Lack of coordination with other agencies hampers services to be delivered by constitutionally empowered local federal units. Medicine shortage faced by state-run health facilities in Kalikot, Bajura and Baitadi districts speaks volumes.

-Prakash Singh, Bajura/Baitadi, Tularam Pandey, Kalikot: Centre for Investigative Journalism-Nepal

Health centres in the remote Bajura, Baitadi and Kalikot districts are ailing. Since they have run out of medicines, the health facilities are unable to treat patients. Local people have been robbed of their fundamental right to health as the authorities fail to maintain the stocks of essential drugs and equipment. Ironically, this happened after the local governments got charge of the health facilities following the local level elections earlier this year.

• Gangaram Luwar of Budhinanda Municipality Ward No 1 in Bajura was returned from the Kolti Primary Health Centre without treatment last month. He had been taken there after a week of high fever.
• When Dharma BK of Budhiganga Municipality-10 took his son having a severe bout of diarrhoea to the Barhabise-based health post, he found no medicine. Health workers had only oral rehydration salts to give him.
• Rana Bhandari of Bajura found no medicines for fever at the Rugin health post in Himali Rural Municipality. The sick person had to trek three hours to Kawadi Bazaar for buying antibiotics at a private drugstore.

The patient  from Budhinanda Municipality was taken to hospital for treatment.

These are but a few representative cases of hardship people are facing as the public healthcare system got worse after decentralisation of power. The central government handed the charge of health posts, primary health centres, community health units, urban health centres and Ayurved centres to the local governments on August 26. Since then the local federal units are responsible for managing the health facilities and their services. The federal government now sends funds for their operation to the local governments. As in Bajura, Baitadi and Kalikot districts, numerous municipalities and village councils across the country have failed to procure drugs and medical equipment.

Padam Baduwal, mayor of Badimalika Municipality in Bajura, said the Rs230,000 released by the central government to them was not enough to buy medicines. The Health Institution Handover Directives (2074) issued by the Health Ministry requires the local level to purchase drugs by “mobilising other resources” if the grant money is insufficient.

The health centres have failed to honour the provision in the directives that health services may be denied under no circumstances. People are at the receiving end of the health institutions not maintaining drug inventories citing inadequacy of funds. Deputy Mayor Shristi Regmi of Budhinanda Municipality in Bajura admits that the health centres have been without drugs due to their inability to plan on time. “The municipality has no staff. Since there are no plans, the budget has not been released,” said Regmi.

The health facilities in Baitadi are no better off. District Health Office chief Dr Gunaraj Awasthi said the Dashrath Chand Municipality had not heeded their calls for providing essential medicines and health materials. “We submitted a 61-page form to the municipality to replenish supplies after facing a shortage of drugs and health equipment,” said Awasthi. “We made our requests in writing and verbally but the people’s representatives ignored us.”

The remote Kalikot district grapples with similar problems. District Health Office chief Dr Kaushal Ali said the local level receives funds from the centre but does not supply it to the health office. “The local units say the funds are meant for particular localities. There’s no budget for the District Hospital,” said Dr Ali. Officials at other local government units argue that operation and management of the district hospital is the responsibility of Khadachakra Municipality, Dr Ali added.

Officials at Khadachakra Municipality, where the hospital lies, have their own argument. Since the hospital is for the whole district, they would not meet all the expenditures alone. Mayor Pande asks all the local authorities to help since the hospital serves patients from all over the district. Triveni Village Council Chairman Dambar Bahadur Shahi is of the view that since the district hospital is situated in Khadachakra, the municipality must provide funds for its operation.

The handover directives require the local level to coordinate with the District (Public) Health Office in matters related to health. According to the rules, the Health Office purchases medicines for distribution among the local federal units on priority basis. In the western hill districts of Bajura, Baitadi and Kalikot, this coordination between the local governments and health offices seems to be lacking.

Mohammad Daud, chief public health administrator at the Health Ministry and coordinator of the federalism implementation unit, stresses coordination between the erstwhile District Health Office and the local level to ensure availability of medicines in health facilities in the context of health organisations having been handed over to the local level and provincial governments yet to be formed.

“The local level lacks capacity and expertise to procure drugs and health equipment,” said Daud, highlighting the need for coordination between the District Health Office and the local level. He believes that the Health Office should aid the local level in drugs purchase while the local governments need to cooperate with the Health Office in order to avert medicine shortages.

As the local units and health organisations fail to work in tandem on treatment services, the common people lack access even to paracetamol. This compels the people in remote hill districts to walk for hours to private hospitals to buy basic drugs paying high prices even for those otherwise available at public health facilities free of cost. This shortage has troubled expecting and post-partum women who need to visit health centres regularly. Expecting mothers are not getting iron supplements.

Sakkare Luwar (left) was taken to Kolti Primary Health Centre in Bajura with high fever, but returned without treatment because it had no medicine because of post-poll confusion about jurisdiction.

Following complaints of the shortages, the Health Ministry on September 18 directed the local governments, District Health Offices and District/Zonal Ayurved Health Centres to make necessary drugs and health equipment available. The ministry also wrote to the local federal units to maintain stocks of 70 essential drugs immediately for free distribution among patients.

The local governments in Bajura and Baitadi have not followed these instructions. As a result, health centres have run out of drugs. Baitadi Health Office chief Awasthi said all the health centres in the district are grappling with medicine shortages. “Stocks have run out. We need money for fresh purchases but the local level does not release funds,” he said.

Dipak Shah, health coordinator for Budhiganga Municipality, blamed the delays in procurement on the local representatives’ lack of realisation of the urgency of health service delivery. This has led to the chaos in health services, he observed.

Health practitioner Satya Shahi at the Bajura-based Kolti Primary Health Centre said there was confusion over the jurisdiction of the local federal units. “With the establishment of the local level, confusion was born over which agency does what,” Shahi said about the failure to purchase drugs. Chief public health administrator Daud holds both the local governments and District Health Offices responsible for supply management until the provincial government takes shape. He made it clear that the government has already released funds for the purpose.

Health centres and health posts in Bajura are relying on limited amounts of medicines donated by non-government organisations. “We’ve been rationing medicines provided by an NGO called Phase Nepal to patients,” said Shahi, adding that the local government had not provided a single kind of medicine.

This dearth of resources has hit other health programmes in the district too. Public Health Officer Ramesh Kunwar at DHO Bajura said other health schemes had been affected in the district since the municipality has not released the budget. According to him, the Rs400 allowance for expecting women given during regular check-up, Rs1,500 provided to encourage women to visit health facilities for delivery and the Nyano Jhola containing warm clothes have been withheld at present. “We try to give the allowances and Nyano Jhola with our internal resources as far as possible,” said Kunwar, “but they cannot be given to everyone this way.”

The programmes not being effectively carried out at the moment include leprosy eradication, family planning, safe motherhood, tuberculosis control, children’s health, nutrition programme, immunisation campaign, iron supplements for adolescent girls, health education, HIV/AIDS control, school nutrition education and health camps, according to Kunwar.