Dr Pramod Kattel
Obviously, the answer is a big NO. This has come with great opportunity as well if can be utilized well. Today the whole world is facing a new challenge in the history of man-kind from the infection caused by SARS-CoV-2 causing COVID-19. Even the so called best health systems of the world are facing difficulty in managing it. It is not just because of new problem but also lack of planning prior hand and thinking that it may not be our problem. In the other way, it is due to lack of farsightedness and not planning before to mange possible crisis situation. The infection rate is so high that it has been difficult to manage the case load with the existing situation in so called better countries in terms of health resources (equipments, manpower and system). Considering the fact, it has made me think more what if our country has to face such situation where health has been on least priority of the government which can be speculated by annual budget of mere five percent and seeing the drivers of health system from Minister Level to Health Secretary to Director General of Department of Health Services (DOHS), none of them being the Medical Professionals and vacant post of Health Secretary of medical field that also at the time of health crisis. Till date, the COVID -19 cases are 110 and luckily all are without severe symptoms with 31 successful treatment cases and none with mortality. Question is what if cases rise drastically beyond our capacity. The better situation seen is just a matter of today which may change anytime in near future if timely intervention is not done. Whatever will be the situation, there is no alternative except facing it without thinking of the probable results.
The Top level officials should rise from the current “Daily Wage thinking”. Advertising for hiring temporary health workforce and misusing Resident Doctors does not solve the situation. Via this method of recruitment, applicants may not be obtained as required and if obtained may also not work due to lack of motivation as per the need of time. Seeking vacancies and using Resident Doctors to tackle new problems of COVID-19 is just a way of making common people fool that government has deployed enough health manpower and working hard on it. Even if the present situation is tackled, it may be difficult to face other waves of this infection or if any other problems arise in future. Had the high level officials learnt from the devastating earthquake that we faced on April 2015, the scenario would have been quite different. We need not have to waste money on name of Temporary Corona Hospitals. It’s also not late. As said “every problems come with opportunities”, we should not miss it this time but my inner core does not say the top level officials will learn this time as well. As said previously unless the daily waged type thinking of authorized officials is changed, it does not change the scenario. Seeing the members of “High-Level Coordination Committee for the Prevention and Control of COVID-19” gives clue regarding the seriousness of government and their reluctant behaviour of utilizing experts. At planning level we should utilize our experts. Not utilizing our experts means devaluing the existing ones and trying to make the scenario worse. Making programs based on INGO’s and NGO’s advice and monetary fund only does not strengthen our health system as it won’t be free from bias. Thinking what Donors say only is true and implementing any program if aid is provided does not help to meet our local and national goals and needs.
Now, it’s high time to start reforming our health system taking COVID-19 pandemic as an opportunity. The Health Minister, Health Secretary or Secretary General of DOHS has been advocating that they have been working well. I thank them if they truly have been working for its management but the scenario does not seem so. They still have been working based on “Daily Wage Thinking” which can be seen by techniques of procurement of health related logistics, using the less useful Rapid Diagnostic Test kits to detect Corona virus infection, their attitudes towards Health Workers along with development of so called Corona Special (Temporary) Hospital at Bharatpur (at Chitwan Expo Centre), Butwal (at Thread Factory), Biratnagar (at National Training Building) etc. investing huge sum of money for temporary purpose. The budget could have been utilized to uplift the existing health set up making it as an opportunity to develop permanent structures upgrading the existing hospitals. Can this loss be compensated?
Till date we are on situation of lockdown for more than 45 days. This lockdown is a temporary measure to develop plans to tackle the problem thinking what if the problem rises exponentially. No effective achievement has been seen and concrete road map the government is heard. Even government is facing problem on increasing number of PCR testing to diagnose cases infected with SARS-CoV-2 virus. This lockdown period should have been utilized for mass testing along with locating risk areas and localizing the cases. Procurement delays and issue of corruptions on central procurement as well as at Corona Special (Temporary) Hospital of Bharatpur has raised further questions though the exact fact is yet to come. At the time of crisis, different stake-holders including the government, ruling parties, opponent parties, experts related to health and health management along with general public should focus on tackling with the existing problem but the circumstances does not seems so. Instead government diverted the situation for bringing political change rather than focusing on existing crisis which in return is making its position at risk. This vividly shows the priority of government is not the pandemic situation but the political position. Though this is not a time to play blame game but to be united and everyone should play their role from their respective position.
What can be done to make health system a firm and permanent structure may form a long list but some important among them are being discussed. First of all, the government should focus on developing permanent physical structures till possible rather than being happy on temporary infrastructures. The temporary corona hospitals are just few examples representing the tip of iceberg. Previously, many health centers are upgraded but the physical structure and manpower they are with are same. Just stating the hospital for previous Primary Health Care Centers (PHCs) do not cause increase on service and provide better facilities to the targeted population. This indicates paper upgradement rather than on reality.
This should be taken as opportunity to develop permanent human resources for health (HRH). What is the situation of existing health workers and how much is the need helps to determine the deficit number of health workers? Government has to work to develop permanent HRH rather than seeking advertisement for health manpower on Daily wages or Contract basis. It seems that government’s mindset has not progressed even in the situation of crisis. It has been long that the new post has not been created and vacancies has not been fulfilled as per the growth of population causing increasing deficit of health workers based on number of Doctor-Patient and Health Worker-Patient Status. Though the new posts are not created but existing vacancy is also not being fulfilled. Less manpower are providing health services causing excessive work-load decreasing quality of service provision. Let us take an example that government is not seeking permanent vacancies of Obstetricians to run Safe Motherhood Program who would even help to strengthen the health system but instead government is making wrong plea that the government have been investing excessively in the program but not getting the specialists so is focusing on Advanced Skill Birth Attendant (ASBA) trainings on Medical Officers (MOs) spending huge sum of money. The stake holders are not thinking critically that the so called investment is wastage of money. They never thought that the vacancy was not fulfilled as it was just tried to be sought temporarily on contract basis for few months. The cost incurred seems high as the SBA training is generally provided to Medical Officers on compulsory service for two years based on their entry as scholarship candidates of MBBS. The service being temporary one and that also they get the opportunity for ASBA training in near end of the service duration which provides less or even no time to provide the intended service. Even if it is provided to permanent Medical Officers they do not stick as MOs and should also not be compelled on it as academic growth of anybody should not be checked. They focus to pursue post graduate degree which is essential and genuine reason as well. In the context of Nepal, General Practitioners (MDGPs) should be recruited to strengthen the rural health system rather than focusing just only on Medical Officers or posting of Resident Doctors on name of community service. This shows if cost incurred does not fall on right path, it does not provide desired outcome and the system starts blaming one way or the other. Had the resources been utilized in proper way, it would have provided more benefit. Regarding the availability of health resources, the scenario at present is not the same as before where there was not enough skilled manpower within the country. Now if the country can utilize the skilled existing human resources and their proper distribution done, then it will definitely help in the upliftment of health status of the country. The state should not think it as expenditure rather should take as an opportunity of doing investment in health.
This is high time to reform health system as the country has entered into federalism and health system has also been influenced by it. The policy makers should make proper distinction on health manpower on preventive aspects and on curative aspects. They should be provided with concrete role based on field with separate chain of command and chance of professional development. The role provided should be based upon the expertise. Right person should be kept at right place. The work distribution should also be correct to get better result. The problem of improper distribution of health worker can be clarified by the practical example given. A doctor may be working at a PHC with role of doing postmortem. A letter of call for training on medico-legal issues is sent to District Public Health Office (DPHO). The designed heath worker who sees the whole district staying at DPHO is either not aware what medico-legal training is nor wishes to provide opportunity for concerned Medical Officer at PHC who could be benefited in providing better service to the area concerned. Similarly, every year DPHO is conducting vasectomy and tubectomy (a permanent method of female sterilization commonly known as minilap) camps within the country but still training on the same is being conducted but it is not properly distributed at desired places and if provided is also given late. Usually Medical Officers serving are the ones getting scholarship for studying MBBS who are supposed to work for two years on compulsory basis who get the opportunity of training generally near the end of their working tenure if provided also. It may be just the waste of resources as they may not get enough time to serve based on training obtained. The provision of late training is sometimes intentional as the concerned individual taking care of family health sector at district level can hire other health professionals on name of lacking concerned manpower to run the camps with them for the sake of manipulating economic benefit by hiring others. It even at times becomes compulsion because of late training due to system default. If the Medical Officers who receive such trainings do Residency on concerned subjects that may even be considered useful but such co-incidence does not happen usually leading to waste of resources. Also at times, to take training of minilap; Doctors of other specialties like Pediatrician working in the post of Medical Officer is sent to receive it which will never be utilized in his life time causing waste of resource in one hand and bypassing possible candidate in other hand. Similar is the reality of training opportunity for other sectors. Thus, from the government point of view they advocate that they have conducted such trainings and utilized but the investment is not on right track. So from these examples one can say just conducting any work does not give desired result. They should be provided to right person at right time.
The state should be more responsible to deploy health workers and by whom as well. One fifth or sixth level staff at DPHO deploying work to eighth level Medical Officer at the PHCs is not free of bias at times due to level differences. Similar is the issue between permanent Medical Officers and temporary, contract based or daily wage based Medical Officers. It may seem simple but the consequence it leaves is not as simple as is observed. So to decrease the problems, government should take this crisis as an opportunity to improve, strengthen or reform the health system in concrete sense. The government should recruit permanent manpower and also should focus on their distribution which can be done scientifically. There are different levels of health workers working from central level hospital to sub-health posts at rural areas. The different level of health workers should be distributed based on qualification not on political attachment. Proper hierarchy of them should be made which is also seen as a problem. Academic qualification should always get priority over trainings. Not all health workers are capable of providing curative services efficiently. Non-availability of Medical Officers at rural area cannot be the justification of providing paramedics providing curative service rampantly. Does Doctors work at remote places of Nepal always? This should not be justification for allowing paramedics to allow practice in haphazard way. The scenario at past and present is not the same. There should be proper guidelines when to allow and on what circumstances. It also does not mean to de-value the service provided by paramedics at rural areas. The work done at the time of need is praiseworthy. It should be made systematic and on hierarchy basis and should allow only for institutionalized practice which can check many pitfalls. If one is allowed private practice in haphazard way, it paralyses the system. There must be restriction on individual practice but allow institutional one based on hierarchy of manpower available. There should be gradual shift in providing quality and standard service provision. At time of crisis and difficulty, one level of health worker served does not mean that should be continued and that also at all places where better alternative is available. Their management should be done properly. The authority of need can be determined by State or Local level officials. If one thinks in conservative way, no system will be permanent and progressive and we cannot allow everyone to work on their own way without considering risk benefit status. Definitely it won’t give good result as well. So, proper check and balances and maintenance of proper hierarchy on work must be present. Service should be upgraded based on qualification, expertise, experience and skill providing due respect to those who provided services at the time when skilled manpower had no approach at rural places. Proper management and channel wise placement of every health professional is a must. If possible one health professional can be made to work at one health set-up only but it needs proper homework regarding the feasibility based on facilities that can be provided taking into consideration of existing situation as well.
The result of health system reform may not come on a day but will definitely give fruitful result in near future if the measures are thought seriously and taken care on time. Thus to reform the health system robustly, priority of government should fall on health sector and adequate budget should be provided. Local experts need to be utilized well. At technical places, there should be placement of technical manpower. Preventive and Curative services should have separate hierarchy and chance of professional development. Permanent health set up and health manpower should be thought off. Gradually less skillful manpower should be replaced by skilled and specialized ones. Trainings should be provided on time. Right person should be placed at right place at right time. Problem of clash among health workers needs to be settled via proper policy. Specialized centers should be developed at central or provincial level. Adequate remuneration and policy of “one health worker at one place” should be implemented. Policies and programs should be based on need rather than only on aid provided by NGO’s and INGO’s.
-(Obstetrician and Gynaecologist at BP SMRITI Hospital, Basundhara)