Health system of Nepal in terms of 6 building blocks

1. Health System of Nepal
Dr. Kishor Adhikari
Assoc. Professor
School of public
health

2. Background
• Nepal is a least developed country (LDC) characterized by slow
economic growth, socio- economic underdevelopment and a
low level of human development.
• It is emerging from a politically and socially fragile post-
conflict situation, structurally generated poverty and
inequality, and deeply entrenched forms of social exclusion.
• The economic growth of the country has averaged 4 percent
over the last decade. Absolute poverty decreased from 42
percent in 1995 to 25 percent in 2010 and decreased further
to 23.8 percent in 2015.

3. Background……..Contd.
• Nepal remains one of the few countries to have accomplished
impressive human development gains over the last two
decades. But having started from a very low base, Nepal still
has a low human development status.
• The country has set the goal of graduating from LDC status by
2022.

4. Background………….Contd.
• The country’s development efforts faced a serious jolt
when the large earthquakes and aftershocks of April
and May 2015 affected almost a third of the country's
population, killed nearly 9,000 people, injured nearly
25,000, and resulted in a loss of more than Nepalese
rupees (NPR) 700 billion of damage to human
settlements, infrastructure, and archaeological sites.
• The government has come up with a massive
rehabilitation and reconstruction strategy to address
the direct needs and to restore the economy into a
better shape.

5. Background……..Contd.
• Despite the economy facing so many challenges,
absolute poverty (measured by the national definition)
decreased from 42 percent in 1995 to 25 percent in
2010 and further to 23.8 percent in 2015 (MoF, 2015)
— a reduction of at least one percentage point on
average every year over the last two decades.
• However, there are large disparities in regional,
caste/ethnicity, gender and geographical outcomes.
• Certain social groups and geographical areas are far
below the national average.

6. Source: UN data, retrived from http://data.un.org/Search.aspx?q=nepal

7. Demographic Indicators
• Population: 28,087,871 (2018)1
• HDI: 0.579 medium for year 2018 (147th)2
• Population below poverty line: 21.6% (2017/2018)3
• Life expectancy at birth (m/f): 69/724
• Probability of dying under 5 per 1000 live birth (2018): 324
1. "Population, total". World Bank. Retrieved 10 November 2019.
2. . "Human Development Index (HDI)". hdr.undp.org. HDRO (Human Development Report Office)
United Nations Development Programme. Retrieved 11 December 2019.
3.
https://mof.gov.np/uploads/document/file/for%20web_Economic%20Survey%202075%20Full%2
0Final%20for%20WEB%20_20180914091500.pdf
4. Global Health Observatory, 2019

8. Health related indicators
• TFR (15-49): 2.3
• CBR: 22.4/1000
• Contraceptive used by currently married
women: 53% (Modern: 43 & traditional: 10)

18. Barriers for Social Inclusion in Health
in Nepal
Source: Nepal Health Sector Strategy 2015-2020

19. Burden of Diseases and Health
Problems
• Nepal faces a triple burden of health problems.
• NCDs account for “more than 44% of deaths, 80% of
outpatient contacts, and 39% of DALYs lost.1
• Mental health remains a much-neglect areas, despite
the fact that mental illnesses alone count for 18% of the
current NCDs burden.2
1. Daniels et al., “Nepal Health Sector Programme II Mid-Term Review.”
2. Government of Nepal, “Multisectoral Action Plan for the Prevention and Control of Non Communicable Diseases (2014-2020),”
(Kathmandu2014).

21. Health Service delivery

22. Health service delivery
• Health services are mixed –both government and
nongovernment organizations (for profit and not for profit)
• The Health System introduced as the General Health Plan in
1956 and has been expanded by focusing on primary health
care, and a comprehensive network-like Health System has
been developed.
• Community based health services and interventions
– immunization
– (mobile clinics -every month),
– Vitamin A and albendazole distribution (twice a year) & Primary
health care out reach clinics (mobile clinics- every month) from
local health facility
• Female community health volunteers and mothers groups
• Hospital and facility based services- general, specialized and
mobile clinics.

23. Health service delivery……Contd.
• In the federal structure, Nepalese health
service has been delivered through chains of
health care institutions organized into 3 tier
health care delivery system i.e. Federal level,
Provincial level and Local level health
institutions.

24. Health service delivery…..Contd.
• Since the 2008 AD, Nepal has initiated free health care
services (essential medicines) to all people over the country at
Health Post level and extended the services to PHCC and
District hospital level by 2009 which includes emergency
services, inpatient services, out patient services along with
essential medicines.
• 70 kinds of medicines are free of cost and since 2009, all the
institutional deliveries are also free of cost with some
monetary incentives.
• Along with 1 lakh treatment subsidy for under privileged for
the treatment of chronic diseases, dialysis facility is free till
kidney transplant.

25. Structure of Health service delivery in Nepal
Federal Government:
• Super specialised hospital
• At least One Tertiary hospital in each Province
• One Academy of health Sciences in each Province
Provincial Level Government:
• Secondary hospital (s)
• Provincial hospital
Local Level Government:
• Basic Health Service Center in each ward of local level.
• Primary hospital (s) in each local level.
25

26. Leadership/Governance
• In the present context of historic transition
toward the institutionalization of Federal
Democratic Republic as per the Constitution of
Nepal(promulgated in 2072 [2015]), the
Ministry of Health (MoH) will be fully
committed to formulate policies and programs
and for their implementation to establish
health as the citizen’s rights and responsibility.

27. Central level organizational structure
• MOHP (Ministry of Health and Population) is
the leading government agency for health
• This complex structure comprises:
– Divisions
– Departments and Centers
– Foundations
– Councils
– Health Directorates/office
– Hospitals and Health facilities

28. Organizational Structure of MoHP in Federal Context
28

29. Source: AR/DoHS-2074/75

30. Organizational structure of Department of Health Services

31. Oranization Structure of MoHP and its entities

33. Organogram of Drug Administration
Department
33

34. Organogram of Ayurveda and Alternative
Medicine Department
34

35. Three Basic Tier of Health Facilities
–Federal Level
–Provincial Level and
–Local Level
35

36. Organization Structure of Provincial Health
Directorate under Ministry of Social Development –
9 Sections
1. Policy, Planning and Program Coordination Section
2. Monitoring, Evaluation and Regulation Section
3. Health Information and Population Management Section
4. Ayurveda and Alternative Medicine Section
5. Curative Services and Disease Control Section
6. Health Promotion and Training Section
7. Nursing Service Management Section
8. Procurement and Logistics Management Section
9. Administration Section
10. Additional: Provincial Reference Laboratory Section
36

37. 37
Provincial Organisation Structure

38. Some issues related to federalization
• Internalization of federal Context
• Facilitating role : MoH, DoHS, RHD and
Districts-up to the Palika level
• Guidelines to be circulated to districts-Palika
guideline either through MOFALD or MOF &
guidelines/request from ministry.
• Salary of all staff ,Contract Staff
• Identify the role of DoHS.

39. Financing

40. Health care financing
• Mix model of health care financing (though OOP is too high).
• The estimated Current Health Expenditure (CHE) in the current
price: NPR 141.46 billion (6.3% of Gross Domestic Product) – 2018 4
• GDP: $29.813 billion (nominal, 2019)5
4. MoHP (2018). Nepal National Health Accounts, 2012/13 – 2015/16, Ministry of Health and Population, Government of Nepal,
Kathmandu, Nepal
5. "World Economic Outlook Database, October 2019". IMF.org. International Monetary Fund. Retrieved 20 October
2019.

41. Current health expenditure & Total Capital formation in current price, 2009/10-
2015/16

42. Source: National Health
Account, 2009/10- 2015/16

43. Summary of Health Accounts Result (Fiscal Year 2015/16)

44. • The overall macroeconomic situation of Nepal
is slowly improving. The average growth of
Gross Domestic Product (GDP) has been 4.3%
over the last five years, i.e. from 2010 to
2014.1
• The share of public spending in GDP has
increased from 21.8% in 2010 to 23% in 2014
which indicates a growing fiscal space.2
1. Ministry of Finance, “Economic Survey Fiscal Year 2013/14,” (Kathmandu: Government of Nepal,, 2014).
2. Asian Development Bank, “Nepal: Economy,” Asian Development Bank,
http://www.adb.org/countries/nepal/economy

45. • However, while the health sector has benefited from larger
public spending, its share in total public spending has declined
in the last two years of the NHSP II period (6.2% in 2010/11 to
5.1% in 2013/14).
• The 2018-2019 fiscal year budget provides promising scope
for improving the health system. Of the total NPR 1.31 trillion
national budget, 56.42 billion (4.29 %) has been allocated to
the Ministry of Health and Population. Similarly, NPR 113
billion (8.6%) and NPR 195 billion (14.8%) has been
transferred to the province and local government respectively
from the federal budget.1
1. Ministry of Finance, Government of Nepal. Budget speech of fiscal year 2018/918. http://www.mof.gov.np/en/archive-
documents/ budget-speech-17.html. Accessed June 30, 2018. Published
November 2017.

46. • As Nepal plans to graduate to LMIC by 2022
and coupled with the fact that the overall
poverty incidence of Nepal is decreasing, it is
likely that in future EDPs’ investment in health
may decrease.
• This gap is then expected to be filled through
increased government investment in health.

47. Health Insurance
• Established through formation order(Social Health Security
Development Committee) in 2015
• Contributory scheme; voluntary enrollment.
• Premium Rs 3500/5 member family /year.
• Cashless system Up to Rs1,00,000 /5member/year
excluding all free health services.
• Provider mostly public facilities, private service provider for
referral services.
• Case based and fee for service method for provider
payment.
• Computerized web based information system.
• Provision of subsidy for poor families.

48. Health Information system
• Integrated Health management information system (HMIS)
was developed and implemented countrywide since 1994
AD.
• Before the integration of all health programme in 1993,
various vertical projects were using their own information
system using separate recording and reporting formats.
• Health Management Information System manages
information on all health services delivered through
governmental and non‐government health facilities.
• Integrated Health Information Management Section under
Management Division, DoHS generates statistical tables with
raw and analyzed data in every three months and produces
performance review report every year.

49. • Health Management Information System (HMIS) Guideline 2075 (2nd
Edition, Revised) has categorized its Register, Card and Reporting Formats
into 9 different sections with distinct areas to reduce the duplication in
reporting.

50. संघीय संरचनामा सूचना प्रवाह

52. Routine Data Quality Assessment System
Local Government
Province
Government
Federal
Government
Web-based tool, e-learning materials, tutorial and references are
available at
www.mohp.gov.np

53. eHealth
• eHealth Strategy 2017-2020 endorsed and implementation started
– Roadmap Developed
– Priorities set
– Activities planned & budgeted for 2074/75
• Smart Health Unit established
– Harmonization of eHealth initiatives and resources
– Enhancing accountability, transparency and evidence-based decision making by
leveraging technology
• Key Initiatives
– Expansion of electronic reporting from facilities
– Electronic Medical Recording system
– Health Facility Registry
– File tracking
– e-attendance

54. Access to essential medicine
• World Health Organisation (WHO, 2002) defines essential
medicines (EMs) as products that satisfy the priority healthcare
needs of the population. Those products should be accessible in the
health facilities at all times in sufficient amounts and available at
affordable prices.
• No countries have included all the drugs listed in the WHO EML in
their list of essential drugs. Among Southeast Asian countries, the
Maldives has 535 products in the list followed by Pakistan (373
items), India (367 items), Sri Lanka (318 items) and Nepal (300
items), while Bangladesh has the least number of drugs (187 items)
in the national essential medicines list (WHO Bulletin, 2019).
• However, the recently revised national list of essential medicines of
Nepal contains 359 medicines (DDA, 2016).

55. • Nepal’s National list of essential medicines covers most
of the diseases prevalent in the country. However, the
coverage for non-communicable diseases in the list still
is not sufficient.
• The Government of Nepal started a free drug scheme
from the fiscal year 2006/7 to provide essential drugs
to the patients receiving services from government
healthcare facilities. It started with 40 drugs and now
the list of free drugs includes 70 products from 2015.
• The problem of stock-out is found to be worrisome,
especially in the mountain region in Nepal.

56. Source: Khanal, S., Veerman, L., Ewen, M., Nissen, L., & Hollingworth, S. (2019). Availability, Price,
and Affordability of Essential Medicines to Manage Noncommunicable Diseases: A National Survey
From Nepal. INQUIRY: The Journal of Health Care Organization, Provision, and Financing.
https://doi.org/10.1177/0046958019887572

57. Drugs independency in Nepal
• The size of drugs market in Nepal is expanding
every year.
• Manufacturing of 45 types of medicines presently
takes place in Nepal and remaining drugs used
here are imported from India and third countries.
(Department of Drug Administration (DDA))
• 80-90 percent of drugs in Nepal are imported
from Indian and third-world countries in
Nepal(Worth NRS 26 billion). (2018, Nepal Medicine
Importers Association (MIA)

58. • According to DDA, 21,000 Nepali pharmacies
have been registered with the governing body
while 5,000 remain unregistered
• Currently, only 70 of the 90 registered
pharmaceuticals in Nepal offer human drugs
• There has been a continuous rise in number of
Nepalese using drugs without prescription
• Hence, the country has a long way to go in
attaining self-sufficiency in drug supply and
manufacture to ensure quality healthcare for its
citizens.

59. Challenges
• Regulatory non compliance comes under legal framework and taking
legal action to them.
• Information management, transparency and lacking of dynamic and
Responsive Information system
• Illegal import of medicine due to open border
• Pharmaco vigilance, post marketing surveillance
• Medicine price regulation and transparency
• Good governance and accountability
• Ethical promotion of medicinal products.
• Regulates of nutraceuticals and feed supplement for human and
veterinary use.
Source: DoHS, Annual report 2073/74

60. Health workforce

61. Health workforce
• Despite pro-poor orientation of health subsidies,
distribution of Human Resources (HR) has been
persistently inequitable. Out of 32, 809 public health
workforce in Nepal, 45% are concentrated in the Central
Region whereas only 7% are in the Far-Western Region.
• The distribution scenario is even worse for private health
workforce; of the total 21,638 health workers, only 2%
are available in the Far-Western Region with 58%
concentrated in the Central Region.1
• Ministry of Health and Population, “Human Resources for Health Nepal Country Profile,”
(Kathmandu: Government of Nepal,, 2013)

62. Situation of HRH in Nepal

63. Composition of HRH
• Approximately 54,177 health workers, of which
32,809 were involved in the public sector and
21,368 in the private sector.
• Most of the jobs are located between workforce
levels 4 and 11.
• Majority of the groups are categorized by the
type of expertise required for the job, with the
exception of the miscellaneous category, which
includes a mix of clinical, support, management
and administrative staff.

64. • On one hand, it is often argued that this skills mix
hardly allows for delivering quality health care
(NHSP IP – 2, pp66).
• On the other there is continuing debate on what
should be the skill mix or what is the right
proportion of health care provider that should be
available at various health facilities.
• While may agree that such mix should be
balanced on population and disease pattern,
exact formula to calculate the mix is yet to come.

65. • The vacancy fulfilment rates (particularly for doctors in
three provinces: 5, 6, and 7) as 44%, 45%, and 39%
respectively (Annual Report of the Department of Health
Services (DoHS), 2016/17) confirms that the majority of the
positions remain vacant.
• In 2015/16, this figure was still lower (only 36%) (NHSS
(2015-2020), indicating slight improvements but there is
still a big challenge in retaining doctors particularly in rural
parts of the country.
• On the other hand, data on the availability of nursing staff
was found to be much better (99%) in province 7 compared
to the other provinces, this could be related to the
adequate local supply and effective recruitment process.

66. Some major progresses
• Staff Adjustment Act (2074) was enacted on 15th October 2017.
• During this FY 2016/17, one new health academic institution (Rapti Academy of
Health Sciences, Province 5) in Dang district was approved by GoN, making a total
of four state owned academic institutions under the MoHP.
• These are the National Academy of Medical Sciences (NAMS) in Province 3,
Pokhara Academy of Health Science in Province 4, Karnali Academy of Health
Science (KAHS) in Karnali Province.
• A memorandum of understanding (MoU) was signed between MoHP and KAHS to
support comprehensive emergency obstetric and neonatal care (CEONC) hospitals
located in 9 districts with skills mix HRH (MDGP, AA, and OT nurse).
• Similarly, under the leadership of Nursing & Social security division a MoU was
signed with the Council for Technical Education and Vocational Training (CTEVT) to
develop proficiency certificate level (PCL) training within the midwifery curriculum.
• Developed deployment procedures to plan deployment of 189 specialists (MD/MS,
MDGP and others) to be graduated during this FY from NAMS, Institute of
Medicine (IoM) and B.P. Koirala Institute of Health (BPKIH) academic health
institutions
• Drafted policy on nursing & midwifery service education program.
• Developed PCL in midwifery curriculum.
Source: Progress of the Health Sector in FY 2017/18 NATIONAL ANNUAL REVIEW REPORT – 2018 (2075 BS)

67. HRH Issues in Nepal
• Like other least developed countries, Nepal
encounter many problems in HR development
and HR management.
• In categories they can be placed as:
– Absolute shortage
– Inadequate competencies
– Uneven-distribution
– Improper HRH Management

68. Challenges in context to federalism
• There is no HRH dedicated unit at MoHP for the
purpose of projection, production, planning,
education, and using data for HRH management
• As per constitutional provision, the Local Government
(LG) is responsible for recruitment of staff on a
contractual basis, but there are no standard guidelines
on the recruitment process, which compromises the
quality.
• Although HRH registry is in place, there is lack of
consolidated data from all professional councils.
• HRH projections, gaps and HRH needs are yet to be
completed as per the new structure including staffing.

69. Challenges…….Contd.
• There is a mismatch of HRH production and actual needs
(e.g. need more MDGPs for primary level hospitals vs.
dentist super specialisation).
• Lack of HRH in new and crucial areas like Hospital
Management.
• Retention of health care providers is a major challenge
particularly in the remote areas. This is due to the absence
of a transparent guideline for management of health
workers across the health system (promotion, transfer,
incentive packages)
• Accountability to provide 24 hour services in public hospital
is low due to low salary in the public sector compelling
doctors to undertake dual practices.

70. Challenges….Contd.
• Unregulated dual practice. (The Britain Nepal Medical Trust
2014: A Desk Review Report: Key Issues, Challenges, and
Gaps in Human Resources for Health in Nepal and
Recommendations to the MoHP and Development Partners
for Action).
• Partnerships with academic health institutions to support
HRH needs did not yield positive results due to lack of
clarity on roles/responsibilities of academic health
institutions and MoHP.
• During FY 2016/17, most of the CEONC hospitals received
their budget to recruit staff locally on contractual basis
directly from their respective provinces. However, few
secondary level hospitals have yet to receive budget from
their respective provinces.
Source: Progress of the Health Sector in FY 2017/18 NATIONAL ANNUAL REVIEW REPORT – 2018 (2075 BS)

71. Way forward
• Establish effective partnership with public and private academic
health institutions to address burning HRH needs, especially for the
remote areas through clear partnership guidelines.
• Establishment of a dedicated HRH unit at MoHP.
• Implement appropriate deployment of 189 specialists as per needs
identified by the referral hospitals.
• Capacity enhancement of provincial and local government to
implement updated HRH Strategic Roadmap.
• Development of seven-year Midwifery education plans (2076-2082)
on projections, production, recruitment, deployment, service
protocols, and a retention plan.
• Revise in-service training programmes: Skilled Birth Attendant (SBA)
Training Strategy.
• Strengthen the HURIC and promote digitalisation of HRH
information.

72. Thank you