Increased access to basic healthcare in Nepal

Nepal has made impressive progress in health, in particular achieving significant reductions in both maternal and child mortality rates. But progress at the national level masks worsening disparities, especially in maternal health across wealth quintiles, social groups and geographic location. Overall, around 22 percent of the population still lacks access to basic health facilities. Across social groups, it is generally Dalits from the Terai (plain areas) and Muslims who fare worse in terms of health care utilisation and outcomes.

The evolution of free health care

The Nepal Government is committed to form an inclusive society where people of all ethnic groups, gender, caste, religion, political orientation and social economic status enjoy equal rights without discrimination. In a significant step to realising this commitment, in 2007 the Government endorsed health care as a basic human right in the Interim Constitution.

This was quickly followed by a policy of free care, which expanded incrementally. In 2009 universal free care (covering a range of basic services) is available at primary health care centres, health posts and sub-health posts and all women have free deliveries. Targeted free care for the poor and vulnerable is also available at district hospitals. Since 2007/08, the Government has underpinned its commitment to health care free at the point of delivery by increasing the budget allocation by 24%.

Impact and challenges

The policy is showing results. There are already indications that the poor and most vulnerable groups are using more services. Facility surveys conducted in 2008 and 2009 show that

* The poor have increased their use of inpatient care by 280% - however, the number of people coming to them is still very small;

* Women have also increased their use of inpatient care by 12%; and

* There was a 19% increase in Dalits using outpatient care.

But challenges remain, partly as a result of the speed at which the policy on free care was implemented. For example, most users - and especially the poor - were not aware of free care, and some of the poor registered themselves as non-poor and so paid fees. In addition, there were more stock-outs of essential drugs lasting more than one week at all levels - hospitals, primary health care centres, sub-health posts and health posts.

DFID's role

DFID has been the largest bilateral donor to the health sector for the past six years. It has provided technical assistance to the Government in developing the free care policy and guidelines, communications and in monitoring implementation. In the future, it will continue to support the development of a comprehensive health care financing strategy.

Key facts

* DFID has been supporting the health sector since the late 1990s. It has been the largest bilateral donor to the health sector for the past six years, providing £71 million of UK aid. From 2004 to 2010, DFID provided £33 million in sector budget support and technical assistance to NHSP-1 alongside money from the World Bank and AusAid.

* In Nepal the maternal mortality ratio has almost halved from a reported 539 maternal deaths per 100,000 live births in 1996 to 281 deaths per 100,000 live births in 2006 (DHS 1996, 2006 surveys). The under-five child mortality rate has declined in rural areas from 143 per 1000 live births in 1996 (DHS 1996) to 50 per 1000 live births in 2009 (NFHS 2009). The Infant mortality rate has declined from 95 per 1000 live births in 1996 (DHS 1996) to 41 per 1000 live births in 2009 in rural areas (NFHS 2009).

* Universal free care is available at all facilities below the district hospital (primary health care, health post and sub-health post) level, free deliveries for women and 40 essential drugs. In addition targeted free care is available for the poor and vulnerable at district hospitals and includes free in-patient, out-patient and emergency care.

* The Nepal Government has increased its budget allocation to health by 24% - from $9.2m in FY 2007/8 to $11.4m in FY 2008/9.