Healthy Future: From Inclusion To Equity

In times of climate crisis and socio-political tensions, there is a growing concern of global health security around the world. Developing countries are particularly struggling to regain the lost progress after facing COVID-19 pandemic, conflict, natural disasters and other crises. Unfortunately, vast majority of poor, socially excluded and vulnerable communities have limited access to essential health care within and across societies. 

Forecasting healthy future is a challenging priority in many developing countries. In this context, defining issues of federal health governance in Nepal are inherently multidisciplinary. Of course, connecting a range of stakeholders for a purposeful partnership is a challenging yet inevitable political process towards building resilient, equitable and sustainable health systems. Still, social inclusion and equity are key concerns to ensure easy access to quality health care for all. 

Legacy

While Nepal’s legacy of health sector is historically distinct, there are stories of both successes and failures that need to be told for public awareness, advocacy and community actions. The interweaving of voices of poor and socially excluded groups, such as indigenous communities, the disabled, the elderly, sexual and gender-minorities, are crucial to address a wide range of socio-cultural, economic and political inequalities that are consistently hindering equitable access to essential health services across provinces. 

More notably, universal health coverage is possible with inclusive health policies and strategic actions to reach out to the poor and vulnerable communities in rural and urban areas. However, Nepal’s federal health system still faces institutional bottlenecks and systemic barriers to ensure equitable access to quality health care at local level. The aim of harnessing a healthier and compassionate future for humanity is largely constrained by social, political, cultural, economic and environmental determinants of health in an increasingly connected world.  

Notably, the national health policy, 2019, and strategic plan (2023-2030) have a sharp focus on good governance, multi-sectoral approach, equity and social justice in the federal context. The strategic plan has envisioned health systems reform to improve efficiency and effectiveness in health care delivery. Moreover, the gender equality and social inclusion strategy seeks to enhance equitable access of poor, disabled, elderly and other socially excluded groups in health services by empowering them to demand their rights to health. 

In this context, the crucial role of provincial and local governments must be enhanced to effectively implement the national policies, strategies, and related guidelines at the local level. Moving forward, participatory and inclusive health planning should be a priority agenda of local governments to ensure no one is left behind. From an implementation perspective, there lack of clarity in terms of coordination, authority, transparency and social accountability at all levels.

In remote areas, local governments’ institutional capacity is further constrained by political instability, limited human resources, poor health infrastructure, inadequate financing, poor monitoring, recording and reporting systems for years. Despite constrained health financing, there is limited supportive supervision and monitoring from provincial and federal governments to facilitate the implementation of inclusive health policies, plans and community-based interventions at the local level.  

Despite notable progress, the institutional bottlenecks are barriers in driving change for improved health outcomes. Sadly, there are no concrete actions yet on the ground. Surely, this will continue to have creeping impacts on the performance of the health sector at large. Development partners are significantly contributing to improving health systems, but their support lacks continuity and sustainability. Like many other countries, Nepal continues to experience global health threats such as the COVID-19 pandemic, climate change, air pollution, disease outbreaks, communicable and non-communicable diseases, including post-disaster community recovery.

 In order to improve the health status of entire populations, we need to reshape sustainable health care models that are locally owned, innovative, more resilient and sustainable. Moreover, partnership with a range of stakeholders is vital in addressing persistent challenges of emerging health threats to co-create a more equitable society together. The inherent interconnectedness of health and environment reveals that planetary health needs to be harnessed for better health outcomes. Unfortunately, coordination and partnership within and beyond the health sector have still been overlooked for years. This is a deepening concern, but it is easier said than done. 

We often talk about the relevance of transparency and social accountability in the health sector. This is more compelling in the federal context. The established views and narratives of health sector reform need to be critically debated and reframed for transformative changes in federal health systems. It is crucial to explore how local governments identify their health priorities, allocate resources and create an enabling environment for multi-sectoral engagement and partnerships. 

Community engagement 

Undoubtedly, community engagement in health care plays a major part in people’s everyday activities. Anthropological perspective in health systems can be more helpful in understanding how local health facilities operate and are organised, how they communicate with the public, and how health care is delivered within and across communities. Equally important is to understand how different communities organise their social life, make sense of their health experiences, and how local narratives of health and illness are produced and reproduced.  

To sum up, inclusive health policies and strategic actions are crucial to achieve Nepal’s commitment to Sustainable Development Goals (SDGs) and realise the relevance of universal health coverage. In recent years, health in all policies is gaining momentum in policy debates as this approach values the crucial role of other sectors such as education, agriculture, environment, transportation, housing and urban development in addressing wider determinants of health. 

(Bhandari is a health policy analyst and has an interest in anthropology.)