Current Health system of Nepal and its challenges

1. Health System of Nepal
Presented by:
 Jahirul Hushen
 Dr. Minani Gurung
 Rakchya Amatya
 Dr. Samukta Chand
 Saurav Aacharya
 Sudhir Mishra
 Dr. Anjan Rijal
Mahidol University, Faculty of Public Health-2018, Batch

3. 3
Nepal: Officially the Federal Democratic Republic of Nepal
Land Area: 143,351 km2
Water Area: 3,830 km2
Total Area: 147,181km2
Population: 29,033,914
Population Density: 202.54/km2
Government: Federal
Parliamentary Republic
INTRODUCTION

4. Geographically Divided in 3 Eco-Zones
Mountains : 16 Districts
35% of total area- (above 4800 meter from sea level)
Hills : 40 Districts
42% of total area- (300-4800 Meter from sea level)
Terai: 21 Districts
Cover about 23 % of total area– (70-300 meter from sea level)
Divided into 7 Provinces, 287 Metro, sub metro and Municipality and 460 rural municipality.

5. Political Division
In 2017, the parliament of Nepal restructured the political
division by replacing an earlier system where Nepal was divided
into 14 administrative zones and 5 development regions.
Now there are 7 federal provinces based on geographical
representations
The provinces’ name and headquarters are yet to be announced
Now rural/municipality is the apex body for local level
governance and development in the framework of devolution

6. Population Status
According to 2011 Census total population is more than 26 million
(26,494,504) with annual growth rate 1.35%
Religion wise, Hinduism is the major religion in Nepal followed by
Buddhism.
81.34
9.04
4.39 3.05
2.13
Distribution of Population based on religion
Hindu Buddhist Islam Kirat Christian and others

7. Demographic Indicators
Sex Ratio 0.95
Population Density 181/square km
Population Growth Rate 1.35 %
Urban Population 18%
Total Fertility Rate 2.12 children born/woman
Contraceptive Prevalance Rate 49.7%
Crude Birth Rate 19.9 births/1000 population
Crude Death Rate 5.7 deaths/1000 population
Doctor to patient ratio 0.2/1000 population
Life Expectancy Rate
70.7 years
(Male 70.1 and Female 71.3
Source: Population and Housing Census, 2011
Nepal Demographic Profile 2018

8. Population Pyramid

9. Background
The health system in Nepal is 129 years old,1 and is
based on primary health care approach
Pattern of diseases differs according to the geographic
variations from the plains in the south to the high
northern parts
Health service providers are government, private and
public private partnership

10. Historical Development of Policy and System after first DemocracyFirstDemocracy1950
1951
1st Health
Policy
(1951-63)
1964
1974
Regionalisation of
Health Services
1975
1992
Vertical Health program
& Implementation of
PHC System
1990: 2nd Democracy
1991: 2nd Health plan
:Focus on Expansion of HS
2002
1993-2002 :Tertiary Care Centres
and Expansion of Primary Health
Care Centres & Involvement private
sector
1997-2017 Second
Long Term Health
Plan
1998:Self Government Act
Introduction of Free Health
Care Service; Provision of
maternity initiatives and
revitalization : Handover HF
In 2008: PHC revitalization
division added
2007
2014 New Health Policy
2014
2015
2015: Nepal Federal
Constitution mention
health as fundamental
Human right
2017
2017: Government of
Nepal handover all
primary level HF to
Local government

11. Nepal’s Free Health Care Policy
• 2008: Nepal launched a program for free essential healthcare for
primary health services and access to a number of essential drugs
for all citizens seeking care at health post. 3
• 2009: Services were extended to primary health care centres and
to district hospitals, all outpatient, inpatient and emergency
services, as well as essential medicines, were given free of charge
to all the citizens of Nepal.

12. Nepal’s Free Health Care Policy
• Since February 2009 institutional deliveries are free of charge to
all women nationwide.
• 70 essential drugs are provided free of cost.
• Upto NRS 100,000 (around USD 1000) is provided to
underprivileged families by them Government towards
treatment of cancer 3

13. Nepal’s Free Health Care Policy Continue
• NRS 400 is provided to all pregnant women who undergo an ANC visit
in a health facility as per protocol (at least 4 visits plus delivery at
health centre).
• Transportation Cost provided to pregnant mother who have
institutional delivery as an incentive to utilize the available health
services
• NRS 1000 for Terai Region
• NRS 2000 for Hilly Region
• NRS 3000 for Mountainous Region (From current Budget speech)

14. Nepal’s Free Health Care Policy Continue
• Iron Tablet Free distribution (225 tablets) for pregnant women with
Albendazole.
• Vitamin A supplementation to mothers
• Treatment of certain conditions of the heart, kidney and liver disease; and
cancer is free for the citizens at government hospitals.
• Dialysis facilities are free for a certain number of sessions per week until
renal replacement therapy (kidney transplants)
Source: Annual Report 2015

15. Nepal Free Health Care Policy continue
• Family Planning Services are provided free of cost by the government
health facilities. Condoms, Depo-provera, Pills, Implant, IUCD, Minilap
and Vasectomy. 3
• TB and Leprosy Screening are done and medicines are provided
accordingly, free of cost under direct supervision of the health worker
• Cotrimoxazole, Zinc tablets and ORS is given free of cost for children
suffering from diarrhoeal disease.

16. The Health Care System
Allopathy or Modern Medicine
Traditional medicine- Ayurveda and Aamchi
Homeopathy
Unani
Other complimentary System
Government System
(Through Department of Health Services &
Department of Ayurveda )
In various communities,people have their own
health practices like Dhami, Jhakri, Gruva,
Lama etc
Practiced in Southern parts of Nepal

17. Health Service Delivery
Female community health volunteers
More than 50000 unpaid volunteers and mother groups who cover
health Education, distribution of medicines (Pills, ORS) and health
prevention (treatment of diarrhea and referral after identification,
counselling to mothers for ANC/PNC check ups, Vitamin A
distribution etc)
Community based health services and intervention:
Immunization (mobile clinic per month ), primary health care out
reach clinic (Health Education, FP/MNCH service, CBIMNCI
service)
Tertiary care centers/hospitals/mobile clinics
Access: Almost half (49%) of households are within 30 minutes of
a government health facility. 3

18. Ministry of Health and Population
Department of Health ServiceDepartment of Ayurveda Department of Drug Administration
Division (7) Center (6)
Central Hospital (6)
Ministry of Social Development
Health Department
Regional Health Directorate (5)
Regional and Sub Regional Hospital /Zonal Hospital (10)
Metro/Sub Metro/ Municipality
Rural Municipality
Social Development -Health Unit
District (public) Health Office (29/48) District /Other Hospital (85)
Primary Health Care Center (200)
Health Post (3808)
Urban/ Community Health unit
FCHV (51,470) PHC/ORC clinic (12,180) PHC/ORC clinic (16,022)
Health Facility Operating and
Management Committee
Source: HMIS, DoHS
Organogram
Center
Province

19. Health Governance
At Center Level
 Ministry of Health and Population : For policy and Guideline
 Department : Health Services, Drug Administration and Department of Ayurveda
 Regulatory Bodies: Nepal Medical Council, Nursing council etc
At Province Level :
 Ministry of Social Development : Policy and guideline formation at province level
 Health Department :In process (Only draft available)
At District Level:
District (Public) Health Office : Technical support to Rural Municipality and health facilities
At Municipality and Rural Municipality Level:
 Rural /Municipality general Assembly : Planning , Management and approval of programs
 Social Unit – Health Section : Monitoring and conducting health programs
 HFMOC at ward level : Local level planning

20. Essential Health Services
Child Health program
Immunization program
Community Based Integrated Management of Neonatal
Childhood Illness
Nutrition Program

21. Family Planning Program including Permanent Methods

22. Safe Motherhood Program
 Antenatal, Delivery and Post natal care
 Female Community Health Volunteer
 Primary Health Care outreach clinics
 Demography and Reproductive health
research

23. Family Planning Program including Permanent Methods

24. Disease Control
Malaria
Kala-azar
Lymphatic Filariasis (LF)
Dengue
Zoonoses
Leprosy
Tuberculosis
HIV/AIDS and STI
Eye Care
Entomology
Epidemiology and Disease Outbreak Management
Disaster Management
Surveillance and Research
Homeopathic Services
Human Organ Transplant Services

25. Logistic Supply and Management

26. Female Community Health Volunteer

27. Health Education and Promotion

28. Out-Reach Clinic

29. Treatment and Cure

30. Laboratory Service

31. National Health Insurance
• Budget for the fiscal year 2016/17 ensures implementation of the
'National Health Insurance Scheme' in a phase-wise manner.
• The scheme targets to provide health insurance facility to every Nepali
citizen within three years.
Source: mof.gov.np

32. Referral and Feedback Mechanism System
Central Hospital
PHC/HP
Regional
/Zonal Hospital
AHW/ANM
Hospital
Level
National/Central
Province Level
District
Catchment
area and
Community
Referral Line
Feedback Line
Source: mohp.gov.np

33. MOH
Centers Divisions
RHD
DHO
PHC/HP
NPC
DoHS
MD/HMIS
SHP
HMIS System:
Data Collection/Information Flow Chart
VHW/MCHW
Hospital
National/
Central
Regional
District
Catchment
area and
Community
Reporting
Frequency
Trimesterly
Monthly
Trimesterly/
Periodic
Monthly
Monthly
Feedback
Frequency
Trimesterly
Trimesterly
Monthly
Latest
Reporting
Time
By end of
1st month
of each
Trimester
By end of
1st month
of each
Trimester
12th day
of Next
Month
•7th day of
next month
•3rd day of
next month
•1st day of
next month
Monthly
By e-system
By e-system
By e-system
By
Person (Hard
Copy)
Mode of
Information
Flow
Central/Regional
/Zonal Hospital
7th day
of Next
Month
By e-system
Reporting Line
Feedback Line

34. Health Financing
Government of Nepal
Donor (25% of total health budget in last FY 2015-16)
Local government (7.2% of total local level grant, allocated to health
by local government)
International non government organization
5.7 % Budget in health sector for upcoming FY 2018-19 (i.e. 56.41
Billion)

35. Major Program Initiative in Health
I. Institutional delivery declared free with maternity incentive scheme
II. Introduction of free health care (service charges abolished and essential drugs
provided free)
III. Surgery of uterine prolapse
IV. Cash support to poor patients suffering from cancer, heart disease, heart
disease, chronic kidney disease
V. Compulsory two year rotation of physicians out side Kathmandu after
completing MBBS course under Government scholarship.
VI. Nutrition supplementation program.

36. Challenges of Health System of Nepal
• Resource gap
• Climate change and health
• Equity and quality health services
• Inter-agency coordination
• Sustainability of Health Programs
• Reemerging and new emerging disease
• Increase in Non communicable disease
• Geographical Constraints
• Traditional Beliefs
• Privatization of health services: increase quality in urban areas but
challenging for rural and remote regions

37. REFRENCES
1. H.Dixit, Quest of health:2014
2. DHS Nepal; 2016
3. Annual report;Nepal:2016

38. Thank You