NATIONAL HEALTH POLICY 1991

ACHIEVEMENT AND CHALLANGES

Dr.Sharad H. Gajuryal

Junior Resident,

MD Hospital Administration

BPKIHS,Dharan

Soon After the re-establishment of a constitutional monarchy and multi-party democracy in Nepal in 1990, The government developed a National Health policy (NHP) in 1991 with following vision and approches and components.

Vision: The government committed to create a socio-economic environment to allow all Nepalese citizen to lead a healthy life.

Objective: To Upgrade the health standards of majority of rural popolation by extending Basic primary health services and making modern facilities and trained manpower available at the village level for rural people.

Priority: Priority was given to rural area using primary health care approach with preventive, promotive and curative health services to reduce infant and child mortality.

National Health Policy was adopted in 1991 (2048 BS) to bring about improvement in the health condition of Nepalese People. The primary objective of National Health Policy was to extend the primary health care system to rural population so that they can be benefited from modern medical facilities and trained health care providers.

THE POLICY HAVE 15 COMPONENTS RANGING FROM PREVENTIVE HEALTH SERVICES TO BLOOD TRANSFUSION SERVICES AND MISCELLANEOUS ISSUES.

1. Preventive Health Services: Priority is Given to the program that directly help to reduce infant and child mortality rate.

2. Promotive Health Services :Priority is given to the programes that enables people to live healthy lives.

3. Curative Health Services: Curative Health Services will be available at all health institutes- Central, Regional, Zonal and district Hospital, PHC, HP, & SHP and at all levels of the healthcare system. Mobile teams will be organized to provide specialist service to remote area. Hospital expansion will be based on population density and on patient loads.

-A referral system will be introduced to direct the rural population to well-equipped institution.

Basic Primary Health Services: Sub Health Post will be established in phased mannner in all VDC. One health post in 205 electoral constituencies will be upgraded in gradual manner and converted to a primary health care center (PHCC)

Ayurveda and other Traditional Health services: The ayurvedic System will be developed and other traditional system ( Unani, Homeopathy, naturopathy) will be encouraged.

Community Participation in Health Services: Community participation will be sought at all level of healthcare through participation of FCHV, TBA, and leaders of various local social organizations. VDCs will provide the site for location of Sub-Health posts.

Organisation and management: Improvement will be made at organization and management level of health facilities at central,Regional, aand district level. This will include the intregation of District hospitals and public health offices into district health offices.

Human Resource for Health Development (HRH): Technically competent human resources will be developed for all health facilities. Training center and academic institution will be strengthened.

Resource Mobilization in Health Service: National and international resources will be mobilized and alternative concepts (health insurance,user charges and revolvind drugs schemes) will be explored

Private,Non-Govermental Health services and inter-sectoral coordination : The Ministry of Helath will co-ordinate activities with private sector, NGOs and non-health sector of Government of Nepal.Private sectors and NGOs will be encouraged to provide health services

Decentralization and regionalization: Decentralization and regionalization will be strenghthened ; peripheral unit will be made more autonomous. District Health office (DHO) will have prominent role in planning and management of curative and promotive health service from district to village level.

Blood Transfusion Services:Nepal Red cross societ will be authorised to conduct all programes related to blood transfusion. The practise of buying,selling and depositing blood will be prohibited.

Drugs Supply: Improvement will be made in supply of drugs by increasing domestic production and upgrading the quality of essential drugs through effective implementation of National drugs policy .

Health Research : Health research will be encouraged for better management of health services.

ACHEIVEMENTS OF NATIONAL HEALTH

POLICY COMPONENTS

1.Preventive Health Services:Objective: To priotise program that directly help to

reduce infant and child mortality rate.-To provide services in integrated manner through sub health post to the rural area.

Achievement: Integrated service delivery has happened at sub-health post level and upto district level which worked well although in many cases resource have been insufficient and staffs inadequately trained. This has succesfully reduced child and infant mortality rate such that Nepal is on course to achieve the infant and child mortality MDG by 2015.

2.Promotive Health Services: Give priority to the probram that enables people to live a healthier lives across the three subjects of :

-Health education and information -Nutrition -Environmental Health

Achievements : A national health education, Information and communication centre was estd. In 1992 to promote public awareness on health matters. However, the provision of health education from central to village level has not had desired impact on changing behaviour.

CONTD..

The environmental health program ( on personal hygiene, solid waste management, food standard and other subjects) have not gone ahead to the required extent mainly due to a lack of coordination between concerned ministries.

3. Curative Health Services : -Making health services available in an integrated

way in rural areas -organizing mobile teams to provide specialized

service to remote area. Establishing zonal and regional hospital in all

zones and regions to provide specialized services Equipping central hospitals with sophisticated

diagnostic and other facilities Developing a referral system to direct the rural

population to well equipped institution and Hospital expansion on population density and

patient loads

Achievements:The target of one hospital per district has been achieved and teams have been mobilised to remote places to provide specialist service to needy one .

Establishement of hospitals at different levels with defined services have not been fully achieved as zonal hospital still lack speciality service and regional hospital have not been establised as plannes with only two existing (surkhet and Pokhara) against five planned.

The central Hospitals mostly lack adequate sophasticated diagnostic and other facilities and referral system poorly developed.

4. Basic Primary Health Services:

-one sub-health post in all VDCs to cover an average of 4,000 people each.

-One health post in all ilakas (=5 adjoining VDCs) to cover an average of 29,000 people each.

One PHC in all 205 electoral constituencies to cover an average of 100,000 people each.

-One DHO/District hospital in all 75 dictrics to cover an average of 200,000 people each

-One Zonal Hospital in all 14 zones to cover average of 1.3 million people each

-One regional Hospital in all 5 regions to cover average of 3.6 million people.

-Central Hospital Providing super-specialist services and teaching facilities

Achievements: -The Target of establishing new sub-health

posts in all VDCs and PHC in all elctoral constituencies has been achieved to greatly improve access to basic health services. Accourding to Annual Health Report 069/70 there are ,205 Primary Health Center (PHC), 822 Health Posts(HP), 2987 Sub-health Posts (SHP) in total . And these facilities are being upgraded gradually to higher levels.

However the commitment mande to exxpand hospital on the basis of patient load and density has not been followed.

The free essential health care policy 2008 has led to user charges and community drug program being replaced by the free provision of basic health services and drugs. This has led to an increse uptake of services.

5. Community Participation in Health Services:

Achievements: Community participation at all level has been encouraging. More than 50,000 FCHV are providing basic health services to communities. Also most VD has donated space (Usually in VDC building) to run sub-health posts.

6.Organizational and management reform -To improve the organization and management

of health facilites at cental, regional and district level.

Achievements: In almost all districts, District Hospitals and Public health offices have been integrated under a single administration, although there are conflicts between nedical and public health personal.

Mandatory rules for health facilities to display the services they offer and their cost.

Although a strong health management information system exists, the data and information it generates is little used for decision making .

Improvements in health logistics management system and expansion of the road network have led to improvement in transporting drugs and euiipments to districts. But these are still significant problems.

7. Development and Management of Human resource for health.

-To develop techically competent human resources for all health facilities and strengthen training centers and acedemic institutions

-provide special benefits for doctors and other health personel to encourage them to work in remote rural areas.

-Reform the system for staff transfer and promotion and carrer development.

In 1991, IOM was only institue training health personal who work in below district level health facilities (mid and basic health level workers)

Achievements:Many public and private institue have been established since 1991 to train human resources for health but some have weak regulatory mechanism and right skill mix of human resource for health is not being produced.

Although many trined doctors and nurses in Nepal. Its still a challenge to get them work in rural and remote areas.It may be due to many attraction in working in urban area with lack of carrer development oppertunities in remote postings

National health training center is the apex body of ministry of health and population for in-service training centers in each of five region of Nepal. However it is yet to be adequately staffed with multidisciplinary faculty

8.Private,NGOs and intersectoral co-ordinations

Achievements: There has been a large growth in number of private hospitals and other health facilities since early 1190s, almost all located in urban areas and focusing on curative services.

However, although guidelines have been developed for minimum standard of private health facility, they have not been fully implemented due to weak monitoring mechanism.

Have lack of coordination with different organization and ministry like health and agriculture, education, drinking water.

9.Ayurveda and traditional health service: In 1991: There were 1 ayurvedic hospital

(kathmandu) 14 zonal ayurveda cllinics (aushadyalaya), 68 district ayurvedic health centers , one homeopathic hospital and one unani dispensary in kathmandu.

Achievements :A national ayurvedic health policy was introduced in 1996. however in nepalese soceity , this system of medicine is not attracting the general public to the desired extent. other system of medicine such as unani ,homeopathy, naturopathy have not been flourished.

As of 2011 ayurvedic health services are being delivered through two avurveda hospitals ( a one bed hospital in kathmandu and 330 bed hospital in Dang), 14 zonal ayurvedic clinics, 61 district ayurvedic health centers and 214 ayurvedic centers. There is one ayurvedic medicine manufacturing unit. There is one homeopathy hospitaal and one unani dispensary in kathmandu.

10.Drugs Supply – NHP 1991 Policy: To improve supply of essential drugs by

increasing domestic production and upgrading the policy of essential drugs by implementing the national drug policy .

Achievements : A new National Drug Policy was introduced in 1995, that has successfully encouraged domestic drug production. The domestic production of essential drugs, mostly by the private sector, has met the expectations of the policy. To some extent drugs produced in Nepal have replaced ones imported from India and other countries. NHP 1991 did not however adequately spell out the need for an overall logistics system including procurement, storage, quality and distribution of medicine, vaccines, contraceptives, equipments and other supplies.

11. Resource Mobilization

NHP 1991 policies: Mobilise national and international resources and explore alternative concepts (such as health insurance, user charges, and revolving drug schemes).

Achievements — The proportion of the national budget dedicated to the health sector has increased to about 7%. The government has on several occasions committed to increasing the health budget to 10% of the total; but this has yet to happen.

12. Health research

NHP 1991 policies: To encourage health research for the better management of health services.

Achievements — The Nepal Health Research Council was established in 1991 to facilitate research in the health sector. However, scant policy research has been carried out and findings from surveys and routine information collection are not adequately used for decision making.

13. Regionalization and decentralization

NHP 1991 policies: Strengthen decentralization and regionalization and make peripheral units more autonomous. Give district health offices (DHO) a prominent role in planning and managing curative

and promotive health services from district to village levels. The proposed organizational structure (see Annex 2) gives five types of regional level health facilities including regional hospitals.

Achievements — Regional laboratories, health training, medical stores and other health facilities have

only been established in some regions. The Local Self Governance Act 1999, gave considerable responsibilities to local government bodies at the district municipality and VDC level for running

health facilities. In line with this legislation the Ministry of Health has moved to decentralize health facilities by forming inclusive health facility operation and management committees. These committees have been

made responsible for managing health facilities. The bottom-up planning of health programms has been introduced involving district development committees and VDCs and micro-planning

procedures have been adopted for extending preventive health services at the village level. The implementation

of the Local Self-governance Act, 1999 is hampered by the continuing lack of elected representatives

at district levels and below.

14. Blood transfusion

NHP 1991 policy: Authorise the Nepal Red Cross Society to conduct all programmes related to blood transfusion. Prohibit the practice of buying, selling and depositing blood.

Achievements — The Nepal Record Cross Society became responsible for the country’s blood transfusion service and the practice of buying, selling and depositing of blood following the introduction of the National Blood Policy, 1993.

15. Miscellaneous issues

NHP 1991 policies: These issues were worker health and safety, law and regulatory reform, anti-smoking, anti-alcohol and substance abuse campaigns, and programmes for disabled persons.

Achievements — Programmes for the welfare of disabled persons have been implemented in coordination with the private and NGO sector and awareness programme have been run against smoking and other harmful practices. Nepal endorsed the international Framework Convention on Tobacco Control (FCTC) in 2006 and following this banned the advertising of tobacco products and alcohol on the electronic media and banned on smoking in public places. The least achievements have been made on health and safety for workers.