202 Nepal’s Quest for Health

6.
PLANS, POLICIES AND THEIR
IMPLICATIONS

In the early days of health planning in this country a number of plans were
made. Subsequent to this, there was a tendency for part of the plans to be
suddenly and periodically changed by ministers and secretaries. With change
in individuals, the priorities were sometimes so drastically altered that it
became difficult to work. It was in that setting that the need was felt to have a
Long Term Health Plan or even just a Plan, which could not just be
arbitrarily changed.

Long Term Health Plan (1975-1990)

Twenty-five years after the ushering in of democracy in Nepal it was felt that
the infrastructure for proper delivery of health care was in place. It was
thought to be the opportune moment to think in terms of a Long Term Health
Plan. An initial draft was made by a group of three doctors at the Ministry of
Health.
With the blessings of the then Minister of Health, an eight-member
committee with five doctors and three baidyas was formed to formulate an
overall health plan for the whole country. The five doctors involved were:
Dr. Lakshmi N. Prasad
Dr. Narendra B. Rana
Dr. Manindra R. Baral
Dr. Sundar Mani A. Dixit
Dr. Nagendra Dhoj Joshi

This team travelled to various parts of the country with the objective of
making a twenty-five year plan. Following initial discussions at the Ministry

+
 Plans and Their Implications 203

some other doctors were added to the committee. The question of whether
the posts at the government hospitals should be “non-practising” or
“practising” was discussed.
After further deliberations at the Janch Bujh Kendra of those days, this
was modified and ultimately resulted in to the Long Term Health Plan 1975-
90 (1). This included therefore the Fifth, Sixth and Seventh Plan periods with
the idea that what was achieved in one plan period would be dovetailed into
another. The inference at that time was that the future health policies,
strategies and activities were to be according to this. The main emphasis in
this LTHP was the provision of basic health services to a large majority of
the people. This was an honest attempt by the authorities to get things
moving in the health field.
This document recorded the state of the health services existing, and the
long-term aspects. Primary health care, hospital services, family planning and
management aspects were also looked at. The annexure gave the criteria of
service and manpower allocations to various grades of health institutions.
As time went on however, it soon became apparent that things were not
going on as per the plan. The general complaint was that when people asked
for activities listed, the excuse was lack of budgetary resources and that it
would be done in due course. What was not in the plan could not be
considered. The end result as per the gossip going around was that only
facilities for the doctors working in the ministry was carried out and
everything else was held in abeyance.
It was the mid-term review of the first of the three plan periods i.e.
1975-1980, which had been done over the period from March 1978 to June
1979 by a special team with the help of New ERA for the collection of data.
To make the survey accurate the authors:
“undertook a sample survey of a variety of health institutions and of
population with differing access to health services. In all, thirty-one of the
seventy-five districts were included in this survey, providing representation
of all four development regions as well as both hill and Terai areas. Over 150
separate health facilities were visited, and interviews were conducted in
nearly 3,700 households in eighty panchayats.”
It is interesting to quote from Chapter 7 of this document (2), which
goes on to state:
“Although health services are provided with the intention of meeting the
needs and health requirements of the people, there is not always unanimity

+
204 Nepal’s Quest for Health

about what those needs are, or about what priority a given individual or
community would place on a particular action to improve health. Because
health planners and health technicians often have rather different ideas about
the importance of various health activities than do non-technical persons, the
perspectives of health service providers and the rest of the community are
often different.”
Even before 1990 came, the general complaint was that whenever one
went to the Health Ministry with a proposal, the first reaction as to its
feasibility was whether it was in the Plan or not. If it was not in the plan,
there was no possibility of getting it done. If it was in the plan, the authorities
would consider it, but in all probability it would not be done because of lack
of funds etc. As a result of all this, ad hoc decisions on the basis of political
expediency were the order of the day. At times when offers simply came out
of the blue e.g. that of a teaching hospital by the Japanese, then there were
grounds for such action. Just as the Teaching Hospital came into existence in
the eighties without really having been fully planned earlier so also the BP
Koirala Institute of Health Sciences (BPKIHS) also came out of the blue in
the post andolan period of the nineties.
All said and done this mid-term review report was ready by June 1979,
but as it was thought to be fairly critical of the state of health and its affairs
and so was not distributed. The observations were categorised into two
groups viz. those regarding policy and those related to management. Some of
these, which were critical, are given below:
On Policy Issues

• District Hospital role in preventive care delivery, training and supervision

largely not being discharged.
• Leprosy and tuberculosis follow-up programmes are largely not being
implemented.
• Government health services still have low geographic accessibility,
extremely limited outreach facility, and as a consequence low use.
• VHWs visit more households than PBWs but both much less than MFWs.
The PHW-VHW difference is greatest in Terai. More VHWs than other
field staff feel the number of houses to be visited is serious constraint to
effectiveness.
• District Health Committees seldom have representation from projects or are
even known to project staff other than ICHP.

+
 Plans and Their Implications 205

• Supply shortages in all projects except Malaria.

• Most post level units do not have their own water supply. At best only half
the post units have latrines with Ayurvedic clinics being the least well
served.
• For over half the staff at district and health post units no housing is
provided. To a small extent this is compensated for by some free
accommodation provided by the community.
• A fixed programme of refresher training is not offered by any project. The
need for further training among field worker is most felt by PBWs.

On Management Issues

• Community awareness and use of family planning and maternal and child
health services, and facilities is low. Understanding is low even among the
aware population in areas where FP and MCH services and facilities are
available.
• Many workers are unclear about role in preventive tasks prescribed by
central organisation.
• Most Health Committees at both district and health post were inactive. Few
people in HP areas knew of the existence of Health Committees.
• Few community leaders had been involved with the selection of local health
worker; those who had been involved were mainly in the VHW selection.
• Critical shortages in disease prevention vaccines in all units, which may
severely inhibit preventive programmes, particularly in hospitals.
• The majority of all units never receive operating funds either development
or regular on time. The situation improves with each quarter of the fiscal
year.
• There is a shortage of written guidelines for supervision in all projects but
primarily in ICHP.

Country Health Resources & Priorities (CHRP)

This exercise may be said to have been done to review what had been
achieved in the Seventh Five Year Plan period and at the same time to help
the National Planning Commission to lay down guidelines for the Eighth
Plan 1990-95.

+
206 Nepal’s Quest for Health

The first phase consisted of a 5-day preparatory workshop, which

looked at various issues on hand. This was followed by a second phase of 14
days where four groups of between 5 to 10 members each looked at the under
mentioned four areas:
a. National Health Policy
b. Development of Health Services and Institutions
c. Minimizing Risk Factors
d. Prevention and Control of Diseases

A fifth working group worked for a further 8 days and made a CHRP
working document which the organising committee then improved and sent
as the second draft to various HMG officials plus various agencies for
comments and suggestions. The final version of the document was brought
out in January 1990 but was never distributed thereafter (3). During the one-
year period of the Interim Government it was not referred to. The National
Planning Commission went on a so-called “one year Plan holiday” which in
fact turned out to be two. Thus the schedule of the Eighth Plan period came
to be 1992-1997.
The World Bank, too, did a survey and came out with suggestions for a
reorganisation (4).
Situation analysis for the re-structuring of the health services was done
over a six month period during end of 1990 and early 1991 (5). Taking the
commitment of Basic Minimum Needs Programme of HMG, it brought into
focus the fact that previous studies had shown that the existing health system
was not, “both quantitatively and qualitatively geared up to achieve the BMN
goals”. Following the period of study, certain macro recommendations were
made for the re-structuring of health services. These were:
a. Strengthening outreach services i.e. health posts and below
b. Strengthening district health system
c. Development of appropriate, effective and efficient Regional and
National (central) health organisations
d. Development of strategic national perspective plan
e. Manpower planning and development

Following elections of 1991 the Nepali Congress formed the

government and the PM took the portfolio of the Health Ministry. It was at

+
 Plans and Their Implications 207

this juncture that a delegation of the Nepal Medical Association met him and
requested a White Paper on Health. This was agreed to and a committee was
formed under the Secretary of Health to think about the matter and proceed
accordingly.
Before any firm decisions were taken, a medical doctor became the new
Minister of Health. HMGN in Sept 1991 formed a committee and
subsequently a number of other subcommittees to draw up a plan of action
with appropriate strategies to provide health services up to the village level
as per the guidelines of the contemplated National Health Policy 1991. The
new group looked at various aspects of health and their reports were
submitted by the deadline of Nov. 1991. In hindsight, it may have been a
strategy to keep people occupied, and to create a state of “make believe” that
something is happening. The first reaction is that this report is now shelved
and unlikely to see the light of day.

National Health Policy - 1991

The National Health Policy of 1991 focuses on two broad areas for singling
out and may be categorised as follows:
Preventive Health Services
Family Planning (FP), Safe Motherhood, Expanded Programme for
Immunisation (EPI), Control of Diarrhoeal Diseases (CDD), Acute Respiratory
Infections (ARI), Malaria.

Promotive Health Services

Health Education, Nutrition and Environmental Health.

Strengthening of the District Health Systems

Special efforts were made to prepare plans and strategies for the
strengthening of the health service delivery at the district levels (6).
But all said and done one has to look for a delivery of health care, which
one can afford. A Global Research Project conducted by SCF(UK) looked at
the sustainability of the health sector in Nepal during the course of 1991/92 (7).
Some of the comments in its executive summary are:
• At approximately $ 1.30 per capita, the expenditure on health by the
Ministry of Health is very low, even for a developing country,

+
208 Nepal’s Quest for Health

although the share of government expenditure on health (about 4% in

recent years) is about average for less developed countries.
• The period between 1951-74 was characterised by the entry into Nepal
of INGOs for direct health service delivery and the establishment of
vertical disease control programmes by major donors.
• The period between 1975-90 was characterised by greater attention to
planning for the health sector for meeting national and global goals.
• Nevertheless, the health sector infrastructure and numbers of staff
continued to expand rapidly, most due to donor initiatives and
funding, while the capacity to manage these new resources tended to
lag behind.

It was in this context too that a special consultation was done towards
the end of 1993 to look into ways and means of strengthening the district
health systems. Task forces were created with a view to tackle the problems.
It was felt that some of the district hospitals could be made into models to
show it’s functioning to be mutually supportive with the district health
systems. To ensure that HRH personnel function effectively to deal with the
health problems of the society, this particular report makes a plea for training
and research to be located in the settings and systems in which the health
workers are most needed. Quoting from a Round Table discussion article
entitled “Educating Tomorrow’s Doctors” in World Health Forum, it goes on
to say:
“The consensus is becoming firm in both developed and developing
countries that academic health centres should associate themselves with
defined populations, where they focus teaching and research related to the
health of the population and the effectiveness of the health care system.”
The recommendation is that the universities should be encouraged to
collaborate with the government in the development of district health systems
for the purposes of education and research. Such thinking is very pertinent in
view of the fact that a number of teaching institutions have been established
over the last decade in different parts of Nepal.
In this same vein it is worthwhile remembering that just prior to starting
of the MBBS course at the Institute of Medicine a number of district health
surveys were done at Tanahu, Bara, Dhankuta and Nuwakot. A later survey
was at Surkhet. Repeat survey done at Dhankuta. Such research identified the
existing situation, the health service demands and the needs. During the
course of the eighties foreign medical graduates did a number of health

+
 Plans and Their Implications 209

studies with accompanying Nepalese medical students and sometimes faculty

in other areas of Nepal. A regular feature of the community oriented MBBS
programme of the IoM is that each batch of medical students have spent time
in the community and done a report of that study. A recent report by Tiwari
(8), which drew on some of these studies stated that “there is generally poor
response by the majority of the people to the available health services
particularly in the rural areas.” This report of April 1994 stated that the
primary health services in the country were inadequate and that the existing
health institutions are not functioning properly due to the lack of trained
manpower, medicines and equipment.
The year 2052 BS (mid-April ‘95 to mid-April ‘96) may be taken as the
policy-making year for during this one year a number of policy documents
were made public. These were:
National Policy for AIDS & STD Control - 2052 BS
National Ayurvedic Health Policy - 2052 BS
Safe Motherhood Policy of HMG/N

Logistic Management Division

The division was started in the Department of Health Services in 1993. This
attempt to systematise health care logistics was started then and is continuing to
this day. An efficient logistic management of health care commodities
(essential medicine, vaccines, contraceptives, medical equipments /
instruments, HMIS / LMIS forms etc) involves technical, managerial and
administrative expertise, which has to be maintained at all, times.

Nepal Multiple Indicator Surveillance (NMIS)

The NMIS was designed as an ongoing monitoring scheme to produce
information useful for planning at national, district, and community and
household levels. Started with a multisectoral baseline survey in early 1995
the NMIS process comprised of repeated cycles of data collection, analysis,
interpretation and communication of results with and objective of stimulating
action (9). Each cycle focuses on a priority set of issues as given below:
Cycle 1. Information about malnutrition and feeding practices among
young children. Indicated need for more information
Cycle 2. Primary Education (in Spring/Summer 1995)
Cycle 3. Diarrhoea, Water and Sanitation (in first half of 1996)

+
210 Nepal’s Quest for Health

Cycle 4. Early Childhood Feeding, Nutrition and Development (in

second half 1996)
Cycle 5. Care during Pregnancy and Delivery

Second Long-term Health Plan (1997-2017)

The specific purpose of the Second Long Term Health Plan (SLTHP) is to
provide a guiding framework to:
• Build successive periodic and annual health plans that would lead to
improvement in the health status of the population.
• Develop appropriate strategies, programmes and action plan that: reflect the
national health needs and priorities; are affordable and consistent with
available resources.
• Establish co-ordination among public, private sectors (including NGOs) and
donor partners (10).

Based on the demographic and disease profile a “Essential Health Care

Services (EHCS)” of highly cost effective public health measures and
essential clinical services for traditional and other systems of medicine is
proposed. The EHCS is to address the essential health needs of the
population at the district level and below during the course of the next twenty
years.
To effectively implement the EHCS the health sector must:
1. redirect resources from high-cost low-impact interventions to those
that could substantially reduce morbidity, mortality and disability
without increasing expenditures;
2. address the issues which limit the effective utilization of scarce human
and financial resources; and
3. adopt alternative financing mechanisms, which seek to mobilize non-
governmental funds to support health care and increase the public-
private mix in terms of financing and provision of services.

Within this context, the Second Long Term Health Plan defines the
EHCS and identifies the key issues and policy options necessary for:
1. improving the efficiency and effectiveness of the health care system;
2. improving inter- and intra-sectoral coordination and providing the
necessary conditions and support for effective decentralisation;

+
 Plans and Their Implications 211

3. overcoming management and organizational constraints for effective

public health sector service delivery;
4. ensuring that appropriate numbers, types and distribution of
technically competent and socially responsible health personnel are
available to provide quality health care to all the people of Nepal,
particularly those living in rural areas;
5. ensuring that the health care system provides care that is effective in
producing positive health outcomes as defined by health care
professionals and in which the community is satisfied that their needs
are being met;
6. providing the requisite data, analysis and interpretation necessary for
informed decision-making and
7. addressing the changing trends of communicable and non-
communicable diseases and emerging health issues.

Strategic analysis of the health sector was done in the presence of

External Development Partners (EDP), NGOs and the private sector in Sept /
Oct. 1999. The purpose was to map out future action with the objective of
operationalisation of the strategies for the improvement of the health services
(11).

While the concept and stress on working through NGOs is a good idea,
the crucial first step is to separate the wheat from the chaff. In the long range,
the SLTHP may turn out to be a document of good intentions, liberal rhetoric
but short in action !

a. NATIONAL HEALTH POLICY NEPAL (1)

The Nepali Congress Government committed itself to creating a

socioeconomic environment to allow all Nepalese citizen to lead a healthy
life in conformity with the saying “Health is Life.” Highest priority was
being given to upgrading the health standard of the ninety-three percent of
the Nepali people who live in rural areas using a Primary Health care
approach. Particular attention is being paid to availability of family planning
and MCH services, preventive health services, and easily accessible referral.
In pursuit of the goal of improved health, the Government wanted to
establish one sub-health post in each village development committee and 205

+
212 Nepal’s Quest for Health

primary health care centres throughout Nepal.

The health system in Nepal has suffered from a number of problems in
the past, including a lack of village orientation, weakness in implementation
of plans, weakness in monitoring and evaluation, centralization of resources,
and unfilled posts. The new health policy of the Nepalese government hoped
to resolve these problems, and will strive, towards the targets of reducing
infant mortality from 107 per thousand to 50 per thousand, reducing
mortality of children under five from 197 per thousand to 70 per thousand,
reducing total fertility from 5.8 to 4, reducing maternal mortality from 8.5
per thousand to 4 per thousand, and increasing life expectancy from 53 to 65
years.
The basic government plan for attacking the health problems of the
Nepalese people was to have the following components:
1. Preventive health service to concentrate on family planning and
MCH, including safe motherhood; expanded immunization;
diarrhoea and acute respiratory infection control; and prevention and
control of communicable and non-communicable diseases.
2. Promotive health services including health education and
information for increased awareness of health matters; promotion of
breast-feeding, use of iron, iodine and Vitamin A supplementation;
and personal and environmental hygiene.
3. Curative health services to be expanded to provide sub-health posts,
health posts and primary health care centres in the rural areas and
district, regional and central hospitals for referral services.
4. Basic primary health care services to be based on the sub-health
posts and 205 primary health care centres.
5. Community participation in health care to involve women
volunteers, TBAs, and local leaders at every level.
6. Organization and management improvements to be made, including
decentralized management, improved supervision, improved
management information and improved logistics and supply
arrangements.
7. Improved manpower development and management policies for
HRH to be implemented, including increased cooperation between
service and training, and improved policies posting, transfer and
promotion.

+
 Plans and Their Implications 213

8. Private, non-government and inter-sectoral coordination with the

government system to be encouraged.
9. The ayurvedic and other traditional systems to be developed in a
gradual manner to assist in the improvement of health in those areas
where they are appropriate.
10. The quality and availability of drugs at the village level to be
increased and effective funding mechanisms will be developed.
11. Every effort to be made to mobilize all government and external
resources possible in a coordinated manner.
12. Health systems research to improve all aspects of service delivery
and effectiveness attainment be encouraged.
13. The regionalization and decentralization process to be strengthened,
district level health organizations to be given a more prominent role
and micro-planning procedures to be adopted at the village level
with special effort to reach the least privileged groups.
14. Nepal Red Cross Society to be authorised to conduct all
programmes related to blood transfusion services, the practice of
buying, selling and depositing of blood to be prohibited.

b. NATIONAL DRUG POLICY - 1995.

This drug policy has been promulgated in accordance with the objective of
the National Health Policy 1991, to fulfil the commitment of HMGN to
provide “health for all” and to improve and manage by establishing co-
ordination among governmental, NGOs and private organizations involved in
the activities related to drug production, import, export, storage, supply,
sales, distribution, quality assessment, regulatory control, rational use and
information flow.
Besides the preamble other sections are:
- Main policy
- Objectives
- Policy Strategies including:
- Drug Management
- Quality Assurance & Regulatory Control Measures
- Rational Drug Use & its Information
- Manpower Development
- National Drug Industry

+
214 Nepal’s Quest for Health

- Traditional Medicines
- Research and Development
- Technical Co-operation
- Monitoring and Evaluation

c. NATIONAL POLICY FOR CONTROL OF AIDS & STDs - 2052 BS

This policy has been promulgated with the objective of controlling the
problems related to AIDS and STDs. This is being done as noted below:
- Policy
- National Executive & District Co-ordination Committee
- Co-ordination with NGOs
- Integrated Programme
- Blood Examination
- Reporting on AIDS and STD patients
- Maintenance of confidentiality
- Non-discrimination
- Stress on Safe Sex behaviour education
- Sterilization of equipment

Middle level executive committee

District level AIDS co-ordination committee

d. NATIONAL AYURVEDIC HEALTH POLICY - 2052 BS

Passed by HMGN on 14th Falgun, 2052 BS / February, 1996, it is divided

into the under mentioned sections:
- Justification
- Objectives
- Organisation of Ayurvedic health services
- Mobilization of Inter Institutional and Community Participation
- Cultivation of herbs, production of medicines and profession
- Ayurvedic education and manpower development
- Ayurvedic manpower management
- Research in Ayurved
- Provision for resource mobilisation

+
 Plans and Their Implications 215

- Nepal Ayurvedic Council

Duties of District Ayurvedic Health Centre

Responsibility of Ayurvedic Aushadhalaya

e. SAFE MOTHERHOOD POLICY

Under the umbrella of the Safe Motherhood programme, which is a

component of PHC, the stress in the coming years will be on improving
maternity care services, including family planning, at all levels of the Health
Care Delivery System, even the community. This policy document has been
arranged as:
Policy Directive
Policy Objectives
- General
- Specific
- Strategies
Maternity Care
- Definition
- Component

Family Level
Community Level
Sub Health Post (SHP) Level
Health Post (HP) Level
Primary Health Care (PHC) Centre Level

District Level
Zonal / Regional Level
Centre Level

Referral System
Institutional Arrangements

Targets

OTHER EFFORTS:

Health Sector Reform

+
216 Nepal’s Quest for Health

Aware that health care facilities are not uniformly distributed in the country,
HMGN is trying to make it more equitable. After much deliberation, MoH
came to the conclusion that it should focus and deal with those health problems,
which are disproportionately, and maximally contributing to the highest level of
mortality and burden of diseases.

This is the rationale of the health care reform that is underway with the
involvement of policy makers, NGOs, INGOs, private sectors and community
in workshops, meetings etc, and a document was prepared in 2002. This was
subsequently endorsed by the Council of Ministers in 2003. Key issues to be
addressed by this strategy include (13):

- better value for the money that the public spends from its own
resources
- strategy for better access of essential health care services (EHCS)
to the poor and vulnerable. This comprises of safe motherhood &
family planning, child health, control of communicable diseases
and OPD services
- running of existing public services by HMGN in a more efficient
manner
- access to facilities of essential health care services provided by
HMGN
- better monitoring of health sector performance.

This reform will be over a 15 years period, which extends to the end of the
Second Long Term Health Plan. There will however be an attempt to have
realistic outputs at the end of the first five years.

The emphasis is on outputs and health outcomes. For this it is envisaged that
there will be better Sector Management, which includes planning,
programming, budgeting, and financing and performance management within
the Ministry of Health.

It must be noted that the Health Sector Reform and is implementation is in the
light of the National Health Policy 1991 and Second Long Term Health Plan
(14).

The Millennium Development Goals (MDG)

+
 Plans and Their Implications 217

These goals were adopted by the United Nations in 2000 with the objective of
initiating concerted action for global Health. In Sept. 2000 representatives
from 189 countries, including 147 heads of state met at the Millennium Summit
in New York to adopt the United Nations Millennium Declaration.
Commitment has been made in seven areas: peace, security and disarmament;
development & poverty eradication; protecting our common environment;
human rights, democracy & good governance; protecting the vulnerable,
meeting the special needs of Africa and strengthening the UN (15).

There is also a Road Map, which has established the goals and targets to be
reached by 2015 in each of the seven areas. The goals in the area of
development and poverty eradication are referred to Millennium Development
Goals (MDG). This means that governments world wide are obliged to do
more to reduce poverty and hunger, tackle ill health, gender equality, lack of
education, lack of access to clean water and environmental degradation.

Three of the eight goals are directly health related; all of the others have
important indirect effects on health without commitment from all the developed
and developing countries the goals will not be met globally.

Vision 20/20.
As from Nov. 1999 Nepal committed itself to Vision 20/20: The Right to Sight.
This is an international campaign to create awareness and mobilise additional
resources for preventing and treating blindness. This global initiative is to
tackle avoidable (preventable and curable) blindness by the ear 2020. Whereas
previously the thrust had been from hospital to community, it is now moving
towards households and individuals. (15). Hopefully this ‘Sight for All by
2000’ will achieve a lot for the Nepali people.

Bed Ratios for Different Nations

At the end of the Seventh Five Year Plan period there were 12 districts
without any hospitals and thus no facilities for admission. The total number
of hospitals, Governmental and non-governmental, including private ones, at
the end of 1990 was 123 with a total bed capacity of 4,717 beds (17). This in
terms of a population of 19 million works out to just 2.4 beds for every
10,000 population.

Table 5.2 Hospital Beds per 1000 population for Different Nations

+
218 Nepal’s Quest for Health

Country Year Hospital Beds

(per 10,000 population)

Bangladesh 1985 2.9

Bhutan 1984 6.1
Burma 1983-84 8.8
DPR Korea 1982 130.0
India 1984) 6.9
Indonesia 1982 8.4
Maldives 1982 6.1
Mongolia 1981 107.6
NEPAL 1988 2.4
Sri Lanka 1983 24.0
Thailand 1982 15.4

Source: Bulletin of Regional Health Information, WHO SEARO.1986.

Three Ministries Comparison.

The present trend is for the budgetary provision to be increased for the two
social sectors – health and education. Because of ongoing conflict within the
country, Nepal’s expenditure on defence has been going up. The figures
pertaining to the ministries, both in Nepal and in the region is given below.

Country Health -% of Education - % Defence - % of

Budget. of Budget. Budget.
Bangladesh 5 11 10
Bhutan 11 17 0
India 2 2 15
Maldives 9 18 10
Myanmar 3 8 29
Nepal 5 18 8
Pakistan 1 1 18
Sri Lanka 6 10 18
Thailand 8 17 6
Source: State of the Worlds Children 2005 (18).

Human Development Index (HDI)

+
 Plans and Their Implications 219

Most newspapers make a great show of the fact Nepal moves up or down the
HDI. Whilst this is a form of assessment of what is happening in the country, it
does not warrant the amount of hullabaloo that is being generated every year.
Noting the fact that Nepal had been making “good progress” over 25 years
(1975-2000), the UNDP ranked Nepal 129 out of 162 countries in 2001.

In 2002 Nepal moved to 142 out of 173 countries with HDI value of 0.490. It
must be pointed out however that 11 new countries were created during the
course of this year and as their position in the ranking was higher than that of
Nepal, one finds our ranking has slipped. This year, Nepal position in the
Human Development Index is at present at 140 amongst the countries of the
world with a HDI value of 0.504.. This is two points up from what it was in
2002. This HD Report, which has been brought out annually by UNDP, is
based on various indications pertaining to the country (19).

Comparison in SEARO

The overall level of public expenditure on health remained at 1% though it

varies among the different countries of South Asia. The public expenditure in
health in terms of percentage of GDP shows that in 1998, Maldives spent the
highest amount at 5.1% whereas India and Pakistan spent the lowest amount on
health viz. 0.8% and 0.9% respectively (20).

Table 6. 1 Expenditures on health in South East Asian Countries as %

of GPD

1990 1998
India 0.9 0.8
Pakistan 1.1 0.9
Bangladesh 0.7 1.7
Nepal 0.8 1.3
Maldives 4.9 5.1
Bhutan 1.7 3.2
Sri Lanka 1.5 1.4
South Asia 1.0 1.0

References

1. Long Term Health Plan, 1975-90. (2034 BS), MoH, Pachali, Kathmandu.
2. Mid Term Health Review 2035. June 1979, MoH, HMG, Kathmandu.

+
220 Nepal’s Quest for Health

3. Final Draft Report on Country Health Resources and Priorities 1990-1995. Jan.1990.
HMG/MOH, Kathmandu.
4. World Bank report with proposals.
5. Restructuring of Health Services in Nepal, Situation - Analysis. Singh, H. 1991.
6. Strengthening of the District Health Systems. Unpublished.
7. Sustainability in the Health Sector. Nepal Case Study. SCF(UK), March 1992.
8. The practice of Health Delivery System of the Government Health Service Centres in
Nepal. MN Tiwari, 1994.
9. Early Childhood Feeding, Nutrition & Development. HMG/N, National Planning
Commission, 1997.
10. Executive Summary of Second Long Term Health Plan 1997-2017, PPFA&MD, MoH,

11. Strategic Analysis to Operationalise Second Long Term Health Plan (1997-2017), HMGN,
MoH, 2001.

12. Koirala S. Reviewing Strategies in Building on Challenges, 2001. BPK Lions Centre for
Ophthalmic Studies.
13. Health Sector Strategy – An Agenda for Reform., 2004, HMG MoH.
14. Nepal Health Sector Programme = Implementation Plan (NHSP-IP), 2004-2009. Oct. 2004,
HMG, MoH.
15. World Health Report, 2003.
16. Sight for all by 2000.
17. Bulletin of Regional Health Information WHO SEARO. 1986.
18. State of the World Children 2004
19. Human Development Index 2003
20. Human Development in South Asia 2002, Mahbub ul Haq, Human Development Centre,
Oxford University Press.