✍️ Upendra Raj Dhakal
History of global health politics
The complex nature of health politics, both globally and in the Nepali context, is a multifaceted issue that requires a grounded approach. It involves examining the interplay between political, social, economic, and cultural factors that influence the provision of healthcare services and the management of health systems. At the global level, health politics is characterized by a range of complex issues, including healthcare financing, healthcare access, and healthcare quality. These issues are influenced by political factors such as international trade agreements, political ideology, and geopolitical power struggles, as well as social and cultural factors such as demographics, migration, and globalization.
In the Nepali context, the complexities of health politics are further compounded by the country’s unique political and economic landscape. The Nepali health system is shaped by issues such as poverty, social inequality, and political instability, as well as cultural factors such as traditional healing practices and beliefs. In order to understand the complexities of health politics, it is necessary to take a grounded approach that considers the local context and the specific challenges faced by different communities. This may involve examining the impact of social and cultural factors on health outcomes, as well as the role of political and economic structures in shaping healthcare delivery.
For addressing the complex challenges of health politics, it requires a comprehensive and integrated approach that considers the interrelated and interdependent nature of the many factors that influence healthcare provision and management. It is necessary to understand the global health politics, if we are concerned in addressing specific health issues. There were different types of practices, often unethical in the span of time. Most of activities were influenced by the power of the individual, community and country which were later guided by political ideology.
The history of health power struggle is a long and complex one that has spanned many centuries and regions of the world. Throughout history, individuals and groups have vied for power and control over health-related issues, often resulting in conflict and struggle.
One of the earliest examples of health power struggle can be traced back to ancient Greece, where physicians competed for prestige and authority in the medical field. This competition often led to disagreement and infighting, with each physician promoting their own approach to medicine. In ancient Greece, health politics were dominated by physicians who competed for prestige and authority in the medical field. These physicians were often members of wealthy families and enjoyed a privileged position in society. The Hippocratic Oath, which was developed by the Greek physician Hippocrates in the 5th century BCE, set ethical standards for physicians and established the importance of patient care and confidentiality. However, despite this code of ethics, competition among physicians was fierce, and disagreements were common.
In Athens, the most prominent physician was Hippocrates’ son-in-law, Polybus. Polybus established a medical school in Athens, which became the leading institution for medical education in Greece. However, other physicians, such as Herodicus of Selymbria, opposed Polybus’ approach to medicine, promoting instead a focus on physical exercise and diet. This competition between different schools of medicine continued throughout ancient Greece, with different physicians and philosophers advocating for different approaches to health and healing. The philosopher Plato, for example, believed that health was a result of balance and harmony in the body, while the physician Galen emphasized the importance of anatomy and physiology. Despite these differences, however, there was a consensus among physicians that medicine was a noble and important profession. Many Greek physicians believed that the pursuit of health was central to the human experience, and that it was the responsibility of physicians to help people achieve good health and well-being.
The history of health politics in ancient Nepal is a complex and fascinating subject. Much of this health-related history has been lost to time, but there are few evidences to suggest that health and medicine played an important role in ancient Nepali society. One of the earliest known texts related to health and medicine in Nepal is the Ayurvedic text, the Charaka Samhita. This text, which is thought to date back to around 400 BCE, contains a wealth of information on traditional medical practices, including herbal remedies, dietary advice, and surgical procedures. Ayurveda emphasizes the use of natural remedies and herbal medicines, along with dietary and lifestyle changes, to promote healing and prevent disease. It was common for healers to be associated with particular temples or religious orders, and medical knowledge was often passed down through families or guilds. The ancient Nepali caste system also played a significant role in healthcare provision. In ancient Nepal, the provision of healthcare was closely tied to religious and social structures. Certain castes, such as the Baidya caste, were traditionally associated with the practice of medicine and held a privileged position in society. This caste-based system of healthcare provision persisted for many centuries, with healers from lower castes often facing discrimination and marginalization. Despite these challenges, healthcare provision in ancient Nepal was often innovative and advanced for its time. The use of herbal remedies, for example, was widespread and sophisticated, and many traditional practices are still used in Nepal today.
There were some malpractices in health, among which few are still carried. Treating the patients by bloodletting was a major practice in ancient era. Bloodletting (phlebotomy) involves the intentional removal of blood from a patient’s body as a means of treating various conditions like fevers, headache, respiratory problems and even hypertension. While bloodletting was a common medical practice in many cultures throughout history, it is now known to be ineffective or even harmful in most cases, though has been found even practiced in high hills. Another practice that might have been considered unethical in modern times was the use of certain animal products such as rhino horn, tiger bone, even direct swallowing of slugs, cow urine, crushed frog with honey, cow dung, clarified butter, bone marrow, etc in medicine.
Globally, the power struggle over health shifted to Church during Middle Ages. It was guided by the Christian science theory, which says to extract bad evil from the body. It is considered less scientific as modern medicines also derives certain extracts from the body during the process of treating certain diseases. Churches were given tremendous power over the health of the people, which they used to maintain their authority. Medical practices were often based on religious beliefs and superstitions, and the Church had a significant amount of power over the practice of medicine. The Church established hospitals, which were often run by religious orders such as the Knights Hospitaller and the Order of St. John. These hospitals provided care to the sick, but also served as a way for the Church to maintain control over the practice of medicine. Medical schools were often associated with universities and were overseen by the Church. However, there were also independent medical schools, such as the Salerno School in Italy, which was one of the most prestigious medical schools in Europe during the Middle Ages. One of the most significant medical texts of the Middle Ages was the Canon of Medicine, written by the Persian physician Avicenna in the 11th century. This text, which was widely translated into Latin and other European languages, had a significant impact on medical education and practice in Europe. In the later Middle Ages, the practice of medicine became more professionalized, with the establishment of guilds and medical associations. These organizations were responsible for setting standards for medical practice and education, and for regulating the behavior of physicians.
In Nepal, traditional healing practices played a significant role in maintaining the health of the population. Traditional practiceners were specially tied with religion. Ayurveda was widely practiced during this time. Buddhist monasteries also played a significant role in promoting health during the Middle Ages. Monks were trained in traditional medicine and provided healthcare services to local communities. They also established monastic hospitals that provided free healthcare to the poor and marginalized. During this period, the ruling class also played a role in health politics by providing financial support to monastic hospitals and promoting the use of traditional healing practices. The kings and queens of Nepal were patrons of Ayurvedic medicine and supported the development of traditional medicine by establishing schools and universities that offered courses in Ayurvedic medicine. Additionally, there were some traditional healers in Nepal who used potentially harmful substances or methods to treat illnesses. For example, some healers even used mercury or arsenic in their remedies, which can be toxic if not administered properly.
In the 19th century, the rise of modern medicine led to a new power struggle. Doctors and scientists began to challenge the traditional approaches to health and medicine, which led to conflicts with established medical institutions and practitioners. The 19th century saw significant developments in health politics and public health policies in many parts of the world. In Europe and North America, there was growing concern about the health of urban populations, as cities grew rapidly and living conditions became increasingly crowded and unsanitary. One of the most significant developments in health politics during this period was the establishment of public health systems. Governments began to take a more active role in promoting public health, by investing in sanitation systems, creating public hospitals, and regulating medical practice. In England, for example, the Public Health Act of 1848 established a system of local boards of health, which were responsible for ensuring clean water supplies, sewage removal, and other public health measures. In the United States, the 19th century saw the development of the first public health agencies, including the U.S. Public Health Service, which was created in 1798 to provide medical care to sailors. In 1879, the National Board of Health was established, which played a significant role in controlling infectious diseases and promoting sanitation. In addition to these government-led initiatives, there were also significant advances in medical science during the 19th century. This period saw the development of anesthesia, which made surgery safer and more effective, as well as the discovery of many new drugs and treatments. There was also growing interest in public health research, as scientists began to study the causes and prevention of infectious diseases. However, progress was not uniform across all countries or populations. In many parts of the world, particularly in developing countries, public health systems were underdeveloped or non-existent, and many people lacked access to basic medical care. In addition, there were significant challenges to implementing public health policies, including resistance from medical professionals, political opposition, and a lack of resources. Overall, however, the 19th century saw significant progress in the development of public health policies and the establishment of public health systems, which laid the groundwork for many of the health policies and practices that we take for granted today.
Mega wars like WW 1 and WW2 happened during this period. During the periphery of war, many trials had been conducted. Nazi doctors conducted experiments on concentration camp prisoners without their informed consent, often using painful and dangerous procedures. Doctors exposed prisoners to extreme temperatures and pressures to test the limits of human endurance. Doctors injected prisoners with infectious diseases, such as tuberculosis and typhus, to test the effectiveness of new drugs and vaccines. Doctors conducted experiments on twins, often subjecting them to painful and dangerous procedures, in order to study genetics and heredity. It was later addressed by Nuremberg Code. Similarly, Tuskegee Syphilis study, Willowbrook Hepatitis Study, vaccine trial in Nigeria, etc were conducted which were addressed by Helsinki declaration. Children were used in trial during meningitis outbreak, where 6 healthy volunteers had suffered seriously and is addressed by Good Clinical Practice (GCP). Experiment done in Stanford involved participants in psychological harm and mistreatment without adequate safeguards. Similarly, Milgram Obedience Study, in which participants were deceived about the true nature of the research and subjected to psychological stress.
Recently, the Cambridge Analytica scandal was into surface about leaking the personal data and being used for political purpose. It was addressed by Belmont Report. Additionally, the Roche Tamiflu trials have been criticized for failing to disclose all relevant data and for potential conflicts of interest involving the researchers and the pharmaceutical company.
In the 19th century, Nepal was ruled by the Rana dynasty, who held absolute power and control over the country’s political and social affairs. During this time, the healthcare system was limited and inadequate, with only a few hospitals and dispensaries in the capital city, Kathmandu, and other major towns. The Rana rulers were not particularly interested in improving the healthcare system, as they saw it as a low priority compared to other matters such as military and political power. However, some efforts were made to modernize the healthcare system, mainly through the establishment of a medical school in Kathmandu in 1918, which trained doctors and nurses in Western medicine. The healthcare system in Nepal at this time was largely influenced by traditional and Ayurvedic medicine, which were prevalent among the general population. Traditional healers and practitioners played a significant role in providing healthcare services, especially in rural areas where access to modern medical facilities was limited. Despite some attempts at modernization, the healthcare system in Nepal during the 19th century was largely inadequate and failed to meet the needs of the population. It was not until the mid-20th century that significant improvements were made, with the establishment of more hospitals, clinics, and medical colleges, as well as the introduction of government policies and programs aimed at improving public health.
Health as a commodity
The idea that health is a commodity is a controversial theory that suggests that healthcare is treated as a product to be bought and sold in the marketplace, rather than a fundamental human right. Proponents of this theory argue that healthcare is increasingly subject to market forces, with healthcare providers, pharmaceutical companies, and insurance companies all motivated by profit and the bottom line. Critics of the theory argue that healthcare is a unique service that cannot be fully commodified like other goods and services, as it is tied to people’s physical and emotional well-being. They argue that healthcare is a basic human right and should be accessible to all, regardless of their ability to pay. The debate over whether health is a commodity is closely tied to broader debates over healthcare reform, the role of government in providing healthcare, and the ethics of healthcare delivery. Ultimately, the answer to whether health is a commodity may depend on one’s political, economic, and ethical beliefs, as well as the specific context in which the question is being asked. The idea of Health is a Commodity, promoted privatization in health service delivery. Though, it was declared failure theory of health, we are following this approach even in 2023. Health Care is a service and basic right, not a matter of commodity.
Structural Adjustment Programs (SAPs) were economic policies that were implemented in the 1980s and 1990s in developing countries. The main goal of these programs was to address economic crises by restructuring and reforming the national economy. In the health sector, SAPs involved a range of policies and strategies aimed at improving the efficiency and sustainability of health systems in developing countries. Some of the key policy measures included:
- Cost recovery: SAPs encouraged the introduction of user fees in public health facilities to generate revenue and reduce the burden on the government budget.
- Privatization: SAPs promoted the privatization of health services and the transfer of ownership of health facilities to the private sector.
- Rationalization: SAPs aimed to rationalize health services by reducing the number of facilities and personnel, and reallocating resources to areas of greater need.
- Decentralization: SAPs aimed to decentralize health services to local authorities, which were given greater autonomy to manage and fund health programs.
While SAPs were intended to address economic crises and promote economic growth, they often had negative impacts on health systems and health outcomes in developing countries. The introduction of user fees, for example, made healthcare less accessible to the poor, while the privatization of health services often led to the concentration of services in urban areas, leaving rural populations underserved.
The Structural Adjustment Programs (SAPs) has been considered failure attributed to a range of factors, including their economic, social, and political impacts. There is always a controversy in defining the failure of SAP. Here are some reasons why SAPs was considered as failure:
- Economic Impact: While SAPs aimed to address economic crises, they often led to negative economic outcomes. The reduction of government spending on social services, including healthcare, education, and social welfare, often had a negative impact on the living standards of vulnerable populations. Additionally, the introduction of user fees, privatization, and rationalization of health services often led to increased out-of-pocket expenses and reduced access to health services for the poor.
- Social Impact: SAPs had negative social impacts, particularly on vulnerable populations such as women, children, and the elderly. The reduction of government spending on social services often led to the deterioration of living conditions and increased poverty rates. The introduction of user fees and privatization of health services often led to increased inequalities in access to healthcare, with the poor and marginalized groups being excluded.
- Political Impact: SAPs were often implemented with little consultation or participation from local communities, which led to a lack of ownership and commitment to the policies. The emphasis on market-oriented policies often led to conflicts with social and political objectives, leading to social unrest, political instability, and in some cases, civil unrest.
- Design and Implementation: The design and implementation of SAPs were often flawed, with a lack of attention to local contexts, institutions, and cultures. The failure to consider the complexity and diversity of local health systems often led to unintended consequences and negative outcomes.
In conclusion, people arguing SAPs as failure argue that it failed to achieve their intended goals of economic growth and stability and had negative impacts on health equity and access to healthcare for vulnerable populations. While there was a need for economic reforms in developing countries, it was important to adopt a more holistic and sustainable approach to health system strengthening that considers local contexts, institutions, and cultures. Overall, the implementation of SAPs in the health sector has been a topic of debate and controversy, with critics arguing that these policies had negative impacts on health equity and access to healthcare for vulnerable populations. In recent years, there has been a shift towards more equitable and sustainable approaches to health system strengthening, with a focus on universal health coverage and health equity.
Issues of GMO
The development of genetically modified Organisms (GMO), specially animals for organ transplantation, also known as xenotransplantation, is a field of ongoing research. The idea behind this approach is to use animals, such as pigs, that have organs similar in size and function to humans, and to modify their genetics to reduce the risk of organ rejection by the human immune system. While there has been progress in this area, including the creation of pigs that lack certain genes associated with immune rejection, there are still many challenges to be overcome. One major challenge is the risk of transmission of viruses and other pathogens from the animal to the human recipient, as well as the potential for the human immune system to recognize and attack the animal cells. There are also ethical considerations surrounding the use of GM animals for organ transplantation. Some critics argue that it is unethical to create animals solely for the purpose of harvesting their organs, or to genetically modify animals in a way that may cause them harm or discomfort. Despite these challenges, the potential benefits of xenotransplantation are significant. The shortage of human donor organs is a major problem worldwide, and xenotransplantation could potentially provide a much-needed source of organs for transplantation. However, it is important that any research in this area is conducted responsibly, with appropriate ethical considerations and oversight.
COVID 19
In more recent times, the health power struggle has shifted towards political and economic interests. Governments and corporations have become major players in the healthcare industry, with many individuals and groups fighting for control and influence over healthcare policy and funding. Today, the health power struggle continues to play out in various ways, with ongoing debates over issues such as healthcare access, funding, and the role of government in healthcare. Despite these ongoing struggles, however, progress has been made in improving health outcomes for individuals and populations around the world. Though, preventive measures adopted in COVID – 19 pandemics are still in controversy, isolation was practiced even during ancient period to control outbreaks. Lepers bell was used to notify that the Leprosy infected person is on the way. It had isolated Leprosy patients, and the bell indicates the use of Syron in ambulance now a days. Often, patients were used to drop in lonely island as an isolation.
The need of cultural transformation of health in a society
There are different milestones, as discussed in history part of the article. Cultural transformation of society in health refers to the changes in cultural values, attitudes, and behaviors that promote health and wellness. Both good cultural practice and bad cultural practices exists in the society. To make the community, adopt good cultural there are some considerations that should be taken into account.
Good transformation aims to shift the focus from a reactive approach to health care to a proactive approach that prioritizes prevention and overall well-being. Cultural transformation in health involves several different factors, including education, awareness, access to resources, and community engagement. It also involves addressing cultural norms and beliefs that may contribute to poor health outcomes, such as unhealthy diets, lack of exercise, and social isolation. Some examples of cultural transformation in health include:
Promoting healthy lifestyle choices through education and awareness campaigns, such as encouraging people to eat a balanced diet, exercise regularly, and avoid smoking and excessive drinking. Providing access to healthcare resources and services to underserved populations, such as low-income communities and rural areas. Encouraging community engagement and collaboration to address health issues, such as establishing community gardens and farmer’s markets, and promoting walking and biking trails. Promoting mental health and well-being by addressing social determinants of health, such as poverty, unemployment, and discrimination. This can be achieved by engaging community people in various ways like: Empowering them to make them understand the necessity of empowerment. Involving marginalized population in decision making process. Educating about healthy lifestyle choices, such as healthy eating habits, regular exercise, and avoiding risky behaviors. School based interventions can be a better option penetrating large community at once. Ethical usage of social medias to reach the corners. Providing community responsive services everywhere. Forming peer groups to discuss and promote healthy behaviors, and providing the opportunity of leadership to the marginalized group.
Cultural transformation in health requires a multi-faceted approach that involves individuals, communities, healthcare providers, policymakers, and other stakeholders working together to promote health and wellness for all.
Superior Complexity, Dunning Kruger Syndrome, and their influences
Superior complexity refers to a level of complexity that is higher than what is typically encountered in each system or problem. This means that the system or problem exhibits characteristics that are more intricate, interconnected, and nuanced than what is commonly seen. Health system is very complex and differs in different countries. To make it standard, and somehow homogenous – various conventions, declarations and summits occurs frequently.
Superior complexity may arise when a problem is not well-defined, when the data available is limited or contradictory, or when the solution requires consideration of multiple perspectives and stakeholder interests. Addressing superior complexity often requires a multidisciplinary and collaborative approach, involving experts from different fields of medicine like Public Health, Clinical Health, Nursing, other disciplines like economics, law, social sciences, and stakeholders with different perspectives. It also requires a willingness to embrace uncertainty and ambiguity, and to continuously adapt and refine solutions as new information becomes available. It can be exaggerated by limited resources, geographic challenges, and health disparities.
Superior complexity can have a significant impact on health policy development and implementation. Health policies are designed to address complex health-related issues such as access to healthcare, quality of care, health outcomes, and health disparities. Superior complexity can arise in various ways in health policy, such as – Multiple stakeholders may have different perspectives, interests, and priorities, which can make it difficult to develop policies that are effective, equitable, and sustainable. Health policy issues are often interconnected and interdependent, requiring consideration of multiple factors, such as social determinants of health, environmental factors, and health behaviors. This can create superior complexity in designing policies that address the root causes of health problems and promote long-term health and well-being. Health policies often require data and evidence to inform decision-making. However, data can be limited or inconsistent, particularly in emerging areas of health research, which can make it difficult to develop evidence-based policies. Health policies are often influenced by political and economic considerations, such as budget constraints, public opinion, and special interest groups. These considerations can make it difficult to develop policies that are based solely on scientific evidence and public health goals.
Superior complexity is a challenge that can arise in complex systems and problem-solving situations and requires a sophisticated and adaptive approach to address effectively. It requires an ongoing commitment to evidence-based decision-making, with an emphasis on continuous monitoring and evaluation of policies to ensure that they are achieving their intended outcomes. Addressing superior complexity in health policy is critical to promoting population health and reducing health disparities.
The Dunning-Kruger Syndrome is a cognitive bias described by David Dunning and Justin Kruger in 1999 in the publication Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Led to Inflated Self-Assessments. Here it is defined as the individuals with limited knowledge or expertise overestimate their abilities and knowledge, while those with more expertise tend to underestimate their abilities and knowledge. Syndrome can have significant impacts on individuals and society. It can lead individuals to make poor decisions, overestimate their abilities, and fail to recognize their limitations, which can have negative consequences in various domains, including personal, academic, and professional settings. It can impact the health system in Nepal, particularly in service providers self-assessment for the competency and knowledge leading to suboptimal care and services.
Political decisions made in developing health policy should be free from this syndrome, and the lesson learnt from history should be fairly adopted. It can have broader societal impacts and can contribute to the spread of misinformation and pseudoscience by propagating false and misleading information. It can only be addressed, if the constructive feedback and criticism is accepted, else it can lead to political polarization and use of extreme powers.
Ways forward
In recent years, Nepal has undergone significant changes in its health politics. In 2015, the government of Nepal implemented a new constitution that included a provision for the right to health. The government has also taken steps to address the shortage of healthcare professionals in Nepal by increasing funding for medical education and providing incentives for healthcare professionals to work in rural areas. In addition, the government has implemented policies to improve access to essential medicines and to regulate the pharmaceutical industry. However, Nepal still faces challenges in its health politics, including inadequate infrastructure, limited resources, and a lack of political will to prioritize healthcare.
Political instability and polarization pose significant challenges to strengthening Nepal’s healthcare system. To effectively address this issue, it is crucial to establish a shared vision, objectives, and strategies that involve all elected political parties across different tiers of government. It is also essential to prioritize evidence-based decision-making and commit to avoiding politically motivated ad-hoc decisions that do not align with established evidence-based practices.
The Ministry of Health in Nepal has established several councils for different purposes, but they need to be revitalized through collaboration and cooperation with other ministries like the Home Ministry and the Ministry of Education. After revitalization, these councils can effectively monitor the various health-related activities being conducted by different authorities at the local government level. To achieve this, self-evaluations and third-party evaluations must be conducted, and the issue of conflicting authorities within and between the councils must be addressed.
The councils should be held accountable and present themselves for monitoring and evaluating different health-related activities being conducted in the community. It is essential that these councils adopt evidence-based contextual findings to develop plans that prioritize semi-clinical human resources, which are crucial for a developing country like Nepal. Public health human resources cannot be ignored in every developmental projects, and lessons can be learned from successful programs such as the barefoot doctors in China, community health workers in Africa, health extension workers in Ethiopia, community health volunteers in Kenya, and village health workers in Thailand. These programs still hold value in Nepal’s communities today.
With the implementation of federalism, local governments in Nepal have gained significant authority and can make independent decisions. Therefore, it is crucial to strengthen their capacity to scientifically analyze various findings and adopt global best practices at the local level. Going beyond their scope can create confusion and undermine the effectiveness of their decisions. Adopting proven models and practices can reduce the risk of project failure, and continuous evidence-based learning and adaptation of strategies can lead to successful implementation and policy-level changes.
To ensure successful implementation, there must be a specific strategy to address cross-cutting issues such as gender inclusivity, and risk mitigation plans must be in place. By tailoring their strategies and learning from evidence-based best practices, local governments can successfully implement projects that have a positive impact on their communities.
To get Nepal’s health system back on track, the government must take a series of steps. Firstly, the government needs to increase funding for healthcare services to ensure that people have access to quality healthcare. This requires a concerted effort to prioritize health spending and allocate resources more effectively. Secondly, Human Resources for Health need to be clearly defined, and prevent non licensed health professionals giving the delicate health service, and even the advice. Working in Public Health, without a valid license is illegal in Nepal. Lastly, corruption is a significant problem in Nepal’s healthcare system, and the government needs to hold corrupt officials and organizations accountable and implement policies that promote transparency and accountability.
The government should invest in building more healthcare facilities and improving existing ones to ensure that everyone has access to quality care. The shortage of healthcare workers in Nepal, particularly in rural areas, must be addressed through investments in training and binded education programs. The government should prioritize disease prevention through public health education campaigns, immunization programs, and other initiatives.
To ensure high standards of quality and safety, healthcare regulation should be strengthened through the development of regulatory frameworks and the strengthening of councils. The government should also work closely with non-governmental organizations (NGOs) to address health issues in Nepal, which can play a vital role in providing healthcare services to underserved communities and advocating for policy changes to improve health outcomes.
Nepal has the potential to lead the trend of global health politics, and the government should keep the floor open to any ideas that can contribute to the strengthening of the healthcare system. By implementing these strategies, Nepal can improve health outcomes and become a SDG role model for other countries to follow.
(Feedback and updates are welcomed)
