National Health Policy 1991

1. National Health Policy 1991
Critical Appraisal
Dr Netrika Prasad Maden Limbu
Junior Resident, 2012
School of Public Health and Community Medicine
BPKIHS,Dharan

2. Policy and Plans in Health Sector in
Nepal (1/2)
• First Long term Health Plan (1976-1992)
• National Health Policy, 1991
• 10th 5 year plan ( PRSP, 2002-2007)
• Three year interim Plan (2007-2010)
• Second Long term Health Plan (1997-2017)
• Millennium Development Goal (2000-2015)
• Medium Term Strategic Plan (MTSP)
• Delivery of Essential Health Services

3. Policy and Plans in Health Sector in
Nepal (2/2)
• Sector Wide Approach (SWAp)
• Free Health Service
• Free Maternity Service
• Urban Health Policy
• Nepal Health Sector Programme -
Implementation Plan 2004-2009
• National Health Policy 2014.

4. National Health Policy, 1991
• Soon after multi-party democracy re-instated
in Nepal in 1990, The interim- government
developed a National Health policy (NHP) in
1991 with following vision, objectives,
approaches and components.

5. National Health Policy, 1991
• Vision: The government committed to create a
socio-economic environment to allow all
Nepalese citizen to lead a healthy life.
• Objective: Upgrading the health standards of
majority of rural population by extending basic
primary health services and making modern
facilities and trained manpower available at the
village level for rural people.

6. National Health Policy, 1991
• Approaches: Priority was given to rural area
using primary health care approach with
preventive, promotive and curative health
services to reduce infant and child mortality.
• 15 Components.

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

8. 1.Preventive Health Services:
Objective: To prioritize program that directly
help to reduce infant and child mortality rate.
-To provide services in integrated manner
through sub health post (SHPs) to the rural
area.

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

10. 2.Promotive Health Services:
Give priority to the problem that enables people to
live a healthier lives across the three subjects of :
-Health education and information
-Nutrition
-Environmental Health
Achievements : A national health education,
Information and communication centre was
established in 1992 to promote public awareness
on health matters.

11. 2.Promotive Health Services:
• However, the provision of health education
from central to village level has not had
desired impact on changing behavior.
• The environmental health program have not
gone ahead to the required extent mainly due
to a lack of coordination between concerned
ministries.

12. 3. Curative Health Services :
• Making health services available in an
integrated way in rural areas
• Organizing mobile teams to provide
specialized service to remote area.
• Establishing zonal and regional hospital in all
zones and regions to provide specialized
services
• Equipping central hospitals with sophisticated
diagnostic and other facilities

13. 3. Curative Health Services :
• Developing a referral system to direct the rural
population to well equipped institution and
• Hospital expansion on population density and
patient loads
Achievements: The target of one hospital per
district has been achieved and teams have been
mobilized to remote places to provide
specialist service to needy one .

14. 3. Curative Health Services :
• Establishment of hospitals at different levels
with defined services have not been fully
achieved as zonal hospital still lack specialty
service.
• 3 regional hospital (against 5 planned).
• The central Hospitals mostly lack adequate
sophisticated diagnostic and other facilities
and referral system poorly developed.

15. 4. Basic Primary Health Services:
Health infrastructure and population ratio

16. 4. Basic Primary Health Services:
Central Hospital Providing super-specialist
services and teaching facilities
Achievements:
• The Target of establishing new sub-health
posts in all VDCs and PHC in all electoral
constituencies has been achieved to greatly
improve access to basic health services.

17. 4. Basic Primary Health Services:
• 8 central level, 3 regional, 2 Sub-regional, 10
Zonal and 72 district/other hospital. 207 Primary
Health Center (PHCC/HC), 1679 (HP), 2127
(SHP) in total ( Annual report 068/69).
• And these facilities are being upgraded gradually
to higher levels. However the commitment made
to expand hospital on the basis of patient load and
density has not been followed.

19. 4. Basic Primary Health Services:
• The free essential health care policy 2008 has
led to user charges and community drug
program being replaced by the free provision
of basic health services and drugs. This has led
to an increase uptake of services.

20. 5. Community Participation in Health Services:
• Seek community participation at all levels,
FCHV, TBA, and leaders of local social org
Achievements: Community participation at all
level has been encouraging. More than 50,007
FCHV are providing basic health services to
communities. Also most VD has donated space
(Usually in VDC building) to run sub-health
posts.

21. 6.Organizational and management reform
To improve the organization and management of
health facilities at all level, including
integration of district hospitals and public
health offices into district health offices.
Achievements: In almost all districts, District
Hospitals and Public health offices have been
integrated under a single administration,
although there are conflicts between medical
and public health personal.

22. 6.Organizational and management reform
• Mandatory rules for health facilities to display
the services they offer and their cost in citizen
charter.
• Although a strong health management
information system exists, the data and
information it generates is little used for
decision making .

23. 6.Organizational and management reform
• Improvements in health logistics management
system and expansion of the road network
have led to improvement in transporting drugs
and equipments to districts. But these are still
significant problems.

24. 7. Development and Management of Human
resource for health.
To develop technically competent human
resources for all health facilities and strengthen
training centers and academic institutions
• provide special benefits for doctors and other
health personnel to encourage them to work in
remote rural areas.

25. 7. Development and Management of Human
resource for health.
• Reform the system for staff transfer and
promotion and carrier development.
• In 1991, IOM was only institute training health
personal who work in below district level
health facilities (mid and basic health level
workers)

26. 7. Development and Management of Human
resource for health.
Achievements: Many public and private institute
have been established since 1991 to train human
resources for health but some have weak
regulatory mechanism and right skill mix of
human resource for health is not being produced.
• Although many trained doctors and nurses in
Nepal. Its still a challenge to get them work in
rural and remote areas.
• lack of carrier development opportunities in
remote postings

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

31. 8.Private, NGOs and inter sectoral co-ordination
MOHP co-ordinate activities with private sector
and NGOs and encouraged them to provide
health services.
Achievements: There has been a large growth in
number of private hospitals and other health
facilities since early 1990s, almost all located
in urban areas and focusing on curative
services.

32. 8.Private, NGOs and inter sectoral co-ordination
• However, although guidelines have been
developed for minimum standard of private
health facility, they have not been fully
implemented due to weak monitoring
mechanism.
• lack of coordination with different
organization and ministry like health and
agriculture, education, drinking water, local
development and other ministries.

33. 9.Ayurveda and traditional health service:
In 1991: There were 1 ayurvedic hospital (ktm), 14
zonal ayurveda aushadyalaya, 68 district
ayurvedic health centers, 1 homeopathic hospital
and 1 Unani dispensary in kathmandu.
• Achievements :A national ayurvedic health policy
was introduced in 1996. however in Nepalese
society, this system of medicine is not attracting
the general public to the desired extent. other
system of medicine such as Unani ,homeopathy,
naturopathy have not been flourished.

34. 9.Ayurveda and traditional health service:
• As of 2011, ayurvedic health services are
being delivered through two ayurveda
hospitals ( a one bed hospital in kathmandu
and 330 bed hospital in Dang), 14 zonal
ayurvedic clinics, 61 district ayurvedic health
centers and 214 ayurvedic centers. There is
one ayurvedic medicine manufacturing unit.
There is one homeopathy hospital and one
Unani dispensary in kathmandu.

35. 10. Drugs Supply
To improve supply of essential drugs by
increasing domestic production and upgrading
the policy of essential drugs by implementing
the national drug policy .
Achievements : National Drug Policy 1995, that
has successfully encouraged domestic drug
production. The domestic production of
essential drugs, mostly by the private sector,
has met the expectations of the policy.

36. 10. Drugs Supply
• To some extent drugs produced in Nepal have
replaced ones imported from India and other
countries. NHP 1991 did not however
adequately spell out the need for an overall
logistics system including procurement,
storage, quality and distribution of medicine,
vaccines, contraceptives, equipments and other
supplies.

37. 11. Resource Mobilization
• Health sector budget <5% of National Budget.
• NHP 1991 policies: Mobilize national and
international resources and explore alternative
concepts (such as health insurance, user charges,
and revolving drug schemes).
Achievements — The proportion of the national
budget dedicated to the health sector has
increased to about 7%. The government has on
several occasions committed to increasing the
health budget to 10% of the total; but this has yet
to happen.

38. 11. Resource Mobilization
• Large amounts of aid for health has been provided
by external development partners. Coordination
and harmonisation in foreign aid has improved as
has the national capacity for planning and
managing financial matters.
• The Health Sector Reform Strategy, 2003 called
for a sector-wide approach (SWAp) for coherent
and sustainable financing, which is currently
being implemented under the Nepal Health Sector
Programmes 2 (2010 to 2015).

39. 12. Health research
• NHP 1991 policies: To encourage health research
for the better management of health services.
• Achievements — The Nepal Health Research
Council was established in 1991 to facilitate
research in the health sector. However, scant
policy research has been carried out and findings
from surveys and routine information collection
are not adequately used for decision making.

41. 13. Regionalization and decentralization
Strengthen decentralization and regionalization and
make peripheral units more autonomous. Give
district health offices (DHO) a prominent role in
planning and managing curative and promotive
health services from district to village levels.
Achievements — Regional laboratories, health
training, medical stores and other health facilities
have only been established in some regions.

42. 13. Regionalization and decentralization
The Local Self Governance Act 1999, gave
considerable responsibilities to local government
bodies at the district municipality and VDC level
for running health facilities.
In line with this legislation the Ministry of Health
has moved to decentralize health facilities by
forming inclusive health facility operation and
management committees. These committees have
been made responsible for managing health
facilities.

43. 13. Regionalization and decentralization
The bottom-up planning of health programms
has been introduced involving district
development committees and VDCs and
micro-planning procedures have been adopted
for extending preventive health services at the
village level. The implementation of the Local
Self-governance Act, 1999 is hampered by the
continuing lack of elected representatives at
district levels and below.

44. 14. Blood transfusion
NHP 1991 policy: Authorise the Nepal Red Cross
Society to conduct all programmes related to
blood transfusion. Prohibit the practice of buying,
selling and depositing blood.
• Achievements — The Nepal Record Cross
Society became responsible for the country’s
blood transfusion service and the practice of
buying, selling and depositing of blood following
the introduction of the National Blood Policy,
1993.

45. 15. Miscellaneous issues
• NHP 1991 policies: These issues were worker
health and safety, law and regulatory reform, anti-
smoking, anti-alcohol and substance abuse
campaigns, and programmes for disabled persons.
• Achievements — Programmes for the welfare of
disabled persons have been implemented in
coordination with the private and NGO sector and
awareness programme have been run against
smoking and other harmful practices.
• .

46. 15. Miscellaneous issues
• Nepal endorsed the international Framework
Convention on Tobacco Control (FCTC) in
2006 and following this banned the advertising
of tobacco products and alcohol on the
electronic media and banned on smoking in
public places. The least achievements have
been made on health and safety for workers.

47. Critical Appraisal

48. Strength
Before 1990, there were health services mainly
concentrated in the urban areas hence large
effort was need to meet the health need of the
rural people.
The policy statement has focused on the justice
and equity. It has clearly addressed the
sentiment and right of the majority of the rural
people who were in the need of the health
service.

49. The National Health Policy provides a
framework to guide the health sector
development in Nepal. Various short term and
long health plans in Nepal are framed being
guided by the National Health Policy.

50. The policy statement has promised to provide the
primary health service basically incorporating
at least 8 elements recommended by the Alma
Ata conference.
It has clearly incorporated the ground reality of
the country that it consists of many villages
and country cannot develop without
developing the village.

51. Reduction of Infant Mortality Rate (IMR),
Maternal Mortality Rate (MMR) and Total
Fertility Rate (TFR). Increase rate of
Contraceptive Prevalence Rate (CPR) and
Expansion of Essential health care services.

52. Weakness
Issue of Floating Population:
People originally from the rural areas have
been residing in the urban areas for the
purpose of employment, education, legal
procedures, etc.
Need and demand of these population were not
taken into consideration during the period
when the policy was endorsed.

54. Issue of urban health services:
When the policy was formulated, it was assumed that
urban population had adequate health services and the
health system in the urban areas was perceived as if
everything was perfect, but this is not true. The people
residing in urban slums still suffer poor health and
urban areas also do have a set of health problems such
as sanitation, poor health of slum dwellers, quality
assurance among the mushrooming health facilities, life
style related diseases and so on that seems to be over
looked during the design of the Policy.

55. Growth of the private sector
During the 1991, it was not envisioned that the
private sector would rise at such speedy pace
and hence the role and responsibility of the
private sector was not well defined and thus
leading to duplication of resources.

56. Implementation Phase: Policy makers are have
extended the international policy to our context,
however the extension of heath services to the rural
areas seem poor in implementation phase because the
disparity in the health services still persist .Still 48
percent of budget is centered in the urban area and
only 52 percent of total budget is allocated for the
rural areas where around 84 percent of the population
reside. Private sectors are densely located in the urban
areas only.

57. • Widening inequality in Health:
Despite the government effort still there is a wide
variation among the health status of the rural and
urban population.
Characteristics Kathmandu Mugu
Life expectancy 74.4 y 37 y
Urban Rural
TFR 2.1/woman 3.3/woman
IMR 37/1000 live birth 64/1000 live birth

58. Sustained finance
The financing mechanism was the much ignored
part in National Health Policy, 1991 which
was only realized during the second Long term
Health Plan(1997-2017).
Actually, Nepalese Health System is much more
dependent on the international agencies which
accounted for 92 percent of National health
budget and the sustained financing mechanism
was not sought to meet the targeted programs.

59. Action plan

60. Strengthening the health system capacity
The capacity of health system both in terms of human
resource and quality assurance needs to be enhanced
through sustained financing, better organization of
health care and effective purchasing of the resources.
This requires government improving the role of
government as steward and a regulator, together with
service provider. All the sanctioned post must be filled
and health workers working at remote rural areas
should be motivated through better incentives

61. Inter sectoral coordination
-for maximum utilization of the resources and
avoid the duplication is equally important.
Services at the rural areas can be consistently
delivered if the inter sect oral coordination is
inadequate.

62. Utilization of health services
Creating demand and utilization of health
services among the rural people
People should be made aware about the
utilization of the health services through
awareness raising programs through mass
media, posters, pamphlets, Behavior Change
Communications, etc.

63. Similarly the attitudes of the health worker also
determine the service utilization hence health
workers also need to be oriented before
placement.

64. Dissolution
• After23 years of implementation of National
Health Policy 1991, this has been dissolved
and replaced by National Health policy 2014.

65. What you think you become

66. References
• Dahal, AR A Textbook of Health Management, Health
Management in Nepalese perspective, Vidyarthi Pustak
Bhandar, Bhotahity, Kathamandu.
• Paudel, NR, Health Policy Design and Implementation
in Nepal: A Policy Discussion, Public Administration
Campus
• Annual Report 2069/70, Government of Nepal, MOHP,
Department of Health Science, Kathmandu
• Bam, K: An analysis of National Health Policy 1991,
DACC Co-ordinator, District Health Office, Doti.
• Shrestha, IB. Pathak, LR, Review of National Health
Policy 1991,