Health System and Health System Strengthening in Nepal Dr BR Marasini, MBBS, MPH Senior Health Administrator Ministry of Health and Population

Background The health system in Nepal is 122 years old and based on primary health care approach Very different diseases in plain southern part and high mountain north parts Health services are mixed –both government and non-government (for profit and not for profit)

The Health Care Systems Allopathic or modern medicine Traditional medicine – Ayurveda and Amchi Homeopathy Unani Other complimentary systems

Health Service Delivery 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

Health Service Organization Sub health post Health post Primary health centre District hospital General hospitals- zonal and regional headquarters National hospitals NGO and Private health institutions

Health Governance Ministry of Health and Population Three Departments - Health Services, Drug Administration and Ayurveda Regulatory bodies- Medical Council, Nursing Council etc Five Regional Health Directorates 75 District Public/Health Offices Facility level health/hospital management committees

Human Resource for Health 18 medical and five dental colleges Nursing colleges Pharmacy colleges Allied health professional colleges 80% positions of the public health facilities are now fulfilled Fulfillment of vacant positions health personnel also initiated through local initiative

Health Financing Government of Nepal Donors Local bodies –increasing trend for last two years International non-government organizations 7.2% budget in health sector in current financial year

Infrastructure Development Building of 700 (apprx.) health facilities is under construction (new or expansion or major renovation) More equipments and logistic support with better timely maintenance initiated The main focus of infrastructure development is maternity services

Major Policies and Initiatives Health sector reform Sector wide approach Millennium development goal Poverty reduction Social inclusion Nepal health partnership compact and international health partnership plus Global health initiative Health System Funding Platform

Major Programme Initiatives in Health Sector Institutional delivery declared free with maternity incentive scheme Introduction of Free Health Care (service charges abolished & essential drugs provided free) Surgery of uterine prolapse Cash support to poor patients suffering from cancer, heart disease, chronic kidney disease, Alzheimer's disease & Parkinson's disease

Major Health Programme---- Compulsory two year posting of physicians out side Kathmandu completing MBBS course in government scholarship Community based neonatal care Nutrition supplementation programme

Health Outcomes and Progress Towards Health Sector MDGs-1 Indicators MDG-1: Nutritional stunting (height for age) % MDG-4:Neonatal mortality rate/1000 live births MDG-4: Infant mortality rate/1000 live births

Health Outcomes and Progress Towards Health Sector MDGs-2 Indicators MDG-4: Under five Child mortality rate/1000 live births MDG-5: Maternal mortality ratio/ live births (1996) Total Fertility Rate

Health Outcomes and Progress Towards Health Sector MDGs-3 Indicators MDG-6: HIV prevalence in year/100,000 population (2007) 390 (2009) Halt & reverse MDG-6: Tuberculosis prevalence rate/ 100,000 population Halt & reverse MDG-6: Malaria prevalence rate/100,000 population at risk Halt & reverse

Core Intermediate Health Indicators IndicatorsCurrent statusTarget for 2015 Remarks Contraceptive prevalence rate 49.6% (any) 45.1% (modern -2009) 67% Skilled Birth attendance rate 28.8% (2009)60%Institutional 24.4% Immunization rate –DPT3 83% (HMIS- 2010) 100% Knowledge on Prevention of HIV Infection (at least one method) Female-58.3% Male- 81% (NDHS-2006) Female- 100% Male- 100%

Health Sector Budget and Expenditure by Year Financial yearTotal Health Budget (NRs billions) Health sector budget as a percent of national budget Actual expenditure rate as a percent of planned budget

Challenges Climate change and health Equity, accessibility, quality and coverage of essential health care services Nutrition Inter agency coordination Sustainability of health programme Reemerging and new emerging diseases

Challenges Deployment and retention of HRH in remote and rural areas Increase in non-communicable diseases

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