Nepal

4. HEALTH RESOURCES

4.1 Human resources for health

Human resource development has been an area of priority of health services delivery programme in Nepal. The integrated and community health programmes of 1974 introduced systematic training process with the aim to develop all health personnel on integrated health care, who were brought in to mainstream of the integrated public health services from vertical health projects.  The revision of the health services structure in 1993 brought the institutional leadership in the area of health manpower training.

The number of personnel trained at central and district level training centres during the 2000-01 and 2002-03, is given below:

Training performance over the three-year period

Source: Ministry of Health, Annual Report 2002/2003.

The above table shows that the training achievements increased from 84 percent in 2000-01 to 87 percent in 2002-03.

The available health manpower at the end of the 8^th five-year plan and in the 9^th five-year plan during financial year 1999-2000, is given below:

Skilled Human Resources

Source: Central Bureau of Statistics, Statistical Year Book of Nepal, 2003.

It may be seen from the table that health manpower has not increased, except for categories of doctors, FCHV/TBAs.  The post of village health worker is a new creation during the 9th plan period.

According to the Central Bureau of Statistics, Nepal, 2003, there was one physician per 5,886 people. 

CBS, Nepal

Human Resources

4.2 Financial resources for health

A public expenditure review of the health sector was carried out during early 2003. The review brought out many important findings, some of which are given below.

Public funding in health care increased from US$ 3.5 to US$ 5.1 during 1999-2002.

The contribution of external development partners (EDPs) in health sector through the ministry of finance was reduced to almost one-third during this period

The share of recurrent budget is being spent more on wages

The funding in health care to rural areas is decreasing. Health services are comparatively less utilised by the female population.

Resources available for health care during fiscal year 2003-04 (in rupees) are as follows:

A. Total outlay in health care

Fund from government                        1,410 million (49.3percent)

Fund from external sources                  1,450 million (50.7percent)

B. Breakdown of the fund

Physical infrastructure                          300 million (10.5percent)

Salary and services                           2,560 million (89.5percent)

C. Percentage outlay in health

Percentage of national budget in health:                                     6.2

Percentage of the current five-year plan allocation in health:        6.0

About 10 percent of the expenditure on health care comes from the state-owned enterprises. Local bodies have been contributing more for the health sector in recent days.

In absolute terms, the budget allocation for the whole nation and for the health sector has gradually been increasing over the last 30 years, but in percentage terms there has been no actual enhancement in the allocation for health. For example, in 1983-84 it was 4.6 percent, in 1993-94 it was 4.0 percent and in 2002-03 it was 4.9 percent. Unfortunately even the allocated budget for the health sector was hardly expended to the fullest. It is on an average 68 percent of the total allocation.

Financial resources in the health sector have been coming down noticeably during the last few years due to mounting concern for maintaining internal security. External donors have also reduced their contributions to the health sector. Funding from the external donors is increasingly going to the international and national NGOs.

Although the policy of the government, as per the 10th five- year plan, is to stress on giving priority to primary health care and to the poor in remote areas, in practice, distribution of funds is mainly urban-centric and more funds are being allocated for areas that already have better infrastructure, e.g., with better transportation and communication facilities.

Government Expenditure in Health Care by Level

In Nepal, total health expenditure as percentage of GDP has been fluctuating since 1998. It was 5.1 percent in 1998 and 5.2 percent in 2002.  Share of public expenditure in total health expenditure declined from 67.2 percent in 1998 to 65.6 percent in 2002, whereas the share of private expenditure increased from 32.8 percent in 1998 to 34.4 percent in 2002.  On the other hand, the share of public expenditure increased nominally as it was 7 percent in 1998 and 7.5 percent in 2002 (World Health Report, 2005).

The per capita total expenditure on health has been increasing gradually as it was US $ 10 in 1998 and US $ 12 in 2002, whereas the per capita public expenditure on health stagnated since 1998 as it was constant at US $ 3 during 1998-2002 (World Health Report, 2005).

Main sources of funding are the royal government and external resources.

In March 2004, the International Labour Organisation launched a national campaign on social security and coverage for the benefit of all Nepalese. It aims at providing access to health insurance and other benefits. It was initiated for the first time in Asia, particularly Nepal, where 95 percent of the people are not included in any form of social security.

4.3 Physical infrastructure for health

The lowest level of formal health care starts from Sub-Health Posts (SHPs) at the Village Development Committee (VDC) level to Health Posts (HPs), Primary Health Centres (PHCs) and hospitals at the district, zonal, sub-regional, regional and central levels. Basically all PHC services provided at various levels in the public sector are by the Department of Health Services (DHS) and the Department of Ayurvedic Medicine (DAM). The SLTHP, periodic plans and the general policy of the government emphasises in providing PHCs to people, particularly living in remote, rural and unserved areas and focusing on pregnant women and children.

Types/Service Delivery Level and Number of Public Sector Health Facilities

Topography-wise the Distribution of the Health Care Facilities

Source: DHS Annual Report 2001-2002

Among the hospitals (including the 85 shown in the above table) 94 are run by the government. The government also has two teaching hospitals, besides nine teaching hospitals managed by the private sector. There are three community-run hospitals, 12 NGOs-run hospitals and 16 eye hospitals.  Also, there are 74 private sector hospitals/nursing homes in Nepal.

Hospital Beds and Their Distribution

Source: Ministry of Health 2001-2002*

* As per an exercise organised by the government, a total of 3,210 beds will   be required for the district level alone by 2017.

In addition to the above-mentioned allopathic hospitals/health care facilities, there are two ayurvedic hospitals (one of which is a 100-bed hospital and the other one a regional hospital) and one regional ayurvedic dispensary. There are 14 zonal, 55 district and 216 general ayurvedic dispensaries throughout the country. Nepal also has a six-bedded homeopathic hospital and one Unani dispensary. All of these are run by the public sector.

Concern on equity, particularly in a country like Nepal, is louder than ever. The concern for the poor, marginalised and the unserved people has been the priority of the government in providing health services, education and employment in general and to the Dalits in particular. Similar provisions have also been made in the community drug programme. On the whole, the ministry spends about 51 percent of its funds in rural areas, 18 percent in semi-urban and 31 percent in urban areas. Each hospital allocates five percent of the contribution received from the government and five percent of their own income for the services of the poor.

The policy of Nepal Government as set out in the SLTH plan, health ministry has given low priority to the hospital based services. In practice, however, this policy could seldom be translated into reality. The policy, as set in the present five- year plan and in the medium-term expenditure framework (2002/03-2004/05), suggests that the private sector will be more involved in catering to hospital based services. 

Due to the thinly scattered population profile in the hilly and mountainous regions, the accessibility to health facilities is still a problem in this Himalayan country.

4.4 Essential drugs and other supplies

The policy on medicine, which came into force in 1995, emphasises on establishment of coordination among the government, NGOs and private organisations involved in production, import, export, storage, supply, sale, distribution, quality assessment, regulation, rational use and information flow of medicines in the country. 

The department of drug administration (DDA) was established in 1979 following the promulgation of the Drug Act the previous year. Since then, it has been implementing the following:

Development of constitution and regulation for the drug consultative council and drug advisory committee

Registration of medicine

Maintaining of medicine standards

Inspection of compliance of the regulations

Promulgation and implementation of the codes for production of medicine

Promulgation and implementation of the codes for sale and distribution of medicine

Promulgation and implementation of the codes on advertisement of medicine.

It has developed and distributed books on the rational use of drugs, Standard Treatment Schedules (STS) for health posts and sub-health posts to encourage and enforce rational use of drugs. The drug administration has also developed and published training manuals for HPs and SHPs on drug quantification, prescribing and dispensing practice to be used for training health workers.

The drug administration also took 317 administrative actions and 33 legal actions during 2002-2003 for non-compliance of the Drug Act and other regulations. Similarly, 14 products from eight domestic and nine from four foreign companies were recalled from the market and import license of seven foreign companies was cancelled during the same period.

The Nepal Drug Research Laboratory is another principal body for testing and analysis of medicines. It works as the national drug control laboratory.

Procurement and supply of drugs, equipment, insecticide, vaccine and medical consumables are organised for all the divisions of DHS by the Logistics Management Division (LMD) and a supply section in the department of ayurvedic medicines for ayurvedic medicines. Quality of medicine is overseen by the drug authority. .

While half of the procurements are still in the hand of the central office at the national level, half of the procurement is now done at five regional health service directorates for the peripheral units. Essential drug procurement is gradually being shifted to SHPs. This has however, raised questions on the quality of the medicine procured.

Since the establishment of the drug authority, Nepal has been producing medicines and meeting 65 percent of the domestic needs (39 percent allopathic and 26 percent traditional).

     EDM- WHO/SEARO

      WHO/HQ 

4.5 International partnership for health

The external development partners are generally involved in strengthening and expanding the health facilities and services in different parts of the country supporting preventive, promotional and curative services. In recent times, a health sector reform committee was formed under the chairmanship of the health minister and a core group was formed consisting of EDPs, international NGOs, national NGOs and private sector to plan and coordinate the use of resources available for health sector programmes from all stakeholders. The group is expected to mobilise bigger resources and also increase the fund absorption capacity of the government. 

Currently, Nepal is partnering with 21 international NGOs, four multi-lateral and six bi-lateral development partners.

The GFATM has provided US$7 million for the HIV/AIDS control programme and US$4 million for the malaria control programme.

The Global Fund