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Health System of NepalRoshan khadka
Mahidol university
The nation will remain as long as the sun and moon is on the earth
Prepare and Presentation by -
Roshan khadka Jeevan bhattaMahidol university Mahidol universitySalaya, Thailand Salaya,Thailand
N
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%
Source: Population and Housing Census, 2011
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.
Source: Population and Housing Census, 2011
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
Source: Population and Housing Census, 2011
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.
Source: Annual Report 2015
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
Source: Annual Report 2015
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.
Source: Annual Report 2015
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.
Source: Annual Report 2015
Nepal’s Free Health Care Policy Continue
• 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
Source: Annual Report 2015
Nepal’s Free Health Care Policy Continue
• 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
Nepal’s Free Health Care Policy Continue
• Nyano Jhola (or warm bag) is the set of dress provided to mother and the child immediately after delivery.
Source: Annual Report 2015
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.
Source: Annual Report 2015
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
Female Community Health Volunteer
Village Development Committees
3,157
Female Community Health Volunteer
Wards48523
1
4
2
3
5 6 7
8 9
Female Community Health Volunteer
Ward
FCHVs51470
Female Community Health Volunteer
Female Community Health Volunteer
• 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
Source: www.mohp.gov.np/index.php/publication-1/guideline
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.
Source: www.mohp.gov.np/index.php/publication-1/guideline
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).
Source: www.mohp.gov.np/index.php/publication-1/guideline
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.
Source: dohs.gov.np Nepal cYMP 2012-2016
National Immunization Program Continue
• 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
Source: dohs.gov.np Nepal cYMP 2012-2016
National Immunization Program Continue
• 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
Source: dohs.gov.np Nepal cYMP 2012-2016
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)
Source: dohs.gov.np Nepal cYMP 2012-2016
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.
Source: dohs.gov.np Nepal cYMP 2012-2016
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
Source: dohs.gov.np Nepal cYMP 2012-2016
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.
Source: dohs.gov.np Nepal cYMP 2012-2016
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