KATHMANDU: Nepal’s health system has come a long way since the shift to federalism in 2015. With 753 local governments now responsible for delivering basic healthcare, the focus has rightly shifted to strengthening primary-level facilities, which are our health posts, basic health service centers, and primary hospitals. But as we invest time, money, and political capital into these facilities, we must ask: are we doing it smartly?

A key tool in this journey has been the Minimum Service Standards (MSS), a framework developed by the Ministry of Health and Population (MoHP) to evaluate whether a health facility is ready to provide essential services. The MSS looks at governance, clinical care, and support services and provides a percentage score that reflects how well a facility meets the expected minimum. It was first introduced in 2072 BS (2015/16 AD) and has since been adapted to various levels of health institutions to include standards for all tiers of health facilities from health posts to tertiary hospitals.

The tool is widely used today. In fact, MSS assessments are allocated dedicated budgets not only by the federal government but also by some provincial and local governments, covering everything from assessment exercises to cross-learning visits and strengthening of facilities to improve MSS scores. For many, MSS is taken seriously. Since it engages Health Facility Operation and Management Committees (HFOMCs) chaired by local-level elected representatives, it has legitimacy, ownership, and political traction.

But here is the catch: we have reached a point where MSS urgently needs revision.

Let’s start with the numbers. Nepal has 3,778 health posts and 7,582 basic health service centers scattered across the country. In theory, they all need to meet a long checklist of MSS indicators, some of which are contextually irrelevant. For instance, we were conducting an MSS assessment recently, and a health worker showed us a bottle of diesel she had procured.

She quietly asked, “I got this to improve our MSS score… but what is it for?” The item was listed under the assumption that the health facility had a generator. It did not.

Stories like this are not rare. Across numerous health posts, especially in rural municipalities, it has been observed that MSS standards require facilities to be prepared for services that are rarely or never used. For example, birthing centers in some areas have reported zero deliveries over periods of up to five years, yet they continue to be assessed and budgeted for under full MSS criteria. These include requirements for equipment, sterile supplies, infrastructure, and human resource readiness.

Even conservative estimates suggest significant financial inefficiencies. If just 10 percent of the 3,778 health posts are maintaining full birthing readiness without providing any delivery services, and each facility is spending an average of NPR 200,000 per year on equipment maintenance, training, and supplies related to birthing readiness alone, this would translate into over NPR 75 million per year in potential waste.

Populations are migrating, fertility is dropping, and some rural areas are slowly depopulating. Should we be maintaining full MSS standards in every facility, or should there be context-specific adaptations backed by economic evaluations?

The National Health Sector Strategy (NHSS) 2023 to 2030 rightly emphasizes service quality, equity, and efficiency. It also highlights the role of primary health care in reducing pressure on overburdened secondary and tertiary hospitals. Strengthening our local-level health posts makes strategic sense. But we must be honest: the current MSS setup demands a separate room for each service-ANC, PNC, immunization, family planning, and more-as a “minimum” standard. That is ideal, yes. But in many municipalities, the infrastructure simply does not allow for it. There is neither space nor population demand to justify it in all cases.

Complicating this further is the inclusion of laboratory services in MSS indicators, even though laboratory units are not yet structurally and administratively integrated into local government health systems. This has led to ambiguity in budgeting, human resource management, and quality oversight. The result is a situation where health facilities are expected to meet standards without the enabling structural authority and resources to do so effectively.

More concerning, perhaps, is the way health workers themselves perceive MSS. They are chasing MSS scores as if it is a performance evaluation-seeing it as competition with others.

It makes sense; the readiness of their facility reflects on their work. But readiness and quality are not always synonymous. MSS can measure whether there is a protocol in place but not how respectfully a woman is treated during an antenatal visit. It can check for the availability of drugs but not whether patients are being prescribed rationally.

And municipal hospitals are another important part of this ecosystem. Their situation, ranging from human resource shortages to budget and governance challenges, is a separate issue that deserves a focused national debate. For now, let us stick to the health posts and basic health service centers, as it is already complicated enough.

This is why we must move towards a smarter MSS, one that respects diversity in health facility profiles, encourages contextual decision-making, and considers value for money. Perhaps a modular or tiered version of MSS could allow facilities to self-identify based on service volume and community needs, then apply standards accordingly.

However, please note MSS is not the problem. In fact, it is one of the few tools that genuinely bridges the gap between data and local decision-making. It has brought discipline to planning and budgeting, pushed local governments to think in terms of evidence, and elevated the role of elected representatives in health governance. But like any system, it must evolve.

Nepal’s public health system has never been flush with resources. Health gets allocated approximately four to five percent of the national budget annually. So what we have, we must use wisely. A revised MSS, aligned with the realities of federalism, economics, and community needs, can become an even more powerful tool for health system strengthening.

(Kusumsheela Bhatta is a Public Health Officer at the Government of Nepal and an early-career researcher focused on strengthening Nepal’s health systems.)