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Primary Health Care in Nepal.pptx

The document provides an overview of the history and development of primary health care in Nepal. Some key points: - Nepal has focused on primary health care since signing the Alma Ata Declaration in 1978, establishing programs like FCHVs and integrating vertical health programs. - The constitution now guarantees every citizen the right to free basic health services. Responsibilities are divided between the federal, provincial, and local governments. - Currently, Nepal faces challenges in ensuring universal access to quality health care, adequate health financing and insurance coverage, and addressing rural/urban disparities. But initiatives continue to strengthen the primary health care system.

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Primary Health Care in Nepal Umesh Chandra Ghimire Roll Number 207 SPH & CM, BPKIHS
• As a signatory of Alma Ata declaration of 1978, Government of Nepal (GoN) continued adherence to the Primary Health Care (PHC) approaches for the development of quality health care services both in rural and urban areas. • Major principles of this declaration are: • a. Universal Accessibility • b. Community Participation. • c. Inter-sectoral coordination • d. Appropriate technology. 2
Emergence of district health system in Nepal • In Nepal, Primary health services started since 1933 starting with establishment of Department of Health Services (DoHS). • Government hospitals and Ayurvedic hospitals were set up gradually. During the 50s, • First Five Year Development Plan (1956-61) was developed and, as a consequence, Malaria Eradication Program came in existence in 1958 however later in 1978 program was modified for malaria elimination program. • More vertical projects were implemented in1960s, which are FP/MCH, Small pox Eradication and the Central Health Laboratory. • With more emphasis on curative service during the Second Plan period (1962-65) emphasis was placed in preventive and curative medicine. 3
• In 1971 vertical programs were integrated to provide services under one door policy, in one district followed by full integration of all vertically run health programs in 6 more districts. • Integrated Community Health Service Development Project established by the Ministry of Health (MoH) was made responsible to integrate all vertical health programs and ran under one umbrella as District Health Office. 4
Human resource and community participation • The Fourth Plan (1970-75) focused more on preventive and human resource development and preventive cure got priority. • Institute of Medicine (IoM) was established under Tribhuvan University to train mid-level health service providers • During 5th Plan (1995-1980) Alma Ata declaration was made and Nepal signed in it. • Nepal commited itself to provide basic health care services (preventive, promotive, curative and rehabilitative health care services using Primary Health Care approach) with gradual integration of vertically rum programs with slogan of health for all by 5
• For community participation in 1988 Nepal launched FCHV program efforts were targeted to increase community participation and selected FCHV were trained and enabled to provide health care services • Female community health volunteers were the excellent example of community workforce with success stories of Vitamin A, polio and immunization, anti Helminthes drug distribution, also managing some cases of ARI, distribution of ORS . • This was another example of community participation as they were selected from the local area itself 6
• Nepal has other health workers called as Village Health Worker (VHW), who was responsible for immunization, and now they are replaced by AHW • Maternal and Child Health Worker (MCHW) responsible for MCH services, who are selected from their own locality now they are trained to become Auxiliary Midwifes and new recruitment is done from ANM 7
Beginning of strategic thinking • The First Long Term Health Plan (1975-90) was developed with an objective to ensure consistent and proper functioning of the health services • Accordingly, the Fifth Plan (1975-80) fully integrated vertical programs into a health infrastructure capable of providing effective services to the people • Emphasis was put on regulating population growth through promotion of family planning, and expansion of maternal and child health services • The Sixth Plan period broke health sector isolation emphasizing inter-sectoral coordination with food supply, safe drinking water etc. 8
• The Seventh Plan (1985-90) witnessed an organizational integration. • The Department of Health Services was dissolved and the Regional Health Services Directorate in five development regions was created in the spirit of decentralization • Ministry of Health created two new departments for Department of Ayurved and Department of Drug Administration. 9
First National Health Policy 1991 • In 1991, the National Health Policy was implemented with objective of upgrading the health standards of the majority of the population by extending the PHC services up to the village level. • The policy addressed the issue of preventive, promotive, curative and basic primary health services • In this regard PHCC, HP, SHP and Out-Reach Clinics were established. The policy also aims to provide opportunity to the rural people to enable them to obtain the benefits of modern medical facilities by making these accessible to them • It has also set up one health facility (at least a Sub Health Post) in every village development committee and a Primary Health Care 10
Second Long term health plan 1997-2017 • The Ministry of Health of His Majesty's Government of Nepal developed a 20-year Second Long-Term Health Plan (SLTHP) for FY 2054-74 (1997-2017). • The aim of the SLTHP is to guide health sector development in the improvement of the health of the population, particularly those whose health needs are not often met 11
The aims of the SLTHP • To provide a guiding framework to build successive periodic and annual health plans that improve the health status of the population; • To develop appropriate strategies, programmes, and action plans that reflect national health priorities that are affordable and consistent with available resources; • To establish co-ordination among public, private and NGO sectors and development partner 12
Millenium Development Goals • Nepal also signed MDG in September 2000 which is an international time-bound commitment to reduce poverty and advance other social development targets by 2015 • Nepal has committed to work on all 8 goals of MDG and has set up targets indicators for each goals to achieve by 2015 • However due to some constrains country failed to achieve all targets of MDG 13
Primary Health Care Revitalization • Nepal Established Primary Health Care Revitalization Division in 2009 under Department of Health Services • The division was mantle to revitalize PHC in Nepal by addressing emerging health challenges in other divisions and different supporting actors • The division was to make inroads stipulated • The division is also expected to make inroads into translating the constitutionally stipulated fundamental roghts af basic free health care into practice addressing the disparities in health services 14
The PHCRD was established to address shift of PHC movement globally Early Attempts to Implement PHC Current Concerns of PHC Extended access to a basic package of health interventions and essential drugs for the rural poor Transformation and regulation of existing health systems, aiming for universal access and social health protection Concentration on mother and child health Dealing with the health of everyone in the community Focus on a small number of selected diseases, primarily infectious and acute A comprehensive response to people’s expectations and needs, spanning the range of risks and illnesses Improvement of hygiene, water, sanitation and health education at village level Promotion of healthier lifestyles and mitigation of the health effects of social and environmental hazards Simple technology for volunteer, nonprofessional community health workers Teams of health workers facilitating access to and appropriate use of technology and medicines 15
Early Attempts to Implement PHC Current Concerns of PHC Participation as the mobilization of local resources and health-centre management through local health committees Institutionalized participation of civil society in policy dialogue and accountability mechanisms Government-funded and delivered services with a centralized top-down management Pluralistic health systems operating in a globalized context Management of growing scarcity and downsizing Guiding the growth of resources for health towards universal coverage Bilateral aid and technical assistance Global solidarity and joint learning Primary care as the antithesis of the hospital Primary care as coordinator of a comprehensive response at all levels. PHC is cheap and requires only a modest investment. PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives. 16
Initiation of PHCRD working modality in Nepal • In 5th April 2010 there was a high level workshop finalized the working modality of PHCRD in Dhulikhel. • The participants of workshop mainly focused in following areas and modality was finalized 1. Social and Health Protection 2. Environmental Health 3. Municipal Health 4. Disability and Community Rehabilitation 5. Extending PHC Services 17
History of Public Health Programs in Nepal • Malaria Eradication Program 1958 – First Public Health Program of Nepal • However this program was converted to malaria elimination program in 2078 • Now we are at end game strategy for malaria elimination in country • Family Planning Program - 1959 • Initiated with vasectomy with the objective to control population • FPAN established to takeover the program in same year 18
• Safe Motherhood Program- 1959 • Started with establishment of district health system • The Safe motherhood policy introduced in 1998 • FCHV Program 1988 • Initiated in 1988 as a part of principle for community participation of ALM ATA declaration • Now more than 52000 FCHV are working countrywide • PHC/ORC Program 1994 • Initiated in 2051 BS to increase accessibility of unreached population • The health service center in VDC (current ward) provides health service once a month in fixed place 19
• Safe Abortion Services – 2002 • Abortion was legalized in Nepal since September 2002 with the implementation of Safe abortion policy • There is safe abortion law in existence in the country • Adolescent Sexual and Reproductive Health Service • With the endorsement of National Adolescent Health and Development (NAHD) Strategy in 2000. An implementation guideline on Adolescent Sexual and Reproductive Health (ASRH) was developed in 2007 • Now ASRH program is implemented countrywide in all health facilities. 20
• CBIMNCI Program (History) • Control of Diarrhoeal Disease Program 1983 • Control of ARI program 1987 • CB-ARI Program – 1995 • CB- ARI and diarrhoea program – 1997 • CB-IMCI – 1997 • CB-NCP 2007 • CBIMNCI – 2014 • National Immunization Program – 2034 BS • Started with 4 antigens BCG and DPT • Now GoN is providing 14 antigens as vaccine against 13 disease 21
• National Nutrition Program • Started with unicef GOBI-FFF strategy of child health • Currently we have nutrition programs have 15 programs to address different issues of nutrition • Kala-azar control Program • The world health assembly in 2005 formalized the memorandum of understanding for kala azar elimination • Strategy was defined in three phases • Preparatory Phase 2005- 2008 • Attack Phase 2008-2015 • Consolidation Phase 2015 onwards 22
• Filariasis Control Program • LF mapping in 2001 and 2005 re-mapping in 2012 revealed the prevalence od 13% of lymphatic filariasis in country • To address this issue Nepal Satarted MDA program in targeted districts with prevalence of > 1% • Still 14 districts are failed to eliminate filariasis despite of continuous MDA program • Dengue Control Program • National Vector borne disease control program is umbrella program for control of Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya, Kala-azar and Lymphatic Filariasis. • The earliest case of dengue was detedctd in 2005 in a tourist • Sporadic outbreaks observed in 2006 2009 and 2010 initially most cases were observed with the travel history of India • Since then every year sporadic outbreaks are onserved 23
• Zoonotic Disease Control Program • This program manages the dog bite and snake bite • Leprosy Control Program • Initiated in 1966 with dapsone monotherapy • Since 2010 Nepal is declared elimination of leprosy from country • National Tuberculosis Control Program • Launched in Nepal in 1962 • The national TB Prevalence Survey 2018-19 estimated there are 17000 TB related death each year in the country 24
• HIV/AIDS and STC Control Program • The program is managed by NCASC under DOHS • First case of HIV in Nepal 1988 • At District level there ART centers to enroll HIV infected persons for staring and continuation of ART • Epidemiologic and Outbreak Surveillance Program • The program in managed by EDCD • There are sentinel sites all over country to report any kinds of outbreak through EWARS system • Disaster Management Program • The program in managed by EDCD • The overall objective of this programme is to enhance the capacities of health sector in emergency preparedness and response by focusing on disaster preparedness, disaster risk reduction and response 25
• Non Communicable Disease and Mental Health • PEN Package • Community Mental Health Program 26
Current Status of Primary Health Care Service in Nepal Key Facts of Primay Health Care System in Nepal • The healthcare system in Nepal is a combination of public and private healthcare services, with the majority relying on the public system. • Nepal faces numerous public health challenges, including low health expenditure, limited healthcare access, poor healthcare quality, insufficient health insurance coverage, and inadequate healthcare infrastructure and services. • Only 60% of the population in Nepal has access to basic healthcare services, and rural areas have limited access to healthcare services and poor quality of care due to inadequate infrastructure and shortage of healthcare professionals. 27
• Healthcare financing and health insurance in Nepal is a significant challenge, with the country spending only 4.3% of its GDP on healthcare and limited health insurance coverage for the population. • Rural health, maternal health, child health, and infectious diseases are major public health challenges in Nepal. • Non-communicable diseases are a growing public health issue in Nepal, with a significant impact on the population. • The government of Nepal and non-government organizations are taking various initiatives to address the public health challenges in the country, including the launch of the "Healthy Nepal" campaign, investment in healthcare infrastructure and services, and improving access to care. • Continued effort and investment are needed to improve the healthcare system in Nepal and meet the health needs of all 28
Health in Constitution • Country have transformed itself in federalism so the transformation of health service. • Constitution of Nepal 2072 in article 35 have mentioned about righrs relating to health • Every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services. • Every person shall have the right to get information about his or her medical treatment. • Every citizen shall have equal access to health services. • Every citizen shall have the right of access to clean drinking water and sanitation. 29
• Nepal’s Constitution have defined the responsibilities of there tier government for provision health care services • Federal Government have the responsibility of preparing Health policies, health services, health standards, quality and monitoring, national or specialized service providing hospitals, traditional treatment services and communicable disease control • Provincial Government have responsibility to run hospitals 50 beds and above • Vast majority of primary health services in responsibility of local government 30
Tertiary Level Hospitals/ Specialized Hospitals Secondary Level Hospitals Primary Level Hospitals Health Post / BHSC/ UHC Current Structure of Health Service Centers in Federalism Federal Government Province Government Local Government 31
• In Nepal various health workforce is providing primary health care services includes doctor’s paramedics nurses and FCHVs • The health system operates in four tiers with the first and basic tier composed of a massive network of the FCHVs. • Second tier is primary health care centers where network of PHC includes BHSc Health Posts ORC • Third tier is Primary Hospitals at municipal level and District Hospitals • Fourth Secondary A and secondary B level hospitals and Current Primary Health Care System in Nepal 32
Current Primary Health Care System in Nepal • Federal Government • Federal government mainly involves in policy formulation and strategy preparation and setting country targets and launching new programs • Federal government also have the responsibility of providing specialized services • Central Hospitals more than 100 bed, specialized hospitals and academic institution cum hospitals are supervised by federal government • Health Workforce Planning • Provincial Government • Provincial government have responsibility to provide health services through 50 bed district hospitals and upto 200 bed provincial hospitals • Provincial Government have another responsibility of supervise and support local government for provision of basic health services 33
• Local Government • Operation of Major Public Health Programs and provision of basic primary health services are responsibility of local government • Local Government have 5-15 beded primary hospitals • Health Posts and Basic Health Service Centers • PHC/ORC • Immunization Clinics • However at service provision level federal and provincial government are also playing major in primary health services 34
Challenges in Primary health care in Nepal • Nepal has made significant progress on health indicators over the past several decades despite of this the challenges exist in the country • Country has recently adopted federalism and primary health care system has been disturbed, • Local level government are given responsibility of primary health care but it has been least priority of LLGs 35
• Shortage of Health workforce in government system has been challenge since long. There are more than 30000 sanctioned post of health worker but only 19000 have been fulfilled • Disparities in primary health in rural and urban population is another challenge to address • For instance, only 61.8% of the households have access to health services within 30 min, with the gap between urban (85.9%) and rural (59%) • Political reformation to federal governance, primary health care services have been further muddled due to a lack of clarity on devolution, responsibility distribution, and coordination 36
• Poor management are reflected in various epidemic management, for instance recent measles outbreak in different districts and current dengue outbreak has been ineffective and random • Lack of coordination among three tier government is another issue in primary health care which has been • Current dispute in health workers salary and posting is also another challenge now and in future 37
38
• Globalization and health have integral impact and warrants a need to transform the health system which can be achieved through re-strengthening primary health care • Immediate implementation of policies for clarity in distribution of responsibility, and accountability to all governance structure (federal, province and local) is critical. • Strengthening of social health security system with improved quality of Universal Health Coverage (UHC) through multi-sectoral collaboration and public-private partnership needs prioritization. • Improvement of quality of existing primary health care services based on community health worker 39
Models of Health Care in Nepal • Beverage Model –Basic Primary Health Care Services • Bishmark Model – Social Security Insurance • Health Insurance Model – Health Insurance Scheme • Out of Pocket Expenditure Model – Private and other secondary and tertiary health are Services 40
Basic Essential Health Care Service in Nepal • Basic health service" means promotional, retributive, diagnostic, remedial and rehabilitative service easily and freely available from the state for the sake of fulfillment of health need of citizens generally, pursuant to sub-section (4) of Section 3 – Nepal Public Health Service Act 41
• Every citizen shall have the right to obtain free basic health services under the following headings, as prescribed: • (a) Vaccination service, • (b) Motherhood, infant and pediatric health service such as integrated infant and pediatric disease management, nutrition service, pregnancy, labor and child birth service, family planning, abortion and reproductive health, • (c) Service relating to communicable disease, • (d) Service relating to non-communicable disease and physical disability, • (e) Service relating to mental disease, • (f) Service relating to elderly citizen's health, • (g) Service of general emergency condition, • (h) Health promotion service, • (i) Ayurveda and other accredited alternative health service, • (j) Other services prescribed by the Government of Nepal by a notification in the Nepal Gazette. 42
• Basic Health Services are free of cost for every citizen • Beside listed basic health services in public health service act 2075 three tier government can provides additional services for free of cost • To fulfil the basic health services of Nepalese citizen federal government provides budget to provincial and local governments • The services that are not covered under basic health services are addressed through health insurance scheme 43
Basic Health Services and universal Health Coverage 44
Basic Health Services and Sustainable Development Goals • Sustainable Development goal is the worldwide agreement of countries that imagines to eliminate all kinds of poverty, equitable development of earth and mankind that creates a world with justice and safety • SDG have 17 goals of which 3rd goal is good health and well being. Under this goal the target 3.8 has ensured about getting health services without economic hardship to increase universal health coverage 45
Rational for BHSP • Constitution of Nepal has ensured basic health service as right of every citizen • To ensure the resources to provide basic health services by government • To categorize the service centers according to their capacity so it helps government to plan resources accordingly • To provide information and health service to every citizen • To decrease the economic hardship of every citizen 46
Government investment modality in Primary Health Services Primary Health Care Services Free Health Service Health Insurance Social Security 47
The services under BHS package 1. Immunization Service 2. Maternal New Born and Child Health 1. Management of Neonatal and Childhood Illness 2. Nutrition Services 3. Pregnancy Delivery and Post Natal Services 4. Family Planning, Safe Abortion, ASRH Services and prevention and treatment of cancer in women 5. Referal Service 3. Curative Services 1. Communicable Diseases 2. Non Communicable Diseases 3. Mental Health Service 4. Geriatrics Service 5. Emergency Services 6. Referal Service 4. Health Promotion Activities 5. Ayurveda and other traditional Services 48
Nepal Key Achievement in Primary Health Care • Eradication of Small Pox 1978 49

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In this document
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Introduction to Primary Health Care in Nepal by Umesh Chandra Ghimire, highlighting the significance.

Nepal's adherence to Alma Ata declaration emphasizes universal accessibility, community participation, and appropriate technology for health care services.

Historical development of primary health services in Nepal since 1933, integration of health programs, and the establishment of district health systems.

Focus on community participation through training of female community health volunteers (FCHVs) and the role of local health workers in reinvigorating health services.

Significant health planning efforts including the First Long Term Health Plan, Seventh Plan’s organizational integration, and the implementation of the National Health Policy 1991.

Introduction of the Second Long-Term Health Plan and its aims to enhance health services, coordination among sectors, and develop action plans.

Nepal's commitment to the Millennium Development Goals and formation of the Primary Health Care Revitalization Division to enhance health services.

An overview of various public health programs including malaria, family planning, immunization, and the recent health initiatives addressing a range of health issues.

Overview of challenges in Nepal's healthcare system, including low expenditure, access issues, and initiatives like the 'Healthy Nepal' campaign.

Constitutional rights relating to health services, delineation of responsibilities between federal, provincial, and local governments under Nepal's federalism.

Four-tier health service model in Nepal detailing the roles of federal, provincial, and local governments in healthcare delivery.

Key challenges including health workforce shortages, access disparities, and coordination issues faced in Nepal's primary healthcare system.

Emphasis on transformative needs for health systems, focusing on primary healthcare strengthening, accountability, and quality improvements.

Discussion of various healthcare models in Nepal, definition of basic health services, and their relation to universal health coverage.

Highlighting the achievement of Small Pox eradication in 1978 as a significant milestone in Nepal's health sector.

Primary Health Care in Nepal.pptx

  • 1.
    Primary Health Carein Nepal Umesh Chandra Ghimire Roll Number 207 SPH & CM, BPKIHS
  • 2.
    • As asignatory of Alma Ata declaration of 1978, Government of Nepal (GoN) continued adherence to the Primary Health Care (PHC) approaches for the development of quality health care services both in rural and urban areas. • Major principles of this declaration are: • a. Universal Accessibility • b. Community Participation. • c. Inter-sectoral coordination • d. Appropriate technology. 2
  • 3.
    Emergence of districthealth system in Nepal • In Nepal, Primary health services started since 1933 starting with establishment of Department of Health Services (DoHS). • Government hospitals and Ayurvedic hospitals were set up gradually. During the 50s, • First Five Year Development Plan (1956-61) was developed and, as a consequence, Malaria Eradication Program came in existence in 1958 however later in 1978 program was modified for malaria elimination program. • More vertical projects were implemented in1960s, which are FP/MCH, Small pox Eradication and the Central Health Laboratory. • With more emphasis on curative service during the Second Plan period (1962-65) emphasis was placed in preventive and curative medicine. 3
  • 4.
    • In 1971vertical programs were integrated to provide services under one door policy, in one district followed by full integration of all vertically run health programs in 6 more districts. • Integrated Community Health Service Development Project established by the Ministry of Health (MoH) was made responsible to integrate all vertical health programs and ran under one umbrella as District Health Office. 4
  • 5.
    Human resource andcommunity participation • The Fourth Plan (1970-75) focused more on preventive and human resource development and preventive cure got priority. • Institute of Medicine (IoM) was established under Tribhuvan University to train mid-level health service providers • During 5th Plan (1995-1980) Alma Ata declaration was made and Nepal signed in it. • Nepal commited itself to provide basic health care services (preventive, promotive, curative and rehabilitative health care services using Primary Health Care approach) with gradual integration of vertically rum programs with slogan of health for all by 5
  • 6.
    • For communityparticipation in 1988 Nepal launched FCHV program efforts were targeted to increase community participation and selected FCHV were trained and enabled to provide health care services • Female community health volunteers were the excellent example of community workforce with success stories of Vitamin A, polio and immunization, anti Helminthes drug distribution, also managing some cases of ARI, distribution of ORS . • This was another example of community participation as they were selected from the local area itself 6
  • 7.
    • Nepal hasother health workers called as Village Health Worker (VHW), who was responsible for immunization, and now they are replaced by AHW • Maternal and Child Health Worker (MCHW) responsible for MCH services, who are selected from their own locality now they are trained to become Auxiliary Midwifes and new recruitment is done from ANM 7
  • 8.
    Beginning of strategicthinking • The First Long Term Health Plan (1975-90) was developed with an objective to ensure consistent and proper functioning of the health services • Accordingly, the Fifth Plan (1975-80) fully integrated vertical programs into a health infrastructure capable of providing effective services to the people • Emphasis was put on regulating population growth through promotion of family planning, and expansion of maternal and child health services • The Sixth Plan period broke health sector isolation emphasizing inter-sectoral coordination with food supply, safe drinking water etc. 8
  • 9.
    • The SeventhPlan (1985-90) witnessed an organizational integration. • The Department of Health Services was dissolved and the Regional Health Services Directorate in five development regions was created in the spirit of decentralization • Ministry of Health created two new departments for Department of Ayurved and Department of Drug Administration. 9
  • 10.
    First National HealthPolicy 1991 • In 1991, the National Health Policy was implemented with objective of upgrading the health standards of the majority of the population by extending the PHC services up to the village level. • The policy addressed the issue of preventive, promotive, curative and basic primary health services • In this regard PHCC, HP, SHP and Out-Reach Clinics were established. The policy also aims to provide opportunity to the rural people to enable them to obtain the benefits of modern medical facilities by making these accessible to them • It has also set up one health facility (at least a Sub Health Post) in every village development committee and a Primary Health Care 10
  • 11.
    Second Long termhealth plan 1997-2017 • The Ministry of Health of His Majesty's Government of Nepal developed a 20-year Second Long-Term Health Plan (SLTHP) for FY 2054-74 (1997-2017). • The aim of the SLTHP is to guide health sector development in the improvement of the health of the population, particularly those whose health needs are not often met 11
  • 12.
    The aims ofthe SLTHP • To provide a guiding framework to build successive periodic and annual health plans that improve the health status of the population; • To develop appropriate strategies, programmes, and action plans that reflect national health priorities that are affordable and consistent with available resources; • To establish co-ordination among public, private and NGO sectors and development partner 12
  • 13.
    Millenium Development Goals •Nepal also signed MDG in September 2000 which is an international time-bound commitment to reduce poverty and advance other social development targets by 2015 • Nepal has committed to work on all 8 goals of MDG and has set up targets indicators for each goals to achieve by 2015 • However due to some constrains country failed to achieve all targets of MDG 13
  • 14.
    Primary Health CareRevitalization • Nepal Established Primary Health Care Revitalization Division in 2009 under Department of Health Services • The division was mantle to revitalize PHC in Nepal by addressing emerging health challenges in other divisions and different supporting actors • The division was to make inroads stipulated • The division is also expected to make inroads into translating the constitutionally stipulated fundamental roghts af basic free health care into practice addressing the disparities in health services 14
  • 15.
    The PHCRD wasestablished to address shift of PHC movement globally Early Attempts to Implement PHC Current Concerns of PHC Extended access to a basic package of health interventions and essential drugs for the rural poor Transformation and regulation of existing health systems, aiming for universal access and social health protection Concentration on mother and child health Dealing with the health of everyone in the community Focus on a small number of selected diseases, primarily infectious and acute A comprehensive response to people’s expectations and needs, spanning the range of risks and illnesses Improvement of hygiene, water, sanitation and health education at village level Promotion of healthier lifestyles and mitigation of the health effects of social and environmental hazards Simple technology for volunteer, nonprofessional community health workers Teams of health workers facilitating access to and appropriate use of technology and medicines 15
  • 16.
    Early Attempts toImplement PHC Current Concerns of PHC Participation as the mobilization of local resources and health-centre management through local health committees Institutionalized participation of civil society in policy dialogue and accountability mechanisms Government-funded and delivered services with a centralized top-down management Pluralistic health systems operating in a globalized context Management of growing scarcity and downsizing Guiding the growth of resources for health towards universal coverage Bilateral aid and technical assistance Global solidarity and joint learning Primary care as the antithesis of the hospital Primary care as coordinator of a comprehensive response at all levels. PHC is cheap and requires only a modest investment. PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives. 16
  • 17.
    Initiation of PHCRDworking modality in Nepal • In 5th April 2010 there was a high level workshop finalized the working modality of PHCRD in Dhulikhel. • The participants of workshop mainly focused in following areas and modality was finalized 1. Social and Health Protection 2. Environmental Health 3. Municipal Health 4. Disability and Community Rehabilitation 5. Extending PHC Services 17
  • 18.
    History of PublicHealth Programs in Nepal • Malaria Eradication Program 1958 – First Public Health Program of Nepal • However this program was converted to malaria elimination program in 2078 • Now we are at end game strategy for malaria elimination in country • Family Planning Program - 1959 • Initiated with vasectomy with the objective to control population • FPAN established to takeover the program in same year 18
  • 19.
    • Safe MotherhoodProgram- 1959 • Started with establishment of district health system • The Safe motherhood policy introduced in 1998 • FCHV Program 1988 • Initiated in 1988 as a part of principle for community participation of ALM ATA declaration • Now more than 52000 FCHV are working countrywide • PHC/ORC Program 1994 • Initiated in 2051 BS to increase accessibility of unreached population • The health service center in VDC (current ward) provides health service once a month in fixed place 19
  • 20.
    • Safe AbortionServices – 2002 • Abortion was legalized in Nepal since September 2002 with the implementation of Safe abortion policy • There is safe abortion law in existence in the country • Adolescent Sexual and Reproductive Health Service • With the endorsement of National Adolescent Health and Development (NAHD) Strategy in 2000. An implementation guideline on Adolescent Sexual and Reproductive Health (ASRH) was developed in 2007 • Now ASRH program is implemented countrywide in all health facilities. 20
  • 21.
    • CBIMNCI Program(History) • Control of Diarrhoeal Disease Program 1983 • Control of ARI program 1987 • CB-ARI Program – 1995 • CB- ARI and diarrhoea program – 1997 • CB-IMCI – 1997 • CB-NCP 2007 • CBIMNCI – 2014 • National Immunization Program – 2034 BS • Started with 4 antigens BCG and DPT • Now GoN is providing 14 antigens as vaccine against 13 disease 21
  • 22.
    • National NutritionProgram • Started with unicef GOBI-FFF strategy of child health • Currently we have nutrition programs have 15 programs to address different issues of nutrition • Kala-azar control Program • The world health assembly in 2005 formalized the memorandum of understanding for kala azar elimination • Strategy was defined in three phases • Preparatory Phase 2005- 2008 • Attack Phase 2008-2015 • Consolidation Phase 2015 onwards 22
  • 23.
    • Filariasis ControlProgram • LF mapping in 2001 and 2005 re-mapping in 2012 revealed the prevalence od 13% of lymphatic filariasis in country • To address this issue Nepal Satarted MDA program in targeted districts with prevalence of > 1% • Still 14 districts are failed to eliminate filariasis despite of continuous MDA program • Dengue Control Program • National Vector borne disease control program is umbrella program for control of Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya, Kala-azar and Lymphatic Filariasis. • The earliest case of dengue was detedctd in 2005 in a tourist • Sporadic outbreaks observed in 2006 2009 and 2010 initially most cases were observed with the travel history of India • Since then every year sporadic outbreaks are onserved 23
  • 24.
    • Zoonotic DiseaseControl Program • This program manages the dog bite and snake bite • Leprosy Control Program • Initiated in 1966 with dapsone monotherapy • Since 2010 Nepal is declared elimination of leprosy from country • National Tuberculosis Control Program • Launched in Nepal in 1962 • The national TB Prevalence Survey 2018-19 estimated there are 17000 TB related death each year in the country 24
  • 25.
    • HIV/AIDS andSTC Control Program • The program is managed by NCASC under DOHS • First case of HIV in Nepal 1988 • At District level there ART centers to enroll HIV infected persons for staring and continuation of ART • Epidemiologic and Outbreak Surveillance Program • The program in managed by EDCD • There are sentinel sites all over country to report any kinds of outbreak through EWARS system • Disaster Management Program • The program in managed by EDCD • The overall objective of this programme is to enhance the capacities of health sector in emergency preparedness and response by focusing on disaster preparedness, disaster risk reduction and response 25
  • 26.
    • Non CommunicableDisease and Mental Health • PEN Package • Community Mental Health Program 26
  • 27.
    Current Status ofPrimary Health Care Service in Nepal Key Facts of Primay Health Care System in Nepal • The healthcare system in Nepal is a combination of public and private healthcare services, with the majority relying on the public system. • Nepal faces numerous public health challenges, including low health expenditure, limited healthcare access, poor healthcare quality, insufficient health insurance coverage, and inadequate healthcare infrastructure and services. • Only 60% of the population in Nepal has access to basic healthcare services, and rural areas have limited access to healthcare services and poor quality of care due to inadequate infrastructure and shortage of healthcare professionals. 27
  • 28.
    • Healthcare financingand health insurance in Nepal is a significant challenge, with the country spending only 4.3% of its GDP on healthcare and limited health insurance coverage for the population. • Rural health, maternal health, child health, and infectious diseases are major public health challenges in Nepal. • Non-communicable diseases are a growing public health issue in Nepal, with a significant impact on the population. • The government of Nepal and non-government organizations are taking various initiatives to address the public health challenges in the country, including the launch of the "Healthy Nepal" campaign, investment in healthcare infrastructure and services, and improving access to care. • Continued effort and investment are needed to improve the healthcare system in Nepal and meet the health needs of all 28
  • 29.
    Health in Constitution •Country have transformed itself in federalism so the transformation of health service. • Constitution of Nepal 2072 in article 35 have mentioned about righrs relating to health • Every citizen shall have the right to free basic health services from the State, and no one shall be deprived of emergency health services. • Every person shall have the right to get information about his or her medical treatment. • Every citizen shall have equal access to health services. • Every citizen shall have the right of access to clean drinking water and sanitation. 29
  • 30.
    • Nepal’s Constitutionhave defined the responsibilities of there tier government for provision health care services • Federal Government have the responsibility of preparing Health policies, health services, health standards, quality and monitoring, national or specialized service providing hospitals, traditional treatment services and communicable disease control • Provincial Government have responsibility to run hospitals 50 beds and above • Vast majority of primary health services in responsibility of local government 30
  • 31.
    Tertiary Level Hospitals/ Specialized Hospitals Secondary LevelHospitals Primary Level Hospitals Health Post / BHSC/ UHC Current Structure of Health Service Centers in Federalism Federal Government Province Government Local Government 31
  • 32.
    • In Nepalvarious health workforce is providing primary health care services includes doctor’s paramedics nurses and FCHVs • The health system operates in four tiers with the first and basic tier composed of a massive network of the FCHVs. • Second tier is primary health care centers where network of PHC includes BHSc Health Posts ORC • Third tier is Primary Hospitals at municipal level and District Hospitals • Fourth Secondary A and secondary B level hospitals and Current Primary Health Care System in Nepal 32
  • 33.
    Current Primary HealthCare System in Nepal • Federal Government • Federal government mainly involves in policy formulation and strategy preparation and setting country targets and launching new programs • Federal government also have the responsibility of providing specialized services • Central Hospitals more than 100 bed, specialized hospitals and academic institution cum hospitals are supervised by federal government • Health Workforce Planning • Provincial Government • Provincial government have responsibility to provide health services through 50 bed district hospitals and upto 200 bed provincial hospitals • Provincial Government have another responsibility of supervise and support local government for provision of basic health services 33
  • 34.
    • Local Government •Operation of Major Public Health Programs and provision of basic primary health services are responsibility of local government • Local Government have 5-15 beded primary hospitals • Health Posts and Basic Health Service Centers • PHC/ORC • Immunization Clinics • However at service provision level federal and provincial government are also playing major in primary health services 34
  • 35.
    Challenges in Primaryhealth care in Nepal • Nepal has made significant progress on health indicators over the past several decades despite of this the challenges exist in the country • Country has recently adopted federalism and primary health care system has been disturbed, • Local level government are given responsibility of primary health care but it has been least priority of LLGs 35
  • 36.
    • Shortage ofHealth workforce in government system has been challenge since long. There are more than 30000 sanctioned post of health worker but only 19000 have been fulfilled • Disparities in primary health in rural and urban population is another challenge to address • For instance, only 61.8% of the households have access to health services within 30 min, with the gap between urban (85.9%) and rural (59%) • Political reformation to federal governance, primary health care services have been further muddled due to a lack of clarity on devolution, responsibility distribution, and coordination 36
  • 37.
    • Poor managementare reflected in various epidemic management, for instance recent measles outbreak in different districts and current dengue outbreak has been ineffective and random • Lack of coordination among three tier government is another issue in primary health care which has been • Current dispute in health workers salary and posting is also another challenge now and in future 37
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  • 39.
    • Globalization andhealth have integral impact and warrants a need to transform the health system which can be achieved through re-strengthening primary health care • Immediate implementation of policies for clarity in distribution of responsibility, and accountability to all governance structure (federal, province and local) is critical. • Strengthening of social health security system with improved quality of Universal Health Coverage (UHC) through multi-sectoral collaboration and public-private partnership needs prioritization. • Improvement of quality of existing primary health care services based on community health worker 39
  • 40.
    Models of HealthCare in Nepal • Beverage Model –Basic Primary Health Care Services • Bishmark Model – Social Security Insurance • Health Insurance Model – Health Insurance Scheme • Out of Pocket Expenditure Model – Private and other secondary and tertiary health are Services 40
  • 41.
    Basic Essential HealthCare Service in Nepal • Basic health service" means promotional, retributive, diagnostic, remedial and rehabilitative service easily and freely available from the state for the sake of fulfillment of health need of citizens generally, pursuant to sub-section (4) of Section 3 – Nepal Public Health Service Act 41
  • 42.
    • Every citizenshall have the right to obtain free basic health services under the following headings, as prescribed: • (a) Vaccination service, • (b) Motherhood, infant and pediatric health service such as integrated infant and pediatric disease management, nutrition service, pregnancy, labor and child birth service, family planning, abortion and reproductive health, • (c) Service relating to communicable disease, • (d) Service relating to non-communicable disease and physical disability, • (e) Service relating to mental disease, • (f) Service relating to elderly citizen's health, • (g) Service of general emergency condition, • (h) Health promotion service, • (i) Ayurveda and other accredited alternative health service, • (j) Other services prescribed by the Government of Nepal by a notification in the Nepal Gazette. 42
  • 43.
    • Basic HealthServices are free of cost for every citizen • Beside listed basic health services in public health service act 2075 three tier government can provides additional services for free of cost • To fulfil the basic health services of Nepalese citizen federal government provides budget to provincial and local governments • The services that are not covered under basic health services are addressed through health insurance scheme 43
  • 44.
    Basic Health Servicesand universal Health Coverage 44
  • 45.
    Basic Health Servicesand Sustainable Development Goals • Sustainable Development goal is the worldwide agreement of countries that imagines to eliminate all kinds of poverty, equitable development of earth and mankind that creates a world with justice and safety • SDG have 17 goals of which 3rd goal is good health and well being. Under this goal the target 3.8 has ensured about getting health services without economic hardship to increase universal health coverage 45
  • 46.
    Rational for BHSP •Constitution of Nepal has ensured basic health service as right of every citizen • To ensure the resources to provide basic health services by government • To categorize the service centers according to their capacity so it helps government to plan resources accordingly • To provide information and health service to every citizen • To decrease the economic hardship of every citizen 46
  • 47.
    Government investment modalityin Primary Health Services Primary Health Care Services Free Health Service Health Insurance Social Security 47
  • 48.
    The services underBHS package 1. Immunization Service 2. Maternal New Born and Child Health 1. Management of Neonatal and Childhood Illness 2. Nutrition Services 3. Pregnancy Delivery and Post Natal Services 4. Family Planning, Safe Abortion, ASRH Services and prevention and treatment of cancer in women 5. Referal Service 3. Curative Services 1. Communicable Diseases 2. Non Communicable Diseases 3. Mental Health Service 4. Geriatrics Service 5. Emergency Services 6. Referal Service 4. Health Promotion Activities 5. Ayurveda and other traditional Services 48
  • 49.
    Nepal Key Achievementin Primary Health Care • Eradication of Small Pox 1978 49