National health policy 1991 (2048 BS) of Nepal

BACKGROUND OF NATIONAL HEALTH POLICY 1991AD

The present low level of health status is attributable to lack of political commitment, inappropriate strategies, and weaknesses in implementation of health programmes up to the grass root level during the past 30 years. Because of these weaknesses, even now the crude death rate is 16 per thousand, crude birth rate is 41 per thousand, child mortality rate is 107 per thousand, maternal mortality rate is 8.5 per thousand, and mortality rate of children below 5 years is 197 per thousand. These facts and figures have confirmed Nepal as an underdeveloped and backward nation.

Regarding health services delivery, there is one hospital for 168 thousand persons and one doctor for 92 thousand persons in the rural areas. Likewise, only one hospital bed is available for nearly 4 thousand persons. There is only one Health post for 24 thousand rural persons, which indicates the inadequacy of PHC services at the rural level.

MAIN DEFICIENCIES IN PREVIOUS HEALTH SERVICES

The policy, objectives and strategies outlined for health services were not village oriented, and there existed deficiencies in the capability of using the available resources since the rural plans and programmes were not formulated as per the requirements of the rural population.
There were weaknesses in implementation of plans and programmes.
The supervision, monitoring and evaluation of the programmes were not conducted in a regular manner.
The resources were centralized.
The posts sanctioned for district level health organizations were not filled.

RATIONALE OF THE NATIONAL HEALTH POLICY 1991

In order to bring about improvement in the present health conditions of the Nepalese people adversely affected by the previous weaknesses and to fulfill the commitment of the present government in the health sector, it is necessary to have a new health policy.

OBJECTIVES OF THE NATIONAL HEALTH POLICY 1991

The primary objectives of the proposed Health Policy are to upgrade the health standards of the majority of the rural population by extending Basic Primary Health Services up to the village level and to provide the opportunity to the rural people to obtain the benefits of modern medical facilities by making the facilities accessible to them.

TARGETS OF THE NATIONAL HEALTH POLICY 1991

By the year 2000 A.D., the following targets will be attained:

Indicators	Current (1991)	Target for 2000 AD
Infant Mortality Rate (per 1000)	107	50
Child Mortality Rate (<5 years, per 1000)	197	70
Total Fertility Rate	5.8	4.0
Maternal Mortality Rate (per 1000)	8.5	4.0
Average Life Expectancy (years)	53	65

PROPOSED HEALTH POLICY

1. PREVENTIVE HEALTH SERVICES

The services that are provided for the prevention of diseases fall under the Preventive Health Services. Under these, priority will be given to those programmes which directly help reduce infant and child mortality rates. These services will be provided in an integrated way through sub-health care centers at the rural level. The main programmes under this service are as follows:

Family Planning and Maternal and Child Health
Expanded Immunization
Safe Motherhood
Diarrhoea and Acute Respiratory Infection Control
Tuberculosis Control
Leprosy Control
Malaria and ‘Kalajaar’ Control
Control and Prevention of Communicable Diseases
Initiation of Prevention of Non-communicable Diseases
Initiation of Primary Health Services in Urban Slums
Prevention and Control of AIDS

2. PROMOTIVE HEALTH SERVICES

The programmes which enable persons and communities to live healthy lives are included under promotive services.

1) Health Education and Information

One of the main reasons for the low health standards of the people is the lack of public awareness of health matters. Therefore, health education will be provided in an effective manner from centre to rural levels. For this, political workers, teachers, students, social organizations, women and volunteers will be mobilized extensively up to the ward level.

2) Nutrition

Priority programmes will be promotion of breast-feeding, growth monitoring, prevention of iodine deficiency disorders, iron and vitamin A deficiency, and health education to enable mothers to meet the daily requirements of children through locally available resources.

3) Environmental Health

Programmes to inform the people about personal hygiene through various media, to collect and manage solid wastes, to inspect and examine hotel foods, drinking water and other edible products, to manage construction of general latrines and urinals, will be initiated in a coordinated manner.

3. CURATIVE HEALTH SERVICES

The following curative health services will be made available at Central, District and Village levels:

Preventive, promotive and curative health services will be made available in an integrated way in the rural areas through sub-health posts, health posts and primary health care centres.
There will be at least one hospital in each district of the kingdom where out-door services, in-door services, family planning and maternity and child health services, immunization services and emergency services will be provided.
One Zonal Hospital will be established gradually in each of the zones of the kingdom. Specialized services relating to pediatrics, gynecology, general surgery, general medicine, eye care will be available.
One Regional Hospital will be established gradually in each of 5 regions of the kingdom. In these hospitals, specialized services e.g. dermatology, orthopedics and psychiatry will be added in addition to those available in zonal hospitals.
The Central Hospital will be equipped with sophisticated diagnostic and other facilities and provide specialty and super-specialty services.
Specialist services will be extended to remote mountain regions, as and when required, through mobile teams.
A referral system will be developed through which the rural population will be provided with the opportunities to obtain services from modern well equipped hospitals, as and when required.
Diagnostic Services e.g. laboratory, X-Ray and other supportive services will be strengthened in the hospitals at all levels.
Hospital expansion will be done on the basis of population density and patient load.

4. BASIC PRIMARY HEALTH SERVICES

Sub-Health Posts will be established in a phased manner in all Village Development Committee Areas of the Kingdom. Each Sub-Health Post will employ one village health worker, one maternal and child health worker and one auxiliary health worker. These Sub-Health Posts will provide general curative, promotive and preventive health services. Immunization, family planning, maternity and child health, health education, nutrition, environmental education, sanitation, and treatment of malaria, leprosy and Tuberculosis will also be extended by these Sub-Health Posts, up to the ward level.
One Health post in 205 electoral constituencies of the kingdom will be upgraded in a gradual manner and converted to a Primary Health Care Centre. In addition to the services as provided by Sub-Health Posts, arrangements will be made for two emergency beds and one maternity bed in these Centres.
The Health Posts operating at present will provide all Health services in the Village Development Committee where they are located as is done by Sub-Health Posts and will also provide training for and supervise and monitor the activities of Sub-Health Posts.

5. COMMUNITY PARTICIPATION IN HEALTH SERVICES

Community involvement will be sought at each level of health care. Participation of women volunteers, traditional birth attendants (sudenies) and local leaders of various social organizations will be mobilized for health programmes at ward levels.

6. ORGANIZATIONS AND MANAGEMENT

Improvements will be made in the organization and management of health facilities at the central, regional and district levels. Hospitals and public health offices at district levels will be operated in an integrated way under one organization.
The technical and administrative supervision and follow-up system for health organizations at various levels will be made more effective.
Hospitals and Health Units at different levels will be classified. A detailed description of the services available at the health facilities at different levels, cost of the services and list of free services will be prepared and made public.
The collection, compilation, recording and reporting systems for health information at each level will be made more effective.
Improvements will be made in transportation and support systems for drugs and equipment at various health facilities.

7. DEVELOPMENT AND MANAGEMENT OF HEALTH MANPOWER

i. Capable manpower required for various health facilities will be developed in a planned manner.

ii. Necessary cooperation will be extended for institutional development of the Institute of Medicine, the main organization of the country producing health manpower, in order to raise its production capacity.

iii. Necessary arrangements for training in foreign countries will be made in order to produce those categories of manpower, which cannot be produced within the country.

iv. The Training Centres under the Ministry of Health will be strengthened institutionally and their production capacity will be raised, as required.

v. Necessary reforms will be made in transfer, promotion and career development procedures for the health personnel at various levels.

vi. Arrangements will be made to provide special benefits for doctors and other health personnel to encourage them to work in remote rural areas.

8. PRIVATE, NON-GOVERNMENT AND INTER SECTORAL COORDINATION

i. If someone in the private sector wants to extend health services through the establishment of hospitals, health units, nursing homes, without any financial liability to His Majesty’s Government, such institutions may be operated after having obtained necessary permission from His Majesty’s Government and subject to minimum standards as prescribed.

ii. Non-Government Organizations and Associations will be encouraged to provide health services under the prescribed policies of His Majesty’s Government.

iii. Necessary coordination will be maintained at each level with the health related sectors including Agriculture, Education, Drinking Water and Local Development.

9. AYURVED AND OTHER TRADITIONAL HEALTH SYSTEMS

i. The Ayurvedic system will be developed in a gradual manner. Organizational structures for different levels will be prepared separately. This section of medicine will be developed and expanded on the basis of evaluation of services through research.

ii. Encouragement will be provided, as possible, to other traditional health systems like Unani, Homeopathic and Naturopathy.

10. DRUG SUPPLY

i. In order to bring about improvements in the supply of drugs in government health organizations as well as those operated under private sector, the domestic production of essential drugs will be increased. In the meantime, the quality of the drugs will also be upgraded by effective implementation of the National Drug Policy.

11. RESOURCE MOBILIZATION IN HEALTH SERVICES

i. National and international resources will be mobilized for health services. National and Foreign Donor Agencies will be requested to provide necessary cooperation for providing resources to implement the programmes under the Health Policy of His Majesty’s Government.

ii. Various alternative measures for resource mobilization in Health Services will be the subject of experiment e.g. Health Insurance, User’s charges, Revolving Drug Schemes and so forth.

12. HEALTH RESEARCH

i. Research in the health sector will be encouraged. The outcome of research will be applied in the process of decision making for better management of health services.

13. REGIONALIZATION AND DECENTRALIZATION

i. Regionalization and decentralization processes will be strengthened. Peripheral health units will be made more autonomous and effective. For this, amendments will be required in the existing Decentralization Regulations.

ii. Of the various organizations providing health services at different levels, the district health organizations will be given a most prominent role. Arrangements will be made for local level planning and management of curative and promotive health services, with priority given to preventive health services, from the district to the village level.

iii. Micro planning procedures will be adopted in formulation of primary health plans at the village level under which health services will be provided to all target groups with special efforts to reach the underprivileged group.

14. BLOOD TRANSFUSION SERVICES

i. The Nepal Red Cross Society will be authorized to conduct all programmes related to blood transfusion.

ii. To run different programmes related to blood transfusion, the Nepal Red Cross Society will seek consent of the Ministry of Health and will run such programmes.

iii. The practice of buying, selling and depositing of blood will be prohibited.

15. MISCELLANEOUS

i. Safety standards will be developed for industrial establishments for the health security of the workers engaged in industries and their implementation will be monitored.

ii. Laws and regulations relating to health will be formulated as necessary.

iii. Extensive publicity will be carried out on the hazardous effects of drug abuse, alcoholic drinks and smoking.

iv. Programmes relating to welfare of disabled and handicapped persons will be prepared in coordination with the private sector and non-government organizations.

v. Coordination will be established with various governmental and nongovernmental social organizations like Red Cross, for disaster preparedness.