Message from the Executive Chair

It is a subject not only close to my heart, but one for which generations of doctors and health professionals have struggled in the past and continue to do so in the present.

In fact, to understand the concept of the “right to health”, in general and in its particular manifestations, it must be placed within the context of struggles for health, struggles that are accentuated by overall crises in the economic or political life of societies, and often come into sharp focus during great democratic movements. The WHO constitution that enshrined “the enjoyment of the highest attainable standard of health as a fundamental right of every human being” was largely an expression of global rethinking generated by the Great Depression in the USA in the 1930s, the aftermath of World War II, and acted as an precursor of article 25 of the UN Declaration of Human Rights. The Constitution of the Federal Democratic Republic of Nepal (2015) has mandated that “Every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services….Every citizen shall have equal access to health services… Every woman shall have the right to safe motherhood and reproductive health.” These constitutionally enshrined rights are the result of a long struggle to ensure health as a human right in Nepal. That struggle expressed itself most emphatically in the People’s Movement of 1990 in which physicians and other health workers played a historical role (1),  and again in the spring revolution of 2006 where the democratic and rebel forces joined hands to oust Monarchy, and subsequently in the realm of policy making in the attempts to create an advancement over the health rights contained in the 2007 interim constitution.

Right to Health essential for Sustainable Development

Here let me also emphasize a point that the non-health sectors—particularly the Ministry of Finance but also the NPC— often appear to ignore or are unaware of. This crucial but often overlooked point is that health is essential for sustainable development. In 2003, the WHO Commission on Macroeconomics and Health had already stated that “Health is an intrinsic human right as well as a central input to poverty reduction and socioeconomic development”. The Commission laid out four simple messages:

1. Diseases create and exacerbate poverty

2. Health will create economic growth.

3. Investment in health is returned in high economic gains.

4. Economic gain is highest when investment in health is targeted at the poor. (2)

The  UN resolution on Universal Health Coverage 2012 goes further, stating that  sustainable development cannot be achieved without improving health. The resolution “calls for countries, civil society and international organizations to include universal health coverage in the international development agenda”. This perspective is not lost on Nepal’s activists working to ensure good health for all. In fact, Nepal’s progressive activists in general have been quite aware of health’s key role in development. When I say this the iconic figure of Professor Mathura Prasad Shrestha looms large before my eyes whose persona gave life to these rather abstract concepts of those times. Ensuring good health is an end in itself, but it is also a vehicle for economic development that Nepal desperately needs now.

The health rights enshrined in Nepal’s Constitution are not as wide-ranging and fundamental as those in the WHO Constitution, but one can hear its echo. These constitutional provisions are the most powerful tool in the ongoing struggle to realize the fundamental right to health. Nor should we fail to notice that the Federal Democratic Republic of Nepal stands out among the very low income countries in the world for the measures it has taken over the past few decades, consistently trying to ensure the right to health in spite of tremendous socioeconomic constraints. Nepal is among 75 countries that have legislation  mandating universal access to health care services regardless of income, and she is among the fewer who have it in their constitution. A seminal report of the WISH Universal Health Coverage Forum (2015) acknowledges Nepal’s Universal Free Health Care Policy of 2008  as a flagship policy of the new government that came into office after a major political upheaval. Indeed it lists that policy among the world’s seventeen most prominent examples, alongside the establishment of the NHS in the UK in 1948, Thailand’s new policy of 2001, South Korea’s 1977 policy, and Indonesia’s 2014 policy, to name a few. (3)

Over the years, Nepal has established an innovative primary health care system that has attempted to reach the furthest corners of her formidably challenging terrain, all of her socially diverse peoples, and those at the bottom of oppressive caste and class hierarchies. Critical to these efforts has been the cultivation of a diverse cadre of community health workers, including the legendary Female Community Health Volunteers, Maternal and Child Health Workers and Village Health Workers, mid-level health workers and community-oriented medical doctors and nurses. Nepal’s medical education itself had a strong community orientation from its very inception, in fact the Institute of Medicine was one of the 17 pioneer community oriented medical school in the world.  Many of those architects, engineers of PHC system and medical and public health education system of Nepal are in the audience today, and I salute their achievements.

We all know that the Alma Ata declaration, which set out the principle of Primary Health Care to achieve Health for All, squarely deals with the dichotomy of health haves and health have-nots and stands in favor of the latter, saying that no society will be truly healthy while such disparity persists.  In Nepal, in spite of periodic change in governments,  the ‘pro-people’ and  ‘pro-have-nots’ orientation  was never derailed. Despite more and less support under different regimes, it moved on with determination and innovation. The result was a viable primary health care system that could survive despite tremendous economic constraints and geographical challenges. Although the system’s potential for efficacy is still not fully tapped, it has demonstrated its resilience in weathering ten years of armed rebellion while simultaneously meeting important Millennium Development Goals.

Nepal’s success story in meeting  or being on track with MDG4 and MDG5 is well documented. Nepal received UN awards for her achievements in MDG, and became one of the top ten movers of Human Development Index (in fact the top third among 135 countries studied) because of her successes in the health and education sector. (4) A series of events appear to have prepared the way for Nepal’s impressive performance regarding the MDG. The national health policy brought out by the first elected government after the 1990 movement emphasized the expansion and deepening of the primary health care structure. It was at this time that the policy of establishing sub-health posts in all the Village Development Committees, and a Primary Health Care Center in each electoral constituency was adopted.

But major reinforcement came after the spring revolution of 2006  with the flagship Free basic health care policy mentioned above, to implement the right to health enshrined in the interim constitution. All services of sub-health posts and health posts were made free to all, including the registration fee.  A basic health care package was made free in District Hospitals and Primary Health Care centers for targeted groups.  The budget for care for poor and underserved populations in zonal and central government hospitals was increased.  The right to safe motherhood was established by making maternity care including caesarian section free in government hospitals, and providing cash incentives to deliver in the hospital. Most of the public health measures including vaccination were already free. Successive governments also tried to make some tertiary care, such as heart valve surgery, and some cancer care free for targeted populations. Most recently the dialysis service has been made completely free for kidney patients.

Right to Health and Universal Health Coverage

It is true that there remains much to be desired in Nepal’s health system. The primary care network is strong and extensive, but suffers from absenteeism, an insufficient manpower quota, and supply chain issues and motivation/incentives for retention.  Limitations of coverage are quite acute at the level of secondary and tertiary care. Lack of resources, infrastructure, communication and technology have all taken a heavy toll on the functioning of the system. Recognizing these issues (not ignoring them as some critics of UHC suggest), Nepal took the bold decision to make the Right to Health a constitutional right, and then to translate that right into everyday reality by adopting the path of  Universal Health Coverage.

Universal Health Coverage (UHC) is, by definition, “a practical expression of the concern for health equity and the right to health”. Thus promotion of UHC advances the overall objective of the WHO, namely the attainment by all peoples of the highest possible standard of health as a fundamental right. It must also be emphasized that UHC signals a return to the ideals of the Declaration of Alma Ata and the WHO Global Strategy of Health for All. (5)  This has been WHO’s position regarding UHC. Nevertheless, the question to what extent UHC can actually ensure right to health has been raised. (5) I believe, with the WHO, that  UHC is a practical way of implementing the right to health provided its true spirit is maintained throughout.

In the Nepali context, the policies mentioned above were implemented to put in place bits and pieces of  Universal Health Coverage. In other words, they were attempts to begin to build such a system incrementally when full implementation was not politically possible, and to create public pressure for further implementation. Now, with the promulgation of the 2015 Constitution, Nepal has an historic opportunity  to create a comprehensive master plan, a roadmap leading to full implementation of Universal Health Coverage that is uniquely suited to Nepal’s socio-economic and topographical challenges. Our now decades-long journey toward UHC gives us a wealth of experience to draw upon to fill conceptual lacuna and improve practical implementation strategies. One can of course anticipate that resistance will be encountered in the course of ensuring UHC. Vested interests working in the service of rich people, profiteers, champions of neoliberal economic policies, and others may promote approaches that work against the principle of equity and tend to dilute both the spirit and the practice of UHC. That such transformational work, which undermines entrenched inequalities on many levels, will encounter challenges should surprise no one.

It cannot be stated too strongly that Universal Health Coverage is an idea whose time has come, globally and in Nepal too. The WHO/World Bank Ministerial Meeting on UHC , the Lancet Commission on UHC, the UN Sustainable Development Solution Network, and the Royal Institute of International Affairs all called for UHC to be included in the 2015 Sustainable Development Goals (SDGs). And it has indeed been included in target 3.8 of SDG-3 which states, ” Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”  It is no surprise that the Director General of the WHO has stated that, “UHC is the single most powerful concept that Public Health had to offer”. This clear and accurate statement in favor of UHC is to be lauded, but one should also expect no less from one of the preeminent public health figures in the world. What is more striking is the statement of the President of the World Bank, the institution that once strongly advocated user fees and cost sharing for low income countries, who is now on record having said, “we must be the generation that delivers the Universal Health Coverage”. (6) This unprecedented convergence in favor of UHC is an opportunity not to be missed! And I believe Nepal is poised to take advantage of this convergence.

Ensuring Implementation:

Dear friends, my major arguments thus far have been as follows: First, ensuring the right to health finds its practical expression in Universal Health Coverage. Second, Nepal has already embarked, at least from 2008, on the path of Universal Health Coverage, drawing upon decades of development of an innovative primary health care system. Third, the  situation is favorable for Nepal to ensure implementation of the Right to Health as there is global convergence from the UN and some major multilaterals in favor of UHC.

It is true that the world is also witnessing blatant corporate attempts to undermine some of the prominent UHC systems of the world, such as the NHS in the UK, and the Canadian single payer system. However, this may be a rare case where the strong role of multilateral agencies in Nepal can work to ensure right to health. Nepal’s constitutional rights embody the lofty ideals of Health as Fundamental Human Right only in a limited way, their full implementation would be a great achievement, particularly in the context of Nepal’s severe resource constraints. Only by first ensuring these relatively lesser rights, a task which still calls for an extraordinary effort, can Nepal move on to ensure more profound health rights, namely  the ‘attainment by all peoples of the highest possible standard of health’, in future.

So let us put some fundamental question to ourselves. How can every citizen of Nepal exercise the right to free basic health services from the state?  How can it be ensured that no one is deprived of emergency health services, and that every citizen enjoys equal access to health services? How can every woman access the right to safe motherhood and reproductive health?

In my opinion, any serious effort to ensure implementation of the constitutionally given health rights in Nepal demands a number of concerted actions be undertaken simultaneously. These actions include:

1. A deeper understanding of Nepal’s own effort to realize Universal Health Coverage in the past, while also taking stock of the valuable experience gained in implementation of UHC in other relevant countries.

2. Developing absolute clarity that implementation of UHC is more of a political challenge than a technical challenge, and that UHC implementation has health science, economic, and political dimensions which must be addressed synthetically.

3. Taking a clear and firm stance that quality is central in UHC and developing a clear understanding that UHC is not ‘poor health care for the poor’, but rather it succeeds by creating a universal risk pool and achieving equitable distribution of common resources.

4. Achieving clarity about healthcare financing mechanisms for UHC, public financing vs. private volunteer insurance, and creation of a concrete financing plan devised to ensure genuine UHC.

5. Incorporating concrete measures to avoid the phenomenon of the ‘missing middle’ in the implementation of UHC.  The ‘missing middle’ refers to the situation in which only the highest and lowest income groups have some health protection while the middle income group are largely left outside health coverage.

6. Participatory research and innovation by a critical mass of experts, to devise ways to overcome the constraints of resources, infrastructure, geography, for example innovative technology of wireless system to reach across difficult terrain, and to build in effective safeguards against corruption and to ensure quality control.

7. Supervision of the implementation process by a powerful body under the Ministry of Health led by visionary leaders determined to translate constitutional rights into everyday realities, through acts, policies, multi-sectoral collaboration, and planning for coordination between the federal and state governments under the new federal setup. The recently formed high level health policy and restructuring coordinating committee may just be the right body for this task.

Friends,  we all know that how to finance Universal Health Coverage is the crux of the issue. The immediate fundamental question is: Does the Ministry of Health strive to increase the health budget, and public financing of the basic health care package, or does it shift the burden to private volunteer insurance subsidized by pubic finance? We face this question now. We had also faced it in the year 2006.  At that time Nepal already had experience of the burden created by experiments with user fees, cost sharing and the community drug scheme to finance the health institutions. The result was that fewer and fewer people utilized the public health institutions, with the poorest suffering from this loss of access the most severely. This has also been the experience in Africa and other economically poor countries. On the other hand, the health institutions did not like to give up the user fee system, because it generated very important revenue for the functioning of the institutions and motivation of the staff. Implementing free health care ran the risk of weakening the health institutions financially, among other noted difficulties.

After a vigorous debate about the two paths, the government of Nepal opted for public financing of a basic health care package, step by step. The policy was implemented in such a way that, rather than weakening of their financial status, the health institutions increased savings as compared to the earlier period while simultaneously being able to exempt patients from user fees in the PHC system. This has become a successful model which has brought Nepal favorable notice in the international arena. Nationally it has been so popular that even though the country has gone through eight changes of government since its implementation, the free basic health care has remained in place and even thrived with further improvements to the package of care and increased number of essential medicines covered.

When the entire governmental system should be undergoing fundamental transformation to bring it into accord with constitutional mandates. However, in the public health system, instead of further strengthening and up-scaling existing components of UHC in the spirit of the constitution through tax-based financing and cooperative-social insurance, there appears to be a tendency to move toward private volunteer insurance supported by public financing. Such an approach endangers UHC and may divert Nepal’s meager government resources to private insurance companies. Faced with this possibility, a brief glance over our own past may be helpful.

I am proud to recall that during the development of the Universal Free Health Care Policy (2006-2009) I was the chief advisor of the then Health Minister (who was also Deputy Prime Minister), and I continued to assist the Health Minister who succeeded him as well. Immediately after the 2006 movement, the new government’s health ministry took two important steps. First, it immediately allocated a minuscule fund of just 15 lakh for  emergency and in-patient care for poor and marginalized groups in the district hospitals  and Primary Health Care Centers (the budget was already in the final stage so there was no room for reallocation). Second, it worked very hard to include the health right of free basic health care among the fundamental rights enumerated in the Interim constitution. When in 2007 it succeeded in including this right to health in the interim constitution, the Ministry gained significant power to argue for increasing the health budget. It could validly argue that if basic health care is a constitutionally given right of the people of Nepal, then there should be sufficient financing to provide a basic health care package to at least poor and marginalized groups, if not for all, free of cost. The budget indeed increased to around 7 % of the total national budget. So the most direct lesson to be drawn here is that since the 2015 constitution unequivocally declares the state’s responsibility to provide free basic health care to all, the Health Ministry should be in strong bargaining position to argue for increased budget allocation to health.

In 2007-8, with the increase of the budget allocated to health, sub-health post and health post services were made free, with 28 and 32 listed essential medicine respectively also made free for all. The registration fee was also abolished for the patients, while the government paid a higher sum to the health institutions for each patient that came, providing a net benefit to them from this change in financing modality. A basic health care package was defined for hospitals and PHCs. The patients were categorized into ultra Poor, poor and non-poor. The premium of Rs. 100  for ultra poor was fully covered by the government, for the poor 50% by the government and 50% by the patient and the non poor would pay out of pocket as before. The service was to be provided on the basis of self declaration of his or her economic status so that the patient could receive medical care immediately. Later the record would be sent to their community to verify the patient’s statement. The idea was to identify the three categories of patients as they walk into the health institutions and trace their families so that the family could be covered as well. Ultimately it was hoped that three different color cards could be issued to the people who could access services accordingly.

Another notable addition was a free safe motherhood policy in public hospitals including caesarian section, and cash incentive for hospital delivery. This was coupled with a drive for community birthing centers and skilled birth attendant training. These provisions have made a substantial impact in reducing maternal mortality and neonatal mortality, and improving mother and child health. Many health institutions also opted to open a cooperative drug store on their premises to sell medicine other than the listed ones in a price lower than the market.

Although this approach was basically tax-based public financing by the government, significant financial support came from external development partners (EDPs). To sustain this policy and reduce dependency on EDPs the government had to:

1) raise tax or at least institute a health tax on illness-generating products and industries, like tobacco and alcohol for example,

2) make the basic health care  package available not only to poor and marginalized citizens but to all as stated by the constitution,

3) find ways for the communities, VDCs, districts, and provinces to generate revenue to share the budgetary burden with the central government.

However, despite preparatory work along these lines, these steps have not been taken. On the contrary the budget has been diminished, and the basic health care package is still confined to certain target groups only, and raising tax for health has not been strongly advocated or taken seriously in recent years. Despite being on the cusp of full implementation of federalism, under which many important responsibilities for health care will devolve to the states, there is little evidence of serious thinking as to how the local governments and communities can take ownership of this model of UHC by raising and contributing local revenues to local health care.

This scenario begs a question that, having moved further two steps towards UHC, are we taking a step backwards regarding financing mechanism for health? In Nepal’s contemporary context, if we are presenting Health Insurance as financing mechanism for UHC the question must be asked: What kind of health insurance we are talking about? What is the rationale and justification of a particular health insurance scheme ? Is it to ensure the constitutional health right of free basic health care to all or is it a market mechanism to provide health care to those who have the ability to pay?

If we are thinking that we can achieve UHC through dependency mainly on private volunteer insurance, I would like to quote a passage from the key policy recommendations of the WISH Universal Health Coverage Forum, 2015 which were issued after distilling the experience of countries implementing UHC:

“UHC can only be achieved through publicly governed mandatory financing mechanism (general taxation and social health insurance contributions) that compel healthier and wealthier members of society to subsidize the poor and the vulnerable. Financing systems dominated by private voluntary financing (user fees and private voluntary insurance) will never achieve UHC.” (3.p4)

The experience of community health insurance of Nepal which, in essence, is a kind of private voluntary insurance subsidized by the state, has not been positive to say the least. On the other hand, a new kind of cooperative-social insurance is emerging from the cooperative movement in which the cooperative members collect the insurance premium and keep it in the cooperative fund, to be drawn upon at the time of need, mainly for the high cost surgical operations. This cooperative-social insurance premium may be as low as Rs 2000 per year per person. Given the widespread cooperative movement in Nepal, such grassroots innovations carry a lot of promise for addressing even the aspects of the secondary and tertiary care financing issue with UHC if it is consolidated at the basic health care level through a publicly governed mandatory financing mechanism.

I find two other recommendations from this report very pertinent to Nepal’s march towards UHC. The first says ” Countries should give a high priority to achieving full population coverage of an affordable package of services, rather than covering selected population groups with more generous packages of services and leaving some people relatively uncovered”.  If Nepal wants to abide by her constitution, then the basic health care package should be free for all. This lesson is very important since clear policy guidance on this point would help political leaders to raise tax for health and also deal with the situation of  the ‘missing middle’  – the middle income group who may remain without coverage because of a preferential policy toward lower income groups, the greater ability to pay of higher income groups, and an unwillingness or inability to purchase costly private insurance.

One very important byproduct of the free basic health care policy of Nepal has been strengthening of the capacity and infrastructure of the public health institutions. A policy of extending the facility to all would further strengthen these institutions. Through tax financing, Nepal can actually follow the path of Thailand, which after an initial four year period of charging a 30 bhat premium at the point of service, made basic healthcare completely free in 2006.  Nepal, similarly can opt for taking no point of service charge from any patient, while at the same time actually raising the amount to be given to the health institution by the government for each patient visit to Rs 200 or 300. This would serve to increase the revenue available for the strengthening the health institutions, a very different proposition than diverting the same amount of government funds into the pockets of private insurance providers. We need health economists to do a great job of examining the financial merit of this proposal, keeping in mind that, according to the WHO Commission for Macroeconomics and Health Report, investment in health increases economic development often by six times the invested sum. And The Lancet Commission on Investing in Health showed that “reductions in mortality accounted for about 11 percent of recent economic growth in low and middle income countries, or even 24 percent of growth if the value of added life years is used to calculate a country’s ‘full income’. (3.p6).

The fear that well-off groups would take advantage of such policy has been contradicted by global experience. The well-off people would be motivated to pay more tax with this policy, and at the same time it has been observed that they also buy private volunteer insurance for other services so that such insurance companies do not substantially suffer from such public health policies.  “Countries like Thailand, Sri Lanka, Malaysia and Brazil show that with universal entitlement system, higher income households still choose to pay voluntarily for services in the private sector”. (3.p14) The point is not to obstruct the business of private insurance companies but to ensure universal coverage for all by public financing.

Ensuring implementation of the right to health calls for visionary leaders and drivers of redistributive justice to create an atmosphere for public financing. UHC is a political process and it demands a strong political will from the leaders. The third recommendation of the WISH report is worth quoting here:

“The transition towards UHC in redistributing health benefits and financial burdens, is a highly [political process that is likely to face opposition from powerful interest groups. Sustained political commitment from the highest level of government including the head of state is therefore essential in implementing successful UHC reforms.” (3.p4)

Many  ways and means could be explored if the highest political leadership is determined to achieve UHC. For example, Indonesian president Jokowi diverted the tax on vehicles to fund free insurance for the people. Countries such as Chile, China,  Brazil, Mexico, Turkey and Thailand have used compulsory public financing mechanisms to close coverage gaps. “These countries are often heralded as UHC success stories because they improved health outcomes, lowered inequality and raised levels of financial protection compared to their peers.” (3.p14)  Rwanda is another notable example of a country that rapidly increased coverage to over 90% by making insurance membership mandatory and heavily subsidized household premiums.

Nepal can learn from these examples. But I would like to add here that although tax financing is an extremely important strategy for Nepal, there is a limitation as to how much tax can be raised in a low income country like Nepal. Therefore, with the federal restructuring of the state, we need to  find innovative ways as to how the communities, VDCs, districts, and provinces can generate revenues through economic activities to share the burden of central budget for health. Here I can only mention a few possibilities that I believe worthy of serious examination:

  • The Ministry of Health and the Federation of Cooperatives may have close collaboration for developing a system of cooperative-social insurance and develop income-generating project to finance health at local level.
  • The Ministry of Health can actually take the lead to establish health-nutrition-development cooperatives which could work multi-sectorally for economic development, ensuring good nutrition and health.
  • The corporate social responsibility of banks may be a good source to finance such projects through grants and soft loans.
  • A certain percentage of remittance could be used for public financing
  • Tax can be increased for consumable items detrimental to health such as cigarettes and alcohol and put in the Health Ministry’s budget allocated specifically for UHC.
  • Individual themselves may be encouraged to save money in their piggy banks every day or month for ‘health tax’ or cooperative -social insurance premium.

Conclusion

Dear friends,

It is my conviction that we can realize the fundamental health rights enshrined in our 2015 Constitution by ensuring the implementation of Universal Health Coverage with tax based public financing, cooperative social insurance and income generation through local development projects. It calls for strong political will as well as careful planning to reach the desired destination. It calls for drivers of redistributive justice, who would argue for raising taxes to pay for health and strengthening the public health care system to ensure health for all, with priority to those most in need during incremental implementation. It also calls for advocates of social justice to expose the social and economic consequences of shifting the burden to the shoulder of private sector and letting loose the free reign of market forces in an area that is the most basic of public goods — the health of the people. It calls for innovative cooperative- social insurance  schemes in which progressive insurance premiums are collected and managed by the target groups themselves, rather than corporate insurance companies who are driven by an unquenchable profit motive. It calls for translating the spirit of the Constitution into health policies and Acts in most specific terms. In keeping with the federal restructuring of the Nepali state in the health sector, it calls for research initiatives for sustainable economic development of local communities so that they can generate public financing to contribute to local health expenditure, substantially reducing the health budget burden of the provincial and central government. In the context of the devastating earthquakes of 2015, with simultaneous loss of health facilities, and increase in health care needs, as well as the difficulties endured by people due to the subsequent economic blockade, It calls for visionary leaders who can turn crises created by periods of exceptional upheavals and turmoil into what are aptly called ‘political windows of opportunity’. The challenge of ensuring implementation of fundamental health rights through UHC is tremendous, and difficulties may even appear insurmountable. But it is also true that never before have the  conditions been as apposite and favorable for Nepal to do just that.

Nepal already has  embarked on the road of Universal Health Coverage and, despite all the difficulties, is favorably positioned to develop a unique model of UHC that takes account of her  formidably challenging terrain, social diversity and hard to reach communities. The Preamble of Nepal’s 2015 Constitution declares its orientation towards socialism. I believe ensuring implementation of Right to Health through publicly financed UHC would be a concrete and determined step towards that destination.

Let me also say that the journey of right to health is a long and uphill venture, we still are very far from the luminous light of its destination summit. The constitution of Nepal that grants the basic health care free for every citizen, is one of its lower summits only. When I was asked by NMACON organizing committee to give this key note speech, two sad incidences occurred one after another in short interval. A boy with kidney failure had committed suicide jumping out from the dialysis ward of Teaching hospital, and a girl suffering from terminal cancer died after writing a long heart wrenching letter to Health Minister Thapa. Both had exposed the weakness of our health system, both symbolized the extreme anxiety of financial burden being caused to their families, and both were lives that could have been saved or at least prolonged. We who are gathered here today to reflect and plan for UHC, let us keep their memory alive, and have the courage to make Right to Health more than just free basic health care package, or perhaps expand basic health care package to include comprehensive care for such diseases as well. The recent policy declaration for free dialysis service is a shining example taken by a bold leadership. Many countries have embarked on the path of comprehensive Universal Health Coverage , and I see no reason why Nepal cannot follow suit, in a phase wise manner.