INTRODUCTION AND POLICY BACKGROUND Chapter 1b

National Policies and Plans

1 NATIONAL HEALTH POLICY, 1991
The National Health Policy was adopted in 1991 (2048 BS) to bring about
improvements in the health conditions of the people of Nepal through extending the
access and availability of primary health care system. The primary objective of the
National Health Policy is to extend the primary health care system to the rural
population so that they benefit from modern medical facilities and the services from
trained health care providers. The National Health Policy addresses the following
areas:

1.1 PREVENTIVE HEALTH SERVICES

Priority is given to programmes that directly help reduce infant and child mortality.
Services are to be provided in an integrated manner throughout the country
through national health systems network.

1.2 PROMOTIVE HEALTH SERVICES

The programmes that enable people to live healthy lives will be given priority.

1.3 CURATIVE HEALTH SERVICES

Curative health services will be made available at all health institutions-central,
regional, zonal and district hospitals; primary health care centres (PHCCs), health
posts (HPs), and sub health posts (SHPs). Hospital expansion will be based on
population density and patient loads. Mobile teams will be organised to provide
specialist services to remote areas. A referral system will be developed to direct
the rural population to well-equipped institutions.

1.4 BASIC PRIMARY HEALTH SERVICES

Sub Health Posts will be established in phased manner in all Village Development
Committees (VDCs). One Health Post in 205 electoral constituencies will be upgraded
in a gradual manner and converted to a Primary Health Care Centre.

1.5 AYURVEDIC AND OTHER TRADITIONAL HEALTH SERVICES

The ayurvedic system will be developed and other traditional health systems (such as
Unani, Homeopathy and Naturopathy) will be encouraged.

1.6 ORGANISATION AND MANAGEMENT

Improvements will be made in the organisation and management of health facilities
at the central, regional and district levels. This will include the integration of the
district hospitals and the public health offices into District Health Offices.

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1.7 COMMUNITY PARTICIPATION IN HEALTH SERVICES
Community participation will be sought at all levels of healthcare through the
participation of female community health volunteers (FCHVs), traditional birth
attendants (TBAs) and leaders of various local social organisations. VDCs will
provide sites for the location of SHPs.

1.8 HUMAN RESOURCES FOR HEALTH DEVELOPMENT (HRH)

Technically competent human resources will be developed for all health facilities.
Training centres and academic institutions will be strengthened to produce
competent human resources.

1.9 RESOURCE MOBILISATION IN HEALTH SERVICES

National and international resources will be mobilised and alternative concepts (such
as health insurance, user charges, and revolving drug schemes) will be explored and
effected wherever possible.

1.10 PRIVATE, NON-GOVERNMENTAL HEALTH SERVICES AND INTER-

SECTORAL CO-ORDINATION
The Ministry of Health & Population will co-ordinate activities with the private
sector, non-governmental organisations (NGOs), and non-health sectors of GoN.
The private sector and NGOs will be encouraged to provide health services to
expand services and access.

1.11 DECENTRALISATION AND REGIONALISATION

Decentralisation and regionalisation will be strengthened; peripheral units will be
made more autonomous. DHOs and DPHOs will have a prominent role in the planning
and management of preventive, curative and promotive health services from district
to village levels.

1.12 BLOOD TRANSFUSION SERVICES

The Nepal Red Cross Society will be authorised to conduct all programmes related
to blood transfusion. The practice of buying, selling, and depositing blood will be
prohibited.

1.13 DRUG SUPPLY

Improvements will be made in the supplies of drugs by increasing domestic
production and upgrading the quality of essential drugs through effective
implementation of the National Drug Policy.

1.14 HEALTH RESEARCH

Health research will be encouraged for helping evidence based policy formulation and
better management of health services.

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2 OPERATIONAL GUIDELINES ON POLICIES AND
PROGRAMMES OF THE MINISTRY OF HEALTH AND POPULATION
The policies and programmes of the Ministry of Health and Population and the
actions and activities of its officials will be as directed by the spirit and feelings of
the last Jana Andolan (Peoples’ movement, 2006/2007) 2062/63.

With the prime objective of bringing about a meaningful change in the overall
health of a Nepal and towards creating a new healthy Nepali society, the Ministry of
Health and Population will perform the following tasks:
2.1 We express our strong commitment to the world wide recognition of "health
being the basic rights of people". Our special focus will be on people of
economically and socially deprived groups, sex, tribes, communities and
regions to guarantee the health of the overall Nepali people.
2.2 Our strong commitment lies on the fact that the state having a major role to
deliver all kinds of health services to the people be it preventive, promotive
or curative. Towards primary health care, the services will be provided
according to the proclamation of the Alma Ata Declaration. Ayurvedic and
other alternative medical practices will be conserved and promoted.
2.3 The present health budget will be increased. Steps will be taken to provide
more funds available to the health sector as in other social welfare sectors. In order
to ensure additional funding in the health services, budgetary cuts will be enforced
in the budget for Royal Palace and Nepal Army. Budget allocated to the health
sector will be used in an effective and efficient way and there will be no let up in
administration for financial corruptions and other irregularities in the health sector.
System of reward and punishment will be practiced with full commitment.
International donor organizations will also be encouraged to extend their
cooperation according to the spirit and feelings of this Guideline.
2.4 Special initiative will be taken to create a provider friendly atmosphere for
doctors and health workers to work in villages and rural areas. Their career
development and opportunity for higher education will be ensured. A two way
feedback system will be made operational.
2.5 Medical education will be made responsive to the requirement of the health
sector of Nepal and a coordination mechanism will be strengthened with the
Ministry of Education, the Universities and other teaching organizations.
Necessary steps will be taken to involve such teaching institutions for the
quality health care provision for the people.
2.6 Support will be provided through necessary policy directives and supervisions
of the private sector in order for them to function responsibly to the society.
Cooperative approach in health will be taken in a way that ensures the participation
and ownership of the community.
2.7 District health system will be organized according to the concept of
integrated approach and decentralization principle. To empower the people
through the mechanism of health related activities, the community based
health workers will be empowered. Special initiatives will be taken to tap the

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 inherent capabilities of these health workers and health volunteers and
ensure effective use of it in their role as a bridge between the people and the
health institutions.
2.8Realizing the fact that health and development have an interdependent relation,
the Ministry will make a concerted effort for an effective intersectoral
coordination.
2.9The population policy of Nepal will be strongly steered towards the aim of
reducing poverty and hunger.
2.10 The Ministry of Health and Population will take immediate steps to provide
health security to the families of those seriously injured and those who
obtained martyrdom during the last Jana Andolan of 2062/63.

3 SECOND LONG TERM HEALTH PLAN, 1997-2017

The Ministry of Health and Population has developed a 20-year Second Long-Term
Health Plan (SLTHP) for FY 2054-2074 (1997-2017). The aim of the SLTHP is to
guide health sector development for the overall improvement of the health of the
population; particularly those whose health needs are often not met.

The SLTHP addresses disparities in healthcare, taking into account gender

sensitivity and equitable community access to quality health care services. The
aims of the SLTHP are to provide a guiding framework to develop successive
periodic and annual health plans that improve the health status of the population;
to develop appropriate strategies, programmes, and action plans that reflect
national health priorities that are affordable and consistent with available resources;
and to ensure co-ordination among public, private and NGO sectors and
development partners.

The SLTHP envisions a healthcare system with consideration of equity and access
and quality services in both rural and urban areas. The system would encompass
the principles of sustainability, community participation, decentralisation, gender
sensitivity, effective and efficient management and public-private partnerships.

3.1 OBJECTIVES
The objectives of the SLTHP are as follows:
• To improve the health status of the population of the most vulnerable groups,
particularly those whose health needs often are not met - women and
children, the rural population, the poor, the underprivileged and the
marginalized population;
• To extend to all districts cost-effective public health measures and essential
curative services for the appropriate treatment of common diseases and injuries;
• To provide technically competent and socially responsible health personnel in
appropriate numbers for quality healthcare throughout the country, particularly in
under-served areas;

(page 15) Introduction and Policy Background

• To improve the management and organisation of the public health sector and
to increase the efficiency and effectiveness of the healthcare system;
• To develop appropriate roles for NGOs, and the public and private sectors in
providing health services; and
• To improve inter-and intra-sectoral co-ordination and to provide the
necessary support for effective decentralisation of health care services with full
community participation.

3.2 TARGETS
The targets of the SLTHP are as follows:
• To reduce the infant mortality rate to 34.4 per thousand live births;
• To reduce the under-five mortality rate to 62.5 per thousand live births;
• To reduce the total fertility rate to 3.05;
• To increase life expectancy to 68.7 years;
• To reduce the crude birth rate to 26.6 per thousand population;
• To reduce the crude death rate to 6 per thousand population;
• To reduce the maternal mortality ratio to 250 per hundred thousand live
births;
• To increase the contraceptive prevalence rate to 58.2 percent;
• To increase the percentage of deliveries attended by trained personnel to
95%;
• To increase the percentage of pregnant women attending a minimum of four
antenatal visits to 80%;
• To reduce the percentage of iron-deficiency anaemia among pregnant
women to 15%;
• To increase the percentage of women of child-bearing age (15-44) who
receive tetanus toxoid (TT2) to 90%;
• To decrease the percentage of newborns weighing less than 2500 grams to
12%;
• To have essential healthcare services (EHCS) available to 90% of the
population living within 30 minutes’ travel time to health facility;
• To have essential drugs available round the year at 100% of facilities;
• To equip 100% of facilities with full staff to deliver essential health care
services; and
• To increase total health expenditures to 10% of total government
expenditures.

3.3 DELIVERY OF ESSENTIAL HEALTH CARE SERVICES

3.3.1 Essential Health Care Services for the Modern System of Medicine:
The Second Long Term Health Plan indicated that priority will be given to health
promotion and prevention activities based on Primary Health Care principles. It
identified Essential Health Care Services (EHCS) that address the most essential

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health needs of the population and that are highly cost-effective. EHCS are priority
public health measures and are essential clinical and curative services for the
appropriate treatment of common diseases. The EHCS for Ayurveda and other
traditional systems of medicines are defined separately.

Main Interventions* Health Problems Addressed

1. Appropriate treatment of
common diseases and injuries
2. Reproductive health
3. The expanded programme on
immunisation (EPI) and
Hepatitis B Vaccine
4. Condom promotion and
distribution
5. Leprosy control
6. Tuberculosis control
7. Integrated Management of
Childhood Illness (IMCI)
8. Nutritional supplementation,
enrichment, nutrition education
and rehabilitation
9. Prevention and control of
blindness
10. Environmental sanitation
11. School health services
12. Vector borne disease control
13. Oral health services
14. Prevention of deafness
15. Substance abuse, including
tobacco and alcohol control
16. Mental health services
17. Accident prevention and
rehabilitation
18. Community-based
rehabilitation
19. Occupational health
20. Emergency preparedness and
management
* Main Interventions are listed in priority order
Common Diseases and injuries
Maternal and Peri-natal health problems including
other RH issues
Diphtheria, Pertusis, TB, Measles, Polio, Neonatal
Tetanus, Hepatitis B
STD/HIV, Hepatitis B, Cervical Cancer
Leprosy
Tuberculosis
Diarrhoeal Disease, Acute Respiratory Infection (ARI),
Protein Energy Malnutrition (PEM), Measles and
Malaria
PEM, Iodine Deficiency Disorders, Vitamin A
Deficiency, Anaemia, Cardiovascular Disease
Prevention, Diabetes, Rickets, Perinantal Mortality,
Maternal Morbidity, Diarrhoeal Disease, ARI
Cataracts, Glaucoma, Pterygium, Refractive Error,
and other Preventable Eye Infections
Diarrhoeal Disease, Acute Respiratory Infection,
Intestinal Helminthes, Vector Borne Diseases,
Malnutrition
Diarrhoeal Disease, Helminthes, Oral Health, HIV,
STDs, Malaria, Eye and Hearing Problems, Substance
Abuse, Basic Trauma Care
Malaria, Leishmaniasis, Japanese Encephalitis
Oral Health
Hearing Problems
Cancers, Chronic Respiratory Disease, Traffic
Accidents
Mental Health Problems
Post Trauma Disabilities
Leprosy, Congenital Disabilities, Post Trauma
Disabilities, Blindness
Chronic Respiratory Disease, Accident, Cancers, Eye
and Skin Diseases, Hearing Loss
Natural and Man-made disasters.

4 NATIONAL HEALTH SECTOR PROGRAMME (NHSP-IP)

4.1 BACKGROUND

(page 17) Introduction and Policy Background

Nepal Health Sector Programme (NHSP) is a sector wide programme focused on
performance results and health policy reforms implemented under a Sector Wide
Approach (SWAP) with an agreed set of programme performance indicators and
policy reform milestones for the programme duration. The policy reform milestones
are outlined in the Nepal Health Sector Programme Implementation Plan (NHSP-IP).
Of the eight NHSP outputs, three are defined for strengthening the health service
delivery: a) delivery of essential health care services, b) decentralised
management of service and c) public private partnership. The remaining five
outputs are designed for improvement in institutional capacity and management in
the areas of: a) sector management, b) health financing and financial management
including alternative financing, c) physical asset management and procurement, d)
human resource management, e) health management information system and
quality assurance.

4.2 PURPOSE
This programme seeks to address disparities in the system and improve the health
of the Nepali population, especially the poor and vulnerable. NHSP marks a new
approach in Nepal which aims at the delivery of basic services to poor and rural
populations and the aid resources will increasingly support a sector programme,
rather than isolated projects. The programme design was led by the efforts of
Nepali themselves and is built under a sound sector strategy. Hence, the Health
Sector Strategy with its Nepal Health Sector Programme Implementation Plan is a
building block of sector wide rationalization aimed towards aid harmonization,
strong performance and reform focus.

4.3 OBJECTIVES
The objective of NHSP is to improve health outcomes by expanding access to and
increasing the use of Essential Health Care Services (EHCS), especially for the poor
with a nationwide coverage.

4.4 STRATEGIC PROGRAMME ACTIVITIES

NHSP strategic programme activities are broadly organized in two components that
consolidate the eight areas of work in the NHSP-IP: a) Strengthened Service
Delivery through the expansion of essential health care services, greater local
authority and responsibility for service provision, and public-private partnerships;
b) Institutional Capacity and Management Development through improved
health sector management; sustainable health financing and financial management;
human resource development; physical asset management and procurement; and
health management information system and quality assurance.

4.5 SUMMARY OF ACHIEVEMENTS DURING FY 2064/65 (2007/2008):

PROGRAMME PERFORMANCE MEASUREMENT STATUS
As defined in the NHSP-IP four key programmatic indicators were agreed to assess
annual achievement in programme performance: (a) contraceptive prevalence rate

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(CPR) (b) skilled attendance at birth (c) immunization coverage and (d) population’s
knowledge about at least one method of preventing HIV/AIDS. As of the Nepal
Demographic and Health Survey (NDHS), 2006 all the above indicators have shown
a remarkable improvement over the period 2001.
According to Health Management Information Section (HMIS) of DoHS the CPR has
slightly decreased from 42.14 % to 40.09% and delivery by trained health workers
increased from 29.7% in 2063/64 to 31.6% in 2064/65. Although the routine
immunization coverage have slightly decreased from 84% to 82% for DPT/Hep-B 3
and from 83% to 79% for measles but still able to maintain the 80 percent
coverage.

5 FREE ESSENTIAL HEALTH SERVICES PROGRAMME

5.1 BACKGROUND
The policies and programmes of the MoHP and the action and activities of its officials
is being directed by the spirit and mandate of the last Jan Andolan (People's
Movement) 2006. Ten points position paper has been introduced by MoHP for
operational guidelines on policies and programmes of MoHP.

The Interim Constitution of Nepal 2063 has emphasized that every citizen shall have
the rights to basic health services free of costs as provided by the law. Ultimately,
government of Nepal decided to provide essential health care services (emergency
and inpatient services) free of charge to poor, destitute, disabled, senior citizens and
FCHVs up to 25 bedded district hospitals and PHCCs (December 15, 2006) and all
citizens at SHP/HP level (8 October, 2007). But MoHP decided to implement from 15th
Jan 2008 for its preparations to manage.
After the evolution of 1st republic budget of Nepal in 19th Sep 2008. Nepal
Government has been emphasized to make free health services up to 25 bedded
district hospital especially to targeted people with listed essential drugs to all citizens.
Therefore MoHP have decided to provide free health service to all citizens in all PHCC
since 16th Nov 2008 on the basis of equity. In the same way MoHP decided to provide
free health care services to all targeted people at district hospitals having less than25
bedded and making free essential drugs to all citizen since 14th Jan 2009. In order to
implement effectively, the MoHP has introduced the operational guide line of national
free health service programme based on new budget policy.

Free Health Care Policy:

Free Health Care policy is directed by the Interim Constitution of Nepal 2007, which is
the spirit of People's Movement II 2062/63 (2006). This policy is based on the citizen's
rights. Policy of free health care is to provide primary health care services free of cost
to every citizen and special attention, that is, safety net to poor, vulnerable and
marginalized people. This is an extended form of current free service and strong
commitment of the Interim government.

(page 19) Introduction and Policy Background

5.2 OBJECTIVES
• To secure the right of the citizens to the health services;
• To increase access of health services especially for the poor, ultra-poor,
destitute, disabled, senior citizens and FCHVs;
• To reduce the morbidity and mortality especially of the poor,
marginalized and vulnerable people;
• To secure the responsibility of state towards the people's health
services;
• To provide quality essential health care services effectively;
• To provide equity of health services.

6 MILLENNIUM DEVELOPMENT GOALS (MDGs)

At the millennium summit of September 2000, the member states of the United
Nations adopted the Millennium Declaration, which aims to bring peace, security
and development to all people. The Millennium Development Goals (MDGs), drawn
from the Millennium Declaration, are a ground breaking international development
agenda for the 21st century to which all nations are committed. The MDGs outline
major development priorities to be achieved by 2015. Numerical targets are set for
each goal and are to be monitored through 48 indicators. The MDGs are:
Goal 1. Eradicate extreme poverty and hunger
Goal 2. Achieve universal primary education
Goal 3. Promote gender equality and empower women
Goal 4. Reduce child mortality
Goal 5. Improve maternal health
Goal 6. Combat HIV/AIDS, Malaria and other diseases
Goal 7. Ensure environmental sustainability
Goal 8. Develop a global partnership for development
Note: Goals no. 4, 5 & 6 are directly related to MoHP/GoN.
Since GoN endorsed the Millennium Declaration, Nepal has been committed to
achieving the MDGs goal.

Targets: The targets based on the above goals of MDGs are as follows:
Target 1. Halve between 1990 and 2015, the proportion of people whose income is
less than one dollar a day;
Target 2. Halve between 1990 and 2015, the proportion of people who suffer from
hunger;
Target 3. Ensure that, by 2015, children everywhere, boys and girls alive, will be
able to complete primary schooling;
Target 4. Eliminate gender disparity in primary and secondary education, preferably
by 2005, and at all levels of education no later than 2015;
Target 5. Reduce by two-thirds between 1990 and 2015 the under 5 mortality rate;
Target 6. Reduce by three-quarters, between 1990 and 2015, the maternal
mortality ratio;
Target 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS;

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Target 8. To have halted by 2015 and begun to reverse the incidence of malaria and
other diseases;
Target 9. Integrate the principles of sustainable development into country policies
and programmes and reverse the loss of environmental resources;
Target 10. Halve by 2015, the population without sustainable access to safe
drinking water and basic sanitations;
Target 11. This target is related to “Develop a global partnership for
development”;
Target 12. Develop further an open, rule based, predictable, non-discriminatory
trading and financial system, includes a commitment to good governance,
development and poverty reduction-both nationally and internationally;
Target 13. Address the special needs of the LDCs, includes: tariff and quota-free
access for LDC exports; enhanced programme of debt relief for HIPC; and
cancellation of official bilateral debt; and more generous ODA for
countries committed to poverty reduction;
Target 14. Address the special needs of landlocked developing countries and
small island developing states;
Target 15. Deal in comprehensive manner with the debt problems of developing
countries through national and international measures in order to make
debt sustainable in the long term;
Target 16. In cooperation with developing countries, develop and implement
strategies for decent and productive work for youth;
Target 17. In cooperation with pharmaceutical companies, provide access to
affordable essential drugs in developing countries;
Target 18. In cooperation with the private sector, make available the benefits of
new techniques, especially information and communications.

Among the above targets, the targets and their respective indicators which are
directly related to MoHP are as follows:
Relates Indicators In In In
with 1990 2005 2015
Target 5 Infant Mortality Rate 108 - 34
Under five years mortality rate 162 - 54
Proportion of one year olds immunized against 42 - 90
Measles
Target 6 Maternal Mortality Ratio 515 - 134
Percentage of deliveries attended by health care 7 - 60
providers (Doctors/Nurses/Auxiliary Nurse
Midwives)
Target 7 HIV Prevalence among (15-49) years of age (in NA 0.5 -
%)
Contraceptive Prevalence rate including condom 24 NA -
(in %)
Target 8 Prevalence rate associated with malaria (no. of 115 - -
cases per 10,000 people at risk)
Proportion of population in malaria risk areas NA - -
using effective malaria prevention measures
Slide Positivity Rate (SPR) 5.1 - -
Prevalence associated with Tuberculosis 460 - -
Death rates associated with Tuberculosis 43 -

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 Proportion of Tuberculosis cases detected NA -
Proportion of Tuberculosis cases cured under NA -
DOTS
Source: Millennium Development Goals

7 THREE YEAR INTERIM PLAN (2007/2008 – 2009/2010)

The plan seeks to establish the right of the citizen to free basic health care services.
Public health issues-preventive, promotional and curative health services-will be
implemented as per the principles of primary health services. The following policies
will be implemented:
• Special programs will be launched in an integrated manner (by involving the
government, private sector and NGOs) to increase the citizens' access to basic health
services.
• Special health programs will be launched targeting those deprived of health
care-indigenous nationalities (Adibasi Janajati), Dalits, people with disability and
Madhesi people.
• Human, financial and physical resources provided by the government, private
sector and NGOs would be managed effectively for improving the quality of health
care services.
• Considering their success, Community Drug Program and Community
Cooperative Clinic services will be encouraged.
• Mutual relationship between health science and medical and public health
studies will be strengthened to make health services effective, efficient and pro-
people.
• Research in health sector will be encouraged, promoted and expanded.

8 INSTITUTIONAL FRAMEWORK OF THE DEPARTMENT OF HEALTH

SERVICES
The overall purpose of the Department of Health Services is to deliver preventive,
promotive and curative health services throughout the country. The Department of
Health Services is one of the three departments under the Ministry of Health and
Population. As seen in Figure 1b.1 the organisational structure of the MoHP outlines
how different levels of the health system relate to form a network under the DoHS.

According to the institutional framework of the MoHP/DoHS, the Sub Health Post
(SHP) from an institutional perspective, is the first contact point for basic health
services. However, in reality, the SHP is the referral centre of the volunteer cadres
like FCHVs as well as a venue for community-based activities such as PHC outreach
clinics and EPI clinics. Each level above the SHP is a referral point in a network from
SHP to HP to PHCC, and to district, zonal and regional hospitals, and finally to
speciality tertiary care centres in Kathmandu. This referral hierarchy has been
designed to ensure that the majority of population receive public health and minor
treatment in places accessible to them. Inversely, the system works as a supporting
mechanism for lower levels by providing logistical, financial, supervisory, and
technical support from the centre to the periphery.

DoHS, Annual Report 2064/65 (2007/2008) (page 22)

 Organisational Structure of the Department of Health Services

figure 1b.1 Source: HMIS/MD, DoHS

Acrony
ms
MD Management Division NTC National Tuberculosis Centre
FHD Family Health Division NCASC National Centre for AIDS and STD
Control
CHD Child Health Division NPHL National Public Health Laboratory
EDCD Epidemiology and Disease Control Division FCHV Female Community Health
Volunteer
LMD Logistics Management Division
LCD Leprosy Control Division PHC/OR Primary Health Care Outreach
C Clinic
NHTC National Health Training Centre EPI Expanded Programme on
Immunisation

(page 23) Introduction and Policy Background

 NHEICC National Health Education, Information and
Communication Centre

DoHS, Annual Report 2064/65 (2007/2008) (page 24)