
  treatment
• Private and state partnership provide for all
  technical education and research activities

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Thank you for your attention.Any questions?