Six months into office, Minister for Health Gagan Kumar Thapa has launched a series of policy reforms in the health sector. A popular youth leader of the Nepali Congress, Thapa has pulled up his weight to carve a similar image as minister. Many of his welfare decisions are intended to benefit the poor, needy and disadvantageous groups. A Master’s degree holder in Sociology, he hogged the political limelight with his rousing speeches against the rule of king Gyanendra. He was ahead of the party in advocating the republican system.
Minister Thapa spoke to The Rising Nepal on his decisions and actions that have often made headlines. Excerpts.
What are the major changes that you have presided over in your six months in office?
When I assumed office, I found the Health Ministry enmeshed in various institutional problems. Entropy ruled the roost at the ministry, and I got down to business from zero level so as to lay the foundation of health services provided by the state to the people. I asked the ministry’s officials to provide the details of doctors working under it, but ironically the ministry is clueless as to how many doctors are currently working under our system. Unable to get data of the doctors despite repeated queries, I finally stopped asking the officials about it. I came to know first-hand how our health system is functioning. The shambolic state impelled me to vigorously pursue systemic reforms in the ministry.
We have now projected that construction of all health infrastructure would be completed in seven years. Currently, there are 10,000 posts for nurses across the country. As per our projection, if we add 10,000 more posts, this will meet the demand of the nurses. However, it will take seven years to produce around 10,000 nurses in Nepal. This shows the false projections that we are making. The ministry should come up with a clear plan as to the medical human resources it need and recruit. Similarly, there is no study of the production and management of doctors and ambulance services, among other things. I have already formed policies regarding the human resources, building of health infrastructure, providing ambulance services and medicine procurement. I am working in a way so that the next health minister, who succeeds me, will not have to ask officials about the details and functioning of the ministry.
Would you highlight some major changes the ministry has witnessed under your leadership?
The curative side of major chronic diseases had so far been ignored. I have taken decisions to strengthen the curative health service, such as providing free valve transplantation for rheumatic heart patients and free kidney transplants. These free health service are not totally new, however. The government had already provided free valve transplantation to people below 15 years of age. But people in the productive age-group were left out. A young person suffering from rheumatic disease can live a productive life after heart valve transplantation. I have only tried to give a new lease of life to them. The government has been providing free dialysis services to the patients with kidney failure. From the economic point of view, kidney transplant is more cost effective than free lifelong dialysis. A patient can live a normal and active life after undergoing a kidney transplant.
The health sector has achieved some tremendous gains in the field of maternal and child health because of the preventive policy adopted after the 1990 political change. We met the international commitment by reducing the child and maternal mortality. Now, we have to do many things in controlling non-communicable diseases.
Providing free service alone is not the solution. I used to question myself many times: How can Nepal provide and sustain free kidney transplant service when the United States, one of the richest nations, is unable to do so? However, I decided to start by utilising the existing and unused funds. and in long term we will focus on the preventive measures. The decision has not put any extra financial burden on the national coffers. The ministry is to start conducting urine tests of school level students from this fiscal year. A simple urine test will help people find out the condition of the kidney and prevent related diseases. They can undergo a urine test for Rs. 250 at the Bir Hospital, but most of the people do not go for that. We will bring out plans, urging the people to go for a simple urine test at least once a year.
Following the recent road accident in Jajarkot, I came to know that the district hospitals do not have the capacity to carry out full-fledged emergency services. So I am mulling over enhancing the institutional capacity of the district hospitals so that they can provide emergency services during big road accidents and natural disasters.
Some media have claimed that the bureaucracy has not cooperated with you in your mission to bring change. What is your comment on it?
I don’t want to blame any individual. I don’t believe that anyone has put a spoke in my wheel of change. If I fail to take them (bureaucrats and health workers) into confidence and muster their support for the implementation of the programmes, it is me to be blamed.
Our bureaucracy is accustomed to working in a comfort zone and not doing anything new that is risky or demands hard work. However, I have the habit of enjoying while accomplishing challenging work and delivering something new and fruitful to the society. That’s why a kind of difference between the bureaucracy and me has surfaced when it comes to the working style. On the other hand, I came from a political movement and want to break ground in the health sector. The bureaucracy tends to indulge in routine works. I have a passion for change and have urged all to put their best foot forward. I want the bureaucracy not to pour cold water on my sprit and speed.
It is said that some of your decisions lack adequate homework and have drawn controversy. For instance, the ministry has issued directives to the doctors to run general OPD from 10 am to 4 pm in government health institutions, and expand the surgical OPD services in the district hospitals. But the announcement came a cropper for lack of proper institutional bases.
No. Any doctor working in a government-run health facility should compulsorily work in the OPD from 9 am to 3 pm. I have increased their allowance by 50 per cent for that. I had proposed providing 100 per cent allowance to them, but the Ministry of Finance did not agree on this. I am committed to increasing their allowance by 100 per cent from next year. I am not grilling them about where they work before and after the given duty hours. But they must attend and serve the patients from 9 am to 3 pm at all cost. Should they be absent or be found serving outside the hospital during their duty time, I will cancel their license.
My plan to extend surgical OPD service (specialty care) to the patients visiting the district hospitals from February 12 has been delayed partly owing to the non-cooperation from the doctors. Agreements have been reached with the National Academy of Medical Sciences, Bir Hospital, the Institute of Medicine, Maharajgunj, the BP Koirala Institute of Medicine, Dharan and 13 districts hospitals in Sarlahi, Gorkha, Dhading, Rolpa, Udayapur, Dhankuta, Arghakhachi, Nawalparasi, Mahendranagar, Saptari, Dang, Nuwakot and Baglung to commence this service. However, the surgical OPD will start within a week and preparations are going on.
Your schemes to oblige all private health institutions to provide free services to 10 per cent of the visiting patients as well as their compulsory registration seem to be ambitious. As the ministry does not have sufficient resources to bring all the private health institutions under its umbrella, how can you implement them?
The private hospitals are also our hospitals as they are running with the permission of the ministry. Ambiguous policies are to blame for the failure of these decisions. The private hospitals should provide free service to 10 per cent of the patients, but the kind of services has not been included in the provision in it. It also lacks clarity regarding the monitoring and implementing agencies, and reward and punishment provisions. It has been difficult to enforce these decisions due to lack of specific rules. The private hospitals have flouted the directives in the absence of monitoring and a legal framework. Now, we have stepped up measures to implement them very soon. We are unveiling the provisions that will mention who will get the free services and what type of punishment will be slapped on the hospitals for flouting the rules.
The ministry recently suspended 18 health workers for obstructing its anti-polio programme. Doesn’t this indicate that anarchy is rife in the health services?
I was speechless by the inhuman act of the health workers. I just thought – could the Nepalis descend to such a level? I am also from the political movement. But we had allowed ambulances to pass even at the height of the political unrest. We, Nepalese, can’t be callous to such an extent. We are kind-hearted people, who weep over the dead bodies of people. I was crestfallen by this incident that show how the Nepali society has degenerated.
The people prefer to go to the private clinics and hospitals, and are ready to pay exorbitant fees as the government hospitals are crowded and unable to serve all visiting patients. How can the condition of the state-run medical facilities improve?
This is because of our weak referral system. The district and zonal hospitals do not meet the basic standards. Ambulance service is not available in the zonal hospitals. Likewise, the district hospitals are unable to provide proper maternal service. This has caused a crowd in the Kathmandu-based hospitals. The ministry is working at full throttle to build the capacities of the district and zonal hospitals so that many people will get standard services in their own home districts.
Likewise, I have asked all the big hospitals, such as Bir and Gangalal hospitals, the extra funds they need to extend their services and install advanced equipment needed to provide the extended services.
It has been perceived that your ministry is infested with corruption. Even at the local level, the nexus between the store-keepers and drug has give rise to fiscal irregularities. How do you intend to check them?
Yes, I agree with you. Transparency International’s report also shows that the Ministry of Health ranks second in the corruption index after the Land Revenue Office. A store-keeper continues to work in the same store for 18-19 years. There is nexus from the lower to the higher levels. However, I don’t want to blame anyone. We have no system in place to punish and reward officials according to their performance. If we build a reward and punishment system, any employee involved in malpractice will not be allowed to go scot-free. That is why I am working to enforce an auto transfer system.