Health care system of nepal

Health System of NepalRoshan khadka

Mahidol university

The nation will remain as long as the sun and moon is on the earth

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Prepare and Presentation by -

Roshan khadka Jeevan bhattaMahidol university Mahidol universitySalaya, Thailand Salaya,Thailand

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Introduction• Name: Federal Democratic Republic of Nepal

• A landlocked country.

• Borders with The People’s Republic of China in the north

• Shares the border with India in east, south and west

• Rectangular in shape– Average length: 885 km( East to West)– Average width: 193 km( North to South)

Source: Ministry of Federal Affairs and Local Development (MoFALD)

IntroductionGeography

Area: 147181 sq kmWater: 4000 sq kmLand: 137181 sq km

Topography

Three ecological zones1. Mountain: 35% of land

area2. Hills: 42% of land3. Terai: 23% of land

Multilingual and Multiethnic

• 125 castes or ethnic groups• 123 different language

• Nepali is the national language Source: MoFALD and

National Population and Housing Census 2011

Introduction

Administrative Division• 5 Development Region• 14 Zone• 75 Districts• 217 Municipalities• 3157 Village

Development Committee

ReligionHindu: 81.3%Buddhist: 9.00%Muslim: 4.4%Kirant: 3.00%Christian: 1.4%Other: 0.5%Unspecified: 0.2%

Source: MoFALD

Demographic and Health Indicator

Total Population 26494504

Sex ratio 0.96 male(s)/female

Population density 180 per square km

Population growth rate 1.35%

Urban population 18.00%

Source: Population and Housing Census, 2011

Demographic ContinueTotal Fertility Rate 2.6

Contraceptive Prevalence rate

49.70%

Crude Birth Rate 22.17 per 1000 population

Crude Death Rate 6.6 deaths per 1000 population

% of population using any improved water sources

88.10%


Demographic Continue

Infant mortality rate 46 per 1000 live births

Under five mortality rate 54 per 1000 live births

Maternal mortality ratio 170 per 100000 live births

* Source: Population and Housing Census, 2011

Life Expectancy• Ranks 165th in the average life expectancy of the world

• The life expectancy was 60.56 in 2007.

• Life expectancy 2014 (estimated)– Overall: 67.19 years– Male: 65.88 years– Female: 68.56 years

Source: CIA World Fact book 2014

Human Development IndexCountry Rank HDI Value (2015)

Japan 20 0.891

Thailand 93 0.726

Bangladesh 142 0.570

Nepal* 145 0.548

Myanmar 148 0.536

Source: Human Development Index Report, 2015, UNDP

* Nepal’s Rank was 157 in 2014.

Literacy

• Literacy Rate: 65.9%– Male: 75.1%– Female: 57.4%

• Literacy rate of 5 years and above

• Literacy rate was 54.1% in 2001.


Economy• Agriculture accounts for the 36.8% of Gross

domestic product.– Unemployment rate : 46% (2008)– Per capita income : $ 735

• Gross domestic product ( GDP) : $42.06 billion ( 2013)

• Carpets and garments constitute the vast majority of Nepal’s officially recorded exports.Source: NDHS/ Ministry of Finance/ CIA world Factbook

Household’s Access to Health Facility

Access within 30 minutes of travel time

• Amongst the development regions, the central has the best while the far west has the least access.

Source: Nepal Living Standard Survey, 2010-11

1995/96 2003/04 2010/11

Health Post

Public Hospital/

PHC

Clinic/ Private

Hospital

44.8% 61.8% 61.8% 33.6% 53.4%

In-patient Top Ten Morbidity

Diarrhea and Gastroenteritis

Chronic Obsteric Pulmonary Disease

Acute Lower Respiratory Infection

Urinary Disorder

Typhoid Fever

Typhoid and Parathypoid Fever

Essential (Primary) Hypertension

Pneumonia, unspecified

Fever, unspecified

Gastritis and duodenitis

0 2 4 6 8 10 12 14

11.529

8.053

7.181

5.514

4.543

4.229

3.981

3.465

3.393

3.349 Diseases per thousand

Source: Annual Report 2015

N= 287,616

DALY(burden of disease)

36.3

18.5

15.4

11.5

7.5

62.9

Percentage

Physical DisabilityBlindness/ Low VisionDeaf/Hard to HearSpeech ProblemMulitiple DisabiltyMental DisabilityIntellectual Disability


History of Health System Post Democracy

1951-1963 New Health Policy

1964-74 Regionalisation of Health Services

1975-92 Emergence of Single Speciality Home and Implementation of Primary

Health Care System

1991: National Health Policy was formulated

1993-2002 Emergence of Tertiary Care Centres and

Expansion of Primary Health Care Centres and Growth of Private Health Institutions

1997-2017 Second Long Term Health Plan

2007: Introduction of Free Health Care Service;

Provision of maternity initiatives and revitalization

of PHC

2009: Primary Health Care Revitalization Division was

added for the improvement of PHC Services

2014 New Health Policy

National Health PolicyAdopted in 2014 (2073 BS)Objective:• To make available free the basic health services that existed as

citizen’s fundamental right.• To establish an effective and accountable health system with

required medicines, equipments, technologies and qualified health professional for easy access to acquire quality health services by each citizen.

• To promote people’s participation in extending health services. For this, promote ownership of the private and cooperative sector by augmenting and managing their involvement.


National Health Care System• Health care system of Nepal is managed by

Ministry of Health( MoH)• MoH is responsible for making necessary

arrangements and formulation of policies for effective delivery of – Curative Services– Disease Prevention– Health Promotion– Establishment of Primary Health Care System


National Health Care System Continue

• Generally known as Public Health SystemMinistry of Health National Hospital

National Health Training/ Research Institute

Regional and Zonal hospital, health team and training/ research institutes

District Hospital, health teams/ health boards/ committeesDistrict Council and Development Committees (intersectoral)

Health PostHealth Facility Operational Management Committee (HFOMC)

Health Assistant, Staff Nurse, Auxiliary Health Workers, Auxiliary Nurse and Midwives

Female Community Health Volunteers Village Development Committes (Intersectoral)

National Level

Region/Zone

District

Village

Village/Ward

Source: mohp.gov.np

Ministry Of Health

Minister

Secretary

Professional Council

Administrative Division

Policy, Planning and International

Aid Division

Curative Service Division

Public Health Administration, Evaluation and

Monitoring Division

Department of Health Service Ayurvedic Department Department of Drug

Administration

Source: mohp.gov.np

Organogram of Health System Of Nepal

Centres

Division

Department of Health Services

Management

Family Health

Child HealthEpidemiology and Disease Control

Logistic ManagementPrimary Health Care

Revitalization

National Health Training

National Health Education Information and Communication

National TuberculosisNational Public Health

Laboratory National Centre for

AIDS and STD Control

Central Hospitals- 6

Regional Health Directorate- 5

Source: mohp.gov.np

Organogram Continue

Regional Health Directorate

Regional Hospital- 3

Sub Regional Hospital- 3Regional Health Training Centre-

5Regional Medical Store- 5

Regional TB Centre- 1

Zonal Hospital- 10

District Public Health Office- 20

District/ Other Hospitals- 75

District Health Office- 55

Source: mohp.gov.np

Organogram Continue

District (Public) Health Office

Primary Health Care Centre- 202 Health Post- 3805

FCHV- 51470 PHC/ORC Clinic- 12908 EPI Outreach Clinic- 16355

Source: mohp.gov.np

Organogram Continue

Human Resource Development• MD/MBBS: National Academy of Medical Science,

Tribhuwan University, Kathmandu University, BP Koirala Institute of Health Sciences and 20 affiliate colleges (MBBS only).

• 4 University (Tribhuwan University, Kathmandu University, Pokhara University and Pubanchal University) and BPKIHS produce paramedics (Bachelors and Masters).

• Council for Technical Education and Vocational Training (CTEVT) produces general medical practitioners (Certificate Level).

Healthcare Expenditure % of Total GDP

2010 2011 2012 2013 20145

5.2

5.4

5.6

5.8

6

6.2

6.4

6.6

6.8

7

6.43

6.73

5.89

5.695.8

Percentage

Soure: data.worldbank.org

National Health System

• However, The Alma-ata and other charters focus on– That the local administration and other sectors

than the health sector alone carry the responsibility for the health of the people in village, district or region

National Health System Continue

• Hence the health system is now widened to inclusion of private sector such as;– Non-governmental (NGO) care, care provided by

missionaries, red cross, local NGOs– Medical practices by private doctors, nurses– The licensed pharmaceutical seller– The large non-biomedical professionalized healing

systems (Ayurvedic, Unani, homeopathic etc)

National Health System Continue

• PHC approach has added not only the medical care providers suffice the health care to the people

• It has taken the people and community at the centre.

Referral and Feedback Mechanism System

Central Hospital

PHC/HP

Regional/Zonal Hospital

AHW/ANM

Hospital

Level

National/Central

Regional

District

Catchment area and

Community

Referral Line

Feedback Line

Source: mohp.gov.np

Health Management Information System

• Integrated Health Management Information System (HMIS) was designed and implemented under DoHS, MoHP in entire country since 1994.

• The current HMIS manages information on all health services mostly delivered through government’s health facilities, and partially from non government health facilities.‐

• MIS Section in Management Division, DoHS generates statistical tables with raw and analyzed data in every three months and produces performance review report every year.

Source; dohs.gov.np

MOH

Centers Divisions

RHD

DHO

PHC/HP

NPC

DoHSMD/HMIS

SHP

Data Collection/Information Flow Chart

VHW/MCHW

Hospital

National/Central

Regional

District

Catchment area and Community

Reporting Frequency

Trimesterly

Monthly

Trimesterly/Periodic

Monthly

Monthly

FeedbackFrequency

Trimesterly

Trimesterly

Monthly

LatestReporting

Time

By end of 1st month of each Trimester

By end of 1st month of each Trimester

12th dayof NextMonth

• 7th day of next month• 3rd day of next month• 1st day of next month

Monthly

By Person/ Intranet

By Person/ Intranet

By AIR /Express

Delivery / Post / Person

By Person

Mode of Information

Flow

Central/Regional/Zonal Hospital

7th dayof NextMonth

By AIR /Express

Delivery / Post / Person

Reporting Line

Feedback Line

Nepal’s Free Health Care Policy

• 2008: Nepal launched a program for free essential healthcare for primary health services and access to a number of essential drugs for all citizens seeking care at health post.

• 2009: the services were extended to primary health care centres and at district hospitals, all outpatient, inpatient and emergency services, as well as essential medicines, are free of charge to all the citizens of Nepal.


Nepal’s Free Health Care Policy Continue

• February 2009 institutional deliveries are free of charge to all women nationwide.

• 70 kinds of Essential Drugs are provided free of costs.

• Upto NRS 100000 is provided to underprivileged family by government for treatment of chronic diseases.



• NRS 400 is provided to all the pregnant women who have ANC Visit in health facility as per protocol.

• Transportation Cost provided to pregnant mother who have institutional delivery.– NRS 500 for Terai Region– NRS 1000 for Hilly Region– NRS 1500 for Mountainous Region



• Iron Tablet Free distribution (225 tablet) for pregnant women with Albendazole.

• Vitamin A supplementation to delivered mothers

• Treatment of Heart, Kidney and Liver disease; and Cancer is free for the citizens at government hospitals.

• Dialysis facility free until Kidney transplant.Source: Annual Report 2015


• Nyano Jhola (or warm bag) is the set of dress provided to mother and the child immediately after delivery.


Nepal Free Health Care Policy continue

• Family Planning Services as provided free of cost by the government Health Facilities. Condoms, Depo-provera, Pills, Implant, IUCD, Minilap and Vasectomy.

• TB and Leprosy Screening is done and medicine is provided accordingly free of cost under direct superision of the health worker.

• Cotrimoxazole, Zinc tablet and ORS is given free of cost for children suffering from diarrhoeal disease.


Programs Under Department of Health Services

• Child Health Program– Expanded Program on immunization– Nutrition Program– Control of Diarrheal diseases– Control of Acute Respiratory infection– Integrated management of Childhood illnesses

• Family Health Program– Family Planning– Safe motherhood– Female Community Health Volunteer– Primary Health Care outreach clinics– Demography and Reproductive health researchSource: mohp.gov.np

Programs Continue

• Disease control program– Malaria control– Kala-azar control– Japanese Encephalitis control– Lymphatic Filariasis– Tuberculosis control– Leprosy control– AIDS and STD control

• Curative Services– Out/In patient care Source: mohp.gov.np

Programs Continue• Supporting programs

– Health Training– Health education information and communication– Logistic management– Community drug program– Laboratory services– Administrative management– Financial management– Management

• FCHV Program

Source: mohp.gov.np

Health Worker/Population at National LevelCategory Total

HW/1000 Population

Physicians 4401 0.17

Dentists 230 0.01

Nursing professionals and associates 13,323 0.50

Paramedical practitioners 9839 0.37

Ayurveda practitioners 715 0.03

Pharmacists 435 0.02

Environment and public health workers 334 0.01

Laboratory workers 2222 0.08

Source: Human Resource for Health Country Profile 2012

National Health Insurance

• Budget for the fiscal year 2016/17 says that it will implement 'National Health Insurance Scheme' in a phase-wise manner.

• The scheme targets to provide health insurance facility to every Nepali citizen within three years.

• The scheme will be expanded in the 25 districts in the upcoming fiscal year 2016/17.

Source: mof.gov.np

National Health Insurance Continue

Source: myrepublica.com

Choice of Practitioners

• 69 percent of people with an acute illness reported to have consulted with some kind of medical practitioner – 28 percent consulted paramedic, – followed by doctor (25 percent), pharmacists (16

percent), and traditional and others (2 percent)

Source: Nepal Living Standard Survey 2010-11

Choice Continue

• 43 percent of people of urban area consult with doctors

• The consultation with a paramedics is higher in rural areas, particularly in the mid and far western hills, where as many as 46 percent of acutely ill people visit these paramedics.

• Urban areas have expensive consultations relative to their rural counterparts (Rs. 2069 versus Rs. 1040) in government facility

Source: Nepal Living Standard Survey 2010-11

Challenges of Health System of Nepal

• Resource Gap

• Geographical Constraints

• Traditional Beliefs

• Privatization of health services: increase quality in urban areas but challenging for remote and far people.

Pictures of Traditional Beliefs

Challenges Continue• Epidemiological transition: Still facing huge

burden of communicable disease (Diarrhea, ARI) with newly emerging Non-communicable disease along with some new concentrated epidemic (HIV/AIDS)

• Human Resource for health: Urban centered highly skilled manpower

• Globalization: – Commercialization (Safe Delivery kit, ORS, FP

devices)– Privatization (Quality increase but accessibility

and affordability)– Introduction of user’s fee in public health

facilities: Affordability for poor people

Female Community Health Volunteer

• Program Initiated in 1988/89. • 5th December is celebrated as FCHV Day to

show respect to FCHVs. • In 19th November 2009, FCHV Program in

Nepal received GAVI awards for the highest average annual rate of reduction of child mortality among all of the 72 GAVI countries since 1990.

Source: www.mohp.gov.np/index.php/publication-1/guideline

WESTERNREGION

CENTRALREGION

EASTERNREGION

MID-WESTERNREGION

MID-WESTERNREGION

Nepal75 Districts


Village Development Committees

3,157


Wards48523

1

4

2

3

5 6 7

8 9


Ward

FCHVs51470



• The innermost circle shows that the action starts at community or ward level by individual FCHV, (as community is the centre of health activities)

• Second circle shows the action is spread in the entire VDC

• Third circle depicts whole district will be covered by FCHV’s actions

• The outermost circle shows that the action of FCHV will cover the whole nation


Female Community Health Volunteer • The main role of FCHV will be concentrated on the health

promotional activities of mothers and children in their working area.

• Help in promoting utilization of available health services and raise awareness on health through MGH.

• FCHV will help in various health programs such as family planning, safe motherhood, newborn care, immunization, nutrition, communicable and epidemic diseases, acute respiratory diseases and diarrheal diseases control, environmental sanitation, health education and other national programs.


Female Community Health Volunteer• FCHV will also provide recommended services

like drug distribution and diseases management as directed by Nepal government based on community based approach.

• FCHV has to submit an annual report to local health institution and her MGH.

• FCHV has to submit a monthly report of her activities to local health worker or supervisor every month).


Female Community Health Volunteers

Backbone of our health system

National Immunization Program

Healthy Children: Healthy Community

National Immunization Program

• A high priority program (P1) program of Government of Nepal.

• One of the most cost effective health intervention.

• Helped in reducing the burden of Vaccine Preventable Diseases (VPDs) and child mortality.

• Contributed in achieving the Millennium Development Goal on child mortality reduction (MDG 4).

Source: dohs.gov.np Nepal cYMP 2012-2016

National Immunization Program Continue

• GoalTo reduce child mortality, morbidity, and disability associated with vaccine preventable diseases.



• Objectives– Achieve and maintain at least 90% vaccination

coverage for all antigens at national and district level by 2016.

– Ensure access to vaccines of assured quality and with appropriate waste management.

– Achieve and maintain polio free status.– Maintain maternal and neonatal tetanus

elimination status



• Objective Continue– Achieve measles elimination status by 2016– Accelerate control of vaccine-preventable

diseases through introduction of new and underused vaccines

– Strengthen and expand VPD surveillance – Continue to expand immunization beyond

infancy


Vaccination ScheduleS.N. Vaccine Dose Age of Administration Route of Administration

1 BCG 1 (0.05 ml) At birth Intradermal (ID)

2 DPT-Hep B-HiB (Pentavalent)

3 (0.5 ml) 6, 10, 14 weeks Intramuscular (IM)

3 OPV 3 (0.5 ml) 6, 10, 14 weeks Oral

4 PCV 3 (0.5 ml) 6, 10 weeks and 9 months Intramuscular (IM)

5 IPV 1 (0.5 ml) 14 weeks (Addon to OPV) Intramuscular (IM)

6 MR 2 (0.5 ml) 9 and 15 months Sub-Cutaneous (SC)

7 JE 1 (0.5 ml) 12 months Sub-Cutaneous (SC)

8 TD 2 (0.5 ml) As soon as pregnancy is known (2 doses 1 month apart)

Intramuscular (IM)


AccomplishmentS.N. Objective Status of Achievement

1 Achieve and sustain 90% coverage of all vaccine of routine immunization

> 90% of coverage since 1990

2 Maintain Polio Free Status

No indigenous wild poliovirus cases reported since August 2010. Nepal was declared Polio Free Country on 27th March 2014.


Accomplishment Continue3 Sustain MNT Status Sustained. No cases

detected since 2005.

4 Initiate Measles Elimination Plan to eliminate measles by 2016

5 Expand VPDs Surveillance Integrated surveillance for AFP, measles, JE, NT and pneumonia for ARI

6 Accelerate Control of VPDs through introduction of new vaccines

Hib, JE and PCV vaccine introduced in regular immunization


Accomplishment Continue7 Expand Immunization

Series beyond InfancyTT immunization continues in 12 districts

“ Every Child Counts”: Till now 16 districts, around 1500 VDCs and 40 Municipalities has been declared All Child Fully Immunized (ACFI) with plan to declare the country ACFI within 2017.


Problems/ Constraints/ Action to be TakenProblems/Constraints Action to be Taken Responsibility

Inadequate HRH and ill defined JD of AHW& ANM

• Provision for alternative vaccinators for the vacant posts• Incorporate responsibility of delivering immunization service in Job Description of all HA, SAHW, AHW/ANM to conduct immunization sessions

MoHP/DoHS/DHO

Poor quality immunization data: Under and over Reporting

• Supportive supervision of Immunization as per HMIS.•Strengthen supportive supervision at all levels• Quarterly review of performance of data atHF/DHO level as HMIS31, HMIS 5.‐

HF/DHO/RHD/CHD/HMIS

Problems/ Constraints/ Action to be Taken Continue

Poor Inventory keeping anddistribution system

•Update inventory of cold chain equipment with their cold chain capacity and vaccine, syringes, diluents etc. and use of stock control register. •Maintain maximum and minimum stock level.•Always make vaccine requisition by deducting the stock at hand from maximum stock level of vaccine/syringes/diluents

RMS/District ColdStore

In effective immunization month celebration

Utilize immunization month as an opportunity to intensify routine immunization activities especially all

Districts

Logo of Immunization Clinic

Thank You

Health care system of nepal

Healthcare

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