Presentation entitled "Localization of Universal Health Coverage for Equitable Health Outcomes in Nepal" by Dr Shiva Raj Adhikari on the 18th Anniversary of Nepalt Health Economics Association.

1. 18th Anniversary
7 MAY 2016, KATHMANDU, NEPAL
“Localization of Universal Health Coverage for
Equitable Health Outcomes in Nepal”

2. We Come through All the Ways of
18 Years of Walk.
What have We Learned, So Far?

3. Localization of Universal Health Coverage for
Equitable Health Outcomes in Nepal:
Have We Find the Solutions?

4. Today’s Program
Time Activities
10:00 - 10:30 AM Registration, Tea/Coffee
10:30 - 10:40 AM Welcome and Opening Remarks - Deepak K Karki, General Secretary, NHEA
10:40 - 10:55 AM Milestones of NHEA - Dr Badri Raj Pande, President of NHEA
10:55 - 11:55 AM Presentation on “Localization of Universal Health Coverage for Equitable
Health Outcomes in Nepal” - Dr Shiva Raj Adhikari, Member, NHEA
Panel Discussion: “Localization of UHC for Equitable Health Outcomes in
Nepal”
Moderator: Dr Tirtha Rana, Member, NHEA
Panelists: Dr Ramesh Kumar Kharel, Director, PHCRD, Ministry of Health
Dr Devi Prasad Prasai, Vice President, NHEA
Prof. Dr Sharad Onta, IOM, TU
11:55 - 12:45 PM Discussion – Open for all
12:45 - 01:00 PM Remarks by Chief Guest - Hon’ble Mr Vijay Bahadur Kunwar, Member, NPC
Closing Remarks - Dr Badri Raj Pande, President of NHEA
01:00 – 02:00 PM Lunch

5. Localization of Universal
Health Coverage for Equitable
Health Outcomes in Nepal
Shiva Raj Adhikari, PhD
Deepak K Karki, MPH

6. UHC and Sustainable Development Goals
?
• 17 goals, 169 targets, 200+ indicators
• SDG 3 (health): 1 goal, 13 targets, 25+ indicators

7. Creating Synergistic Effects

8. Universality
SDGs
• Universality: every nation
… and every sector.
• Integration: inter-
connected (not related to
single goal)
• Transformation:
fundamental changes in
how we live on Earth
UHC (Umbrella goal for
health)
• Universal Coverage:
• Coverage with health
services;
• with financial risk
protection;
• for all

9. Why localization? Or Glocalization?
• Glocalization: a combination of the words "globalization" and
"localization"
(global product: how can we understand at the local level)
• There are opponents and proponents of UHC… it means different
things to different people
• Perspective/ way of thinking about UHC (among policy makers)
• Understanding of service providers
• All services should be provided by the government?
• What is the role of private sector?
• Understanding of service users
• All services should be provided by free of cost? Why discrimination among
the citizen?
• National context (fiscal, administrative, political, social) conditions
both what can be achieved and what can be implemented

10. Fundamental Rights
• Health is a fundamental right as mentioned in the
constitution
• “All human rights are universal, indivisible and
interdependent and interrelated.
• The right to health does not only mean we have a right to be
healthy. However, the state does have a duty to promote
health services, provide access to health care and to
facilitate access to the conditions needed to be healthy.

11. Understanding UHC
• Political process/will
• Health systems engineering/strengthening
• Health care financing
• Social determinant of health

12. Cube of UHC
 Public health community focus on key health services
 Economists focus on financial protection/catastrophic
and impoverishment impact
 Cube clearly marries these two perspectives…

13. Architecture of UHC: Power of Financing
Covering all services but not population
Financial coverage but not
population and services
Population coverage but not
Services and financial

14. Health Financing Policies
Universal
Health
Coverage
Cost/Affordability
(Efficiency)
Quality
(Effectiveness)
Access (Equity)
Health financing policies
that promote equity,
efficiency and effectiveness,
and ensure that the rights of
the most vulnerable are not
forgotten

15. OOP & Government Health Spending

16. Per Capita Income and Total
Government Spending

17. 0
1
2
3
4
5
6
<10 10-20 20-30 30-40 40-50 50-60 60-70 70<
PercentageofHouseholds
Out of pocket payment as % of THE
Effects of OOP on Catastrophic
and Impoverishment Impact
Financial catastrophe Impoverishment impact
Linear (Financial catastrophe) Linear (Impoverishment impact)

18. Fundamental rights Federal
Government
Provincial
Government
Federal and
provincial
Government
Local
Government
Right to healthcare:
1) Every citizen shall have
the right to seek basic
health care services from
the state and no citizen
shall be deprived of
emergency health care.
2) Each person shall have
the right to be informed
about his/her health
condition with regard to
health care services.
3) Each person shall have
equal access to health
care.
4) Each citizen shall have
the right to access to
clean water and hygiene.
Central health
policy (setting
standard, quality
and monitoring of
the health services,
national/special
service provider
hospitals,
traditional
treatment services,
control of
communicable
diseases
Insurance policy
Health
services
Family planning and
population
management ,
medicines ,
Insurance operation
and management
Basic health and
sanitation

19. Mentioned in the Constitution
• Optimization of human rights
• Fundamental rights:
• Basic health care (can be defined by the local
government) that is related to Local level
government
• (this is not the role of central government)
• District level court

20. What is Access?
• Geographical equity: Tarai access high catastrophic
also high
• Geographical access does not work for family
programming services for Muslim community (blanket
policy does not fit)

21. (Intended and Unintended)
Effects of Policies
• Free health care: increased utilization but catastrophic
payment and impoverishment impact?
• Introducing health insurance or reducing user-fees
does not necessarily reduce out of pocket payments
• Target achievement policy (Muslim community)

22. Financing Options
• Using market/existing
system/path dependent)
• Creating market/
new system

23. Health System Efficiency
 Efficiency gains would effectively result in increasing
the available funds for health by 20-40%. i.e.
substantially more health for the money could be
obtained by reducing inefficiency
 Management (style) matters to improve health
systems (hospital) performance

24. Distribution of Management Score
in Public and Private Hospitals
Public hospitals Private Hospitals
Average management score was 2.1 The management score for
private hospitals (2.08) > public hospitals (1.94). However, No
statistically significant.

25. Bed
occupancy
rate
Total
impatient
days
IP-
practice
score
Impatient
days per
technical staff
Recurrent
expenditure per
impatient day
Estimate 0.319 0.210 0.161 0.303 -0.171
Robust
Std. Err.
0.092 0.075 0.080 0.090 0.108
t-value 3.470 2.790 2.020 3.360 -1.590
p-value <0.001*** 0.007** 0.047** 0.001** 0.117
R-
squared
0.470 0.650 0.570 0.560 0.340
* 10%, **5%, ***less than 1%
Relationship between Hospital Performance
and Management Practices

26. So, Let’s Explore How to Explore to
Localization of UHC in Nepal
• Human Centered Approach
• Quality Service Delivery to
People is the Key
• Equity is Outcome; it is to
Ensure the Process; it is the
Determinants of Health; it
is …. so forth and so on

27. Because, Localization of UHC is the
Call of the Day
• Clear understanding !
• More robust evidences !
• Leading by local people (local evidence)
• The path to UHC must be home grown

28. Thank You for Your Interest !