Local health facilities are now supposed to be managed by municipalities themselves, but even while the budget from the centre has been cut, they have not been given the authority to raise enough local taxes to pay for these services.
“The central government still controls the budget, which makes it difficult to meet local needs,” admits Baburam Marasini, the former chief of the Epidemiology and Disease Control Division. “This means most local governments do not have the wherewithal to make the necessary policies, budgets, plans, and implement them.”
Before 2017, it was the district health office that made all health related plans and polices under direction from the national government. With federalism, there is confusion about budget and jurisdiction that has not been cleared up in the last five years.
“There is no consistency in policy and implementation,” laments former health secretary Senendra Raj Uprety. “Most local officials do not possess the qualifications or experience to draw up proper budgets.”
Nepal set aside Rs141 billion for healthcare last year of which the largest chunk (74%) was for the federal level, only 5.16% for provinces, and 20.93% for municipalities.
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Local government budgets are not enough to address needs at the grassroots. Health specialist Kedar Baral says the pressure on central hospitals can only be lessened by decentralising quality health care and making it more affordable.
“If we do not improve the primary service, not only does access to health become more expensive, but the entire system can collapse,” he adds.
Aside from municipalities that have prioritised health, other local governments have wasted money on unnecessary infrastructure, buildings, or view towers.
The reason local officials are not too interested in investing in health is because it takes up to two decades for returns on investment, remarks Guna Raj Awasthi of the Far-West Health directorate.
WHO recommends that low-income countries must invest $83 per person per year in the health sector. In Nepal, this figure is a woeful $17.3 per person.
According to the Nepal Health Sector Strategy 2015-2020, 31% of people are forced to travel to city hospitals, to pay above their means for essential services that should have been provided free locally.
Says Marasini: “The increase in the number of admissions at hospitals in Kathmandu means that local health centres have failed. Otherwise, why would anyone spend five times as much for treatment in Kathmandu?”
Translated by Ashish Dhakal from the Nepali original in Himalkhabar monthly.
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