Review and achievements of National Health Policy 1991

1. NATIONAL HEALTH
POLICY 1991
ACHIEVEMENT AND
CHALLANGES
Dr.Sharad H. Gajuryal
Junior Resident,
MD Hospital Administration
BPKIHS,Dharan

2.  Soon After the re-establishment of a constitutional
monarchy and multi-party democracy in Nepal in
1990, The government developed a National Health
policy (NHP) in 1991 with following vision and
approches and components.

3.  Vision: The government committed to create a socio-
economic environment to allow all Nepalese citizen to
lead a healthy life.
 Objective: To Upgrade the health standards of majority
of rural popolation by extending Basic primary health
services and making modern facilities and trained
manpower available at the village level for rural people.
 Priority: Priority was given to rural area using primary
health care approach with preventive, promotive and
curative health services to reduce infant and child
mortality.

4.  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.

5. THE POLICY HAVE 15 COMPONENTS RANGING
FROM PREVENTIVE HEALTH SERVICES TO
BLOOD TRANSFUSION SERVICES AND
MISCELLANEOUS ISSUES.
1. Preventive Health Services: Priority is Given to
the program that directly help to reduce infant and
child mortality rate.
2. Promotive Health Services :Priority is given to
the programes that enables people to live healthy
lives.

6. 3. Curative Health Services: Curative Health Services
will be available at all health institutes- Central,
Regional, Zonal and district Hospital, PHC, HP, &
SHP and at all levels of the healthcare system.
Mobile teams will be organized to provide specialist
service to remote area. Hospital expansion will be
based on population density and on patient loads.
-A referral system will be introduced to direct the
rural population to well-equipped institution.

7.  Basic Primary Health Services: Sub Health Post will
be established in phased mannner in all VDC. One
health post in 205 electoral constituencies will be
upgraded in gradual manner and converted to a
primary health care center (PHCC)

8.  Ayurveda and other Traditional Health services: The
ayurvedic System will be developed and other
traditional system ( Unani, Homeopathy,
naturopathy) will be encouraged.
 Community Participation in Health Services:
Community participation will be sought at all level of
healthcare through participation of FCHV, TBA,
and leaders of various local social organizations.
VDCs will provide the site for location of Sub-Health
posts.

9.  Organisation and management: Improvement will
be made at organization and management level of
health facilities at central,Regional, aand district
level. This will include the intregation of District
hospitals and public health offices into district
health offices.
 Human Resource for Health Development (HRH):
Technically competent human resources will be
developed for all health facilities. Training center
and academic institution will be strengthened.

10.  Resource Mobilization in Health Service: National
and international resources will be mobilized and
alternative concepts (health insurance,user charges
and revolvind drugs schemes) will be explored
 Private,Non-Govermental Health services and inter-
sectoral coordination : The Ministry of Helath will
co-ordinate activities with private sector, NGOs and
non-health sector of Government of Nepal.Private
sectors and NGOs will be encouraged to provide
health services

11.  Decentralization and regionalization:
Decentralization and regionalization will be
strenghthened ; peripheral unit will be made more
autonomous. District Health office (DHO) will have
prominent role in planning and management of
curative and promotive health service from district
to village level.
 Blood Transfusion Services:Nepal Red cross societ
will be authorised to conduct all programes related
to blood transfusion. The practise of buying,selling
and depositing blood will be prohibited.

12.  Drugs Supply: Improvement will be made in supply
of drugs by increasing domestic production and
upgrading the quality of essential drugs through
effective implementation of National drugs policy .
 Health Research : Health research will be
encouraged for better management of health
services.

13. ACHEIVEMENTS OF
NATIONAL HEALTH
POLICY COMPONENTS

14. 1.Preventive Health Services:
Objective: To priotise program that directly help to reduce
infant and child mortality rate.
-To provide services in integrated manner through sub
health post to the rural area.
Achievement: Integrated service delivery has happened at
sub-health post level and upto district level which
worked well although in many cases resource have
been insufficient and staffs inadequately trained. This
has succesfully reduced child and infant mortality rate
such that Nepal is on course to achieve the infant and
child mortality MDG by 2015.

15.  2.Promotive Health Services: Give priority to the
probram 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 estd. In
1992 to promote public awareness on health
matters. However, the provision of health education
from central to village level has not had desired
impact on changing behaviour.

16. CONTD..
 The environmental health program ( on personal
hygiene, solid waste management, food standard
and other subjects) have not gone ahead to the
required extent mainly due to a lack of coordination
between concerned ministries.

17. 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
 Developing a referral system to direct the rural
population to well equipped institution and
 Hospital expansion on population density and
patient loads

18.  Achievements:The target of one hospital per district has
been achieved and teams have been mobilised to
remote places to provide specialist service to needy one
.
 Establishement of hospitals at different levels with
defined services have not been fully achieved as zonal
hospital still lack speciality service and regional hospital
have not been establised as plannes with only two
existing (surkhet and Pokhara) against five planned.
 The central Hospitals mostly lack adequate
sophasticated diagnostic and other facilities and referral
system poorly developed.

19. 4. Basic Primary Health Services:
-one sub-health post in all VDCs to cover an average of 4,000
people each.
-One health post in all ilakas (=5 adjoining VDCs) to cover an
average of 29,000 people each.
One PHC in all 205 electoral constituencies to cover an average
of 100,000 people each.
-One DHO/District hospital in all 75 dictrics to cover an average
of 200,000 people each
-One Zonal Hospital in all 14 zones to cover average of 1.3
million people each
-One regional Hospital in all 5 regions to cover average of 3.6
million people.
-Central Hospital Providing super-specialist services and
teaching facilities

20.  Achievements:
 -The Target of establishing new sub-health posts in
all VDCs and PHC in all elctoral constituencies has
been achieved to greatly improve access to basic
health services. Accourding to Annual Health
Report 069/70 there are ,205 Primary Health
Center (PHC), 822 Health Posts(HP), 2987 Sub-
health Posts (SHP) in total . And these facilities are
being upgraded gradually to higher levels.

21.  However the commitment mande to exxpand
hospital on the basis of patient load and density has
not been followed.
 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 increse
uptake of services.

22.  5. Community Participation in Health Services:
Achievements: Community participation at all level
has been encouraging. More than 50,000 FCHV
are providing basic health services to communities.
Also most VD has donated space (Usually in VDC
building) to run sub-health posts.

23.  6.Organizational and management reform
 -To improve the organization and management of
health facilites at cental, regional and district level.
 Achievements: In almost all districts, District
Hospitals and Public health offices have been
integrated under a single administration, although
there are conflicts between nedical and public
health personal.
 Mandatory rules for health facilities to display the
services they offer and their cost.

24.  Although a strong health management information
system exists, the data and information it generates
is little used for decision making .
 Improvements in health logistics management
system and expansion of the road network have led
to improvement in transporting drugs and
euiipments to districts. But these are still significant
problems.

25.  7. Development and Management of Human
resource for health.
 -To develop techically competent human resources
for all health facilities and strengthen training
centers and acedemic institutions
 -provide special benefits for doctors and other
health personel to encourage them to work in
remote rural areas.
 -Reform the system for staff transfer and promotion
and carrer development.
 In 1991, IOM was only institue training health
personal who work in below district level health
facilities (mid and basic health level workers)

26.  Achievements:Many public and private institue
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 trined doctors and nurses in Nepal.
Its still a challenge to get them work in rural and
remote areas.It may be due to many attraction in
working in urban area with lack of carrer
development oppertunities in remote postings

27.  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

28.  8.Private,NGOs and intersectoral co-ordinations
 Achievements: There has been a large growth in
number of private hospitals and other health facilities
since early 1190s, almost all located in urban areas and
focusing on curative services.
 However, although guidelines have been developed for
minimum standard of private health facility, they have
not been fully implemented due to weak monitoring
mechanism.
 Have lack of coordination with different organization and
ministry like health and agriculture, education, drinking
water.

29.  9.Ayurveda and traditional health service:
 In 1991: There were 1 ayurvedic hospital
(kathmandu) 14 zonal ayurveda cllinics
(aushadyalaya), 68 district ayurvedic health centers
, one homeopathic hospital and one unani
dispensary in kathmandu.
 Achievements :A national ayurvedic health policy
was introduced in 1996. however in nepalese
soceity , 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.

30.  As of 2011 ayurvedic health services are being
delivered through two avurveda 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
hospitaal and one unani dispensary in kathmandu.

31.  10.Drugs Supply –
NHP 1991 Policy: To improve supply of essential drugs by
increasing domestic production and upgrading the policy of
essential drugs by implementing the national drug policy .
Achievements : A new National Drug Policy was introduced in
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. 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.

32. 11. Resource Mobilization
 NHP 1991 policies: Mobilise 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.

33.  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.

34. 13. Regionalization and decentralization
NHP 1991 policies: 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. The proposed organizational structure (see
Annex 2) gives five types of regional level health facilities including regional hospitals.
Achievements — Regional laboratories, health training, medical stores and other health facilities have
only been established in some regions. 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. 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.

35. 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.

36.  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. 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.