Critical review of National Health Policy 1991

1. National Health Policy 1991
Presented by:
Gaurav Devkota
Kamal Chaulagain
Sujata Dhakal
Sushmita Ghimire
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Moderator: Dr Netrika Prasad Maden Limbu
B Tech (Food),
MBBS, MD Community Medicine
Lecturer
School of Public Health
Patan Academy of Health Sciences

2. Outline of the Presentation
• Contextual Factors
• Objective
• Areas of National Health Policy 1991
• Critical review
• Reference
2

3. Contextual Factors that affect Policy
Political
Economic
Socio -cultural
Demographic
International or Exogenous Factors
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4. Political context
 Political system- Constitutional Monarchy(residual
effect)
 Individual influence and poor team effort
 Country was just steping towards multiparty
democratic system after Panchayat regime
 Sovereignty of people ensured by the new constitution
of Nepal 2047 BS
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5. Contd…
 First elected government was formed and people’s
expectations in new dimensions-to address
 Lack of political commitments to address the health
needs of people in earlier periods
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6. Health Context
 Integration of Vertical Projects
 To implement “COMBINA” in real sense –the Basic
Minimum Health Needs
 Lack of concrete vision specially regarding national policy,
strategies and program to organize promotive, preventive and
curative health services to entire communities
 Technological advance- Poor; Health was not given in priority
till Fourth 5- year plan; only medium level HRs produced
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7. Demographic Context
 CDR 16/1000
 CBR 41/1000
 IMR 107/1000
 U5MR 197/1000
 TFR 5.8
 MMR 850/100000
 Total population: 18491097 (1991 census)
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8.  Average life expectancy 53 years
 Falling life expectancy and increasing CMR
 One hospital per 168 thousand persons
 One doctor per 92 thousand persons
 One hospital bed per around 4 thousand persons
 One health post for 24 thousand rural people
Contd…
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9. Economic context
 Closed economy
 A large disparity existed among the people’s
economic condition and high gaps on access and
services to health care
 High poverty:
 71% below poverty line (World Bank 1990),
 40% BPL as per National Planning Commission estimation
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10. Year 1975 1980 1985 1990
HDI 0.301 0.338 0.380 0.427
Contd…
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11. Contd…
Budget of 7th Plan (1985-90)
 General – 62.10 crore
 Development- 61.61 crore
Save the Children Fund (UK), 1991/92 study
 Per Capita Gov. Health Expenditure-
 $1.30 (lower than Developing countries)
 Share of Tot. Expenditure-
 4%(average of developing countries)
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12. Socio-cultural context
 Ayurveda and traditional healing systems in
predominance
 Formal hierarchies in societies-caste, gaps between haves
and have-nots
 The position of ethnic minorities or linguistic differences-
ethnic minorities were voiceless and Nepali was official
and formal language
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13.  Stigma: considerable stigma about the disease- about
leprosy, TB, small pox etc. needs ‘door-step’ strategy
 Religious Factors e.g. Hinduism dominance
 Illiteracy: 86% of the population
Contd…
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14. International Context
 PHC – Alma-Ata Conference 1978 –endorsed
 Ottawa Charter-1986
 Bamako Initiative- aimed to increase access to primary
health care by raising the effectiveness, efficiency,
financial viability and equity of health services
 Structural Adjustment Program -World Bank, IMF -
Privatization in health
 Indian context- National Health Policy 1983
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15. Objective
• To extend the primary health care system to the rural
population so that they benefit from modern medical
facilities and the services from trained health care
providers
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16. 16
Areas of National Health Policy
1991

17. 1. Preventive Services
• Family planning
• MCH including safe motherhood
• Expanded program on immunization
• Diarrhea and ARI control
• Prevention and control of communicable and non
communicable diseases
• Extension of PHC services to remote areas
• Control of HIV and AIDS
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18. 2. Promotive Services
• Health education and information for increased awareness
of health related matters
• Promotion of breast feeding, Iron, Iodine and Vitamin A
supplementation
• Personal and Environmental hygiene
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19. 3. Curative Health Services
• Curative services was made available at Central, Regional,
Zonal and District hospitals, PHCCs, HPs, SHPs
• Hospital expansion based on population density and patient
loads
• Mobile teams to provide specialist services to rural areas
• A referral system to link rural population to well equipped
institution
• Support lab and x-ray facilities at different level of health
facilities
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20. 4. Strengthening Basic Primary
Health Care Services
• Establishment of sub health post (SHP) in phased manner
in all Village Development Committees (VDCs)
• One Health Post in 205 electoral constituencies was
upgraded in a gradual manner and converted to a Primary
Health Care Centre (PHCC)
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21. 5. Community mobilization for
health programming
• Community participation at all levels of healthcare:
- FCHVs
- TBAs
- Local Leaders
• VDCs provide the sites for SHPs
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22. 6. Organization and Management
• Decentralized management
• Improved supervision
• Improved management information
• Improved logistics system
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23. 7. Human Resources
• Technically competent human resources will be
developed for all level health facilities
• Training centers and academic institutions will be
strengthened to produce competent human resources
• Improved manpower development and management
policies will be implemented
• Improved policies for posting, transfer and promotion
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24. 8. Private, Non-governmental health
services and inter-sectoral coordination
• Encouragement of Private sectors and NGOs to provide
health services
• Coordination with private sectors, non-governmental
organizations (NGOs) and non-health sectors of
Government
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25. 9. Other System
• The ayurvedic and other traditional health systems
(Unani, Homeopathy and Naturopathy) developed to
assist in the improvement of health in those areas where
they are appropriate
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26. 10. Drug Supply
• Improvements in drug supplies by increasing domestic
production
• Upgrading quality of essential drugs through effective
implementation of the National Drug Policy
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27. 11. Resource mobilization in health
services
• Mobilization of National and international resource
• Alternative financing concepts was explored and effected
- Health insurance
- User charges
- Revolving drug scheme
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28. 12. Health Research
• Health system research was encouraged for evidence
based policy formulation and better management
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29. 13. Decentralization and
Regionalization
• Peripheral units was made more autonomous
• Prominent role of DHOs and DPHOs in planning and
management of preventive, curative and promotive health
services from district to village levels
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30. 14. Blood Transfusion services
• Nepal Red Cross society was given the authority to
conduct all programs related to blood transfusion services
• The practices of buying, selling and depositing of blood is
prohibited.
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31. 15. Miscellaneous Issues-
• Programmes for the welfare of disabled persons have
been implemented and progress made against
smoking and other harmful practices. There has been
little progress on health and safety for workers.
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32. Critical Review
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33. Equity
• The policy has targeted rural areas but no clear strategy
has been mentioned
• Referral linkage to rural places
• The policy is silent in regards to women and deprived
community participation
• Centralized and single authority to IOM
• Specific strategy to address lack of Human Resource at
remote rural areas 33

34. Contd…
• Not well addressed since marginalized were not benefited
by alternative financing scheme
• lack clear strategy to collaborate with women, dalit and
community based organization
• Rural area lack blood transfusion service
• Domestic production emphasized for availability
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35. Collaboration
• Guideline on how to collaborate with other stakeholders
has not been mentioned clearly
• Referral mechanism within HFs
• Collaboration among the other groups and institutions
(like IGA, forestry, water and sanitation)is not mentioned
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36. Contd…
• Collaboration with national private sector was missing in
human resources production and mobilization
• NRCS has been given the sole responsibility for blood
transfusion
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37. Community Participation
• Inclusion of FCHVs, TBAs and VHWs, MCHWs and
local leaders has been mentioned but participation of
beneficiaries has been ignored in preventive and curative
services
• Voluntary Blood donation program
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38. References
 Leichter (1979) in Making Health Policy(2006). Kent
Buse, Nicolas Mays & Gill Walt.Tata McGraw-Hill
 MOH. National Health Service Policy. Government of
Nepal. 1991
 MOH. First Long-Term Health Plan. Government of
Nepal. 1976
 Dixit,H.,Nepal’s Quest for Health(3rd ed.). Educational
Publishing House.2005
 The Impact of Political Context upon Health Policy
Process in Pakistan. Context Analysis: Political
 The Impact of Economic & Socio-cultural Context upon
Health Policy Outcomes in Pakistan
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39. Thank You
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