Health System and Health System Strengthening in Nepal

Dr BR Marasini, MBBS, MPH

Senior Health Administrator

Ministry of Health and Population

Background

• The health system in Nepal is 122 years old and based on primary health care approach

• Very different diseases in plain southern part and high mountain north parts

• Health services are mixed –both government and non-government (for profit and not for profit)

The Health Care Systems

• Allopathic or modern medicine

• Traditional medicine – Ayurveda and Amchi

• Homeopathy

• Unani

• Other complimentary systems

Health Service Delivery

• Community based health services and interventions- immunization (mobile clinics -every month), Vitamin A and albendazole distribution (twice a year) & primary health care out reach clinics (mobile clinics- every month) from local health facility

• Female community health volunteers and mothers groups

• Hospital and facility based services-general, specialized and mobile

Health Service Organization

• Sub health post

• Health post

• Primary health centre

• District hospital

• General hospitals- zonal and regional headquarters

• National hospitals

• NGO and Private health institutions

Health Governance

• Ministry of Health and Population• Three Departments - Health Services,

Drug Administration and Ayurveda• Regulatory bodies- Medical Council,

Nursing Council etc• Five Regional Health Directorates• 75 District Public/Health Offices• Facility level health/hospital management

committees

Human Resource for Health

• 18 medical and five dental colleges• Nursing colleges• Pharmacy colleges• Allied health professional colleges• 80% positions of the public health facilities

are now fulfilled• Fulfillment of vacant positions health

personnel also initiated through local initiative

Health Financing

• Government of Nepal

• Donors

• Local bodies –increasing trend for last two years

• International non-government organizations

• 7.2% budget in health sector in current financial year

Infrastructure Development

• Building of 700 (apprx.) health facilities is under construction (new or expansion or major renovation)

• More equipments and logistic support with better timely maintenance initiated

• The main focus of infrastructure development is maternity services

Major Policies and Initiatives

• Health sector reform • Sector wide approach• Millennium development goal• Poverty reduction• Social inclusion • Nepal health partnership compact and

international health partnership plus• Global health initiative• Health System Funding Platform

Major Programme Initiatives in Health Sector

• Institutional delivery declared free with maternity incentive scheme

• Introduction of Free Health Care (service charges abolished & essential drugs provided free)

• Surgery of uterine prolapse • Cash support to poor patients suffering from

cancer, heart disease, chronic kidney disease, Alzheimer's disease & Parkinson's disease

Major Health Programme----

• Compulsory two year posting of physicians out side Kathmandu completing MBBS course in government scholarship

• Community based neonatal care

• Nutrition supplementation programme

Health Outcomes and Progress Towards Health Sector MDGs-1

Indicators 1990 2001 2006 2009 2015MDG-1: Nutritional stunting (height for age) %

57 48 42.7 30

MDG-4:Neonatal mortality rate/1000 live births

50 39 33 20 16

MDG-4: Infant mortality rate/1000 live births

108 79 48 41 34

Health Outcomes and Progress Towards Health Sector MDGs-2

Indicators 1990 2001 2006 2009 2015

MDG-4: Under five Child mortality rate/1000 live births

161.6 91 61 50 54

MDG-5: Maternal mortality ratio/100000 live births

515 539 (1996)

281 229 134

Total Fertility Rate 4.6 4.1 3.1 2.9 2.4

Health Outcomes and Progress Towards Health Sector MDGs-3

Indicators 1990 2001 2006 2009 2015

MDG-6: HIV prevalence in 15-49 year/100,000 population

- 290 490 (2007)

390 (2009)

Halt & reverse

MDG-6: Tuberculosis prevalence rate/ 100,000 population

460 310 280 Halt & reverse

MDG-6: Malaria prevalence rate/100,000 population at risk

196 52 25 Halt & reverse

Core Intermediate Health IndicatorsIndicators Current status Target for

2015Remarks

Contraceptive prevalence rate

49.6% (any) 45.1% (modern -2009)

67%

Skilled Birth attendance rate

28.8% (2009) 60% Institutional 24.4%

Immunization rate –DPT3

83% (HMIS-2010)

100%

Knowledge on Prevention of HIV Infection (at least one method)

Female-58.3%

Male- 81%

(NDHS-2006)

Female-100%

Male-100%

Health Sector Budget and Expenditure by Year

Financial year Total Health Budget

(NRs billions)

Health sector budget as a percent of national budget

Actual expenditure rate as a percent of

planned budget

2004-05 6.5 5.86 70.0

2005-06 7.5 5.95 76.5

2006-07 9.2 6.40 81.0

2007-08 12.2 7.15 81.0

2008-09 14.9 6.33 84.9

2009-10 17.8 6.24 90.0

Challenges

• Climate change and health

• Equity, accessibility, quality and coverage of essential health care services

• Nutrition

• Inter agency coordination

• Sustainability of health programme

• Reemerging and new emerging diseases

Challenges

• Deployment and retention of HRH in remote and rural areas

• Increase in non-communicable diseases

Thanking you for your kind patience