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5. DEVELOPMENT OF
THE HEALTH SYSTEM
5.1 Health policies
and strategies
After the world nations agreed to attain the goal of ‘Health
For All’ (HFA) by the year 2000AD through primary health care approach, Nepal
also stepped ahead to extend and strengthen the integrated approach to meet
the national goals.
The ninth five-year plan (1997) had set a target to
improve public health status by strengthening of the existing infrastructure
for preventive, promotive, curative and
rehabilitation services.
The second long-term health plan (1997-2017) aims at
improving health status of the people, particularly those whose health needs
are often not met; the most vulnerable groups, women and children, the rural
population, the poor, the under-privileged and the marginalized. It emphasises on assuring equitable access by extending
quality essential health care services with full community participation and
gender sensitivity by technically competent and socially responsible health
personnel throughout the country.
In addition to essential health care, specialist services
are also to be extended gradually on a cost-effective basis. The targets to be achieved by the second
long- term health plan (SLTHP) by the end of the plan period of 1997-2017,
are as follows:
i. IMR will be reduced to 34.4 per thousand live
births from its present level ;
ii. Under-
five mortality rate to be reduced to 62.5 per thousand live births from the
its present level;
iii. TFR
to be reduced to 3.05 from its present level;
iv. Increase
life expectancy to 68.7 from its present level;
v. To
reduce CBR to 26.6 per thousand population from the its present level;
vi. To
reduce CDR to 6 per thousand population from its present level;
vii. To
reduce maternal mortality ratio to 250 per 100,000 births from the its
present level;
viii. To
increase CPR to 58.2 percent of its present level;
ix. To
reduce percentage of new born < 2,500 gm to 12, and
x. To
provide essential health care services at district level to 90 percent of the
population living within 30 minutes of travel time
Millennium
Development Goals (MDGs)
The progress made towards achievement of health related MDGs is given at Annex-2.
 Health
Policy
5.2 Organisation of the health system
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 (DoHS) is
one of three departments under the Ministry of Health. As seen in Figure 1, the organisational structure of the ministry MoH outlines how different levels of the health care
system relate to each other in the form of a health care network under the DoHS.
According to the institutional framework of DoHS and MoH, the Sub-Health
Posts (SHPs), from an institutional perspective, is
the first contact point for basic health services. However, in reality, the SHPs are the referral centres
of the volunteer cadres like TBAs and Female
Community Health Volunteers (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 SHPs to HPs to PHCs, and to district,
zonal and regional hospitals, and finally to the speciality
tertiary care centres in Kathmandu.
This referral hierarchy has been designed to ensure that the majority
of population receives public health care facilities and minor treatment in
places accessible to them and at a price they can afford. 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.
FIGURE 1
Organisational Structure of the Department of Health
Services
There are a few private non-profit hospitals as well.
These hospitals have mobilised their resources from
various sources, the main being the charges for services. One of these
hospitals gets a substantial contribution from its local communities and the
local government as well.
Almost all the private sector hospitals, including those
runs by NGOs and private profit-oriented nursing homes that are for profit,
are situated in the urban areas and have been expanding during in the last 10
years. The outlook of the private hospitals clearly gives a psychological
advantage to the people of better quality of services. The easy access to
them in urban areas have an added advantage over the resource constraints,
inadequately motivated, poorly managed public health facilities; which are
supposed to be utilised by people with very little
health awareness, education and often having difficult access or who are
unwilling to leave their household chores in preference to their health
needs.
The charges at the private hospitals and medical colleges
are quite high and beyond the control of the government though efforts have
been made time and again in the past to rationalise
their service fees.
The Planning Division has initiated a Health Sector Reform
(HSR) planning in the last about two years with close involvement and support
from all interested External Development Partners (EDPs),
International Non-Governmental Organisations (INGOs) and National Non-Governmental Organisations
(NNGOs) and the private sector. This HSR planning
has already carried out about 14 studies in different areas in the process of
situation analysis in different initiatives taken in the past in providing
health services in the country. This whole exercise of HSR has resulted in a
joint planning of the Nepal Health Sector Planning – Implementation Plan
(NHSP-IP). A memorandum of understanding between the government and the EDPs has recently been signed in this regard. It is
expected to be of much help in shaping the future of the health services of
the country jointly by the government, EDPs, INGOs and NNGOs, the private
sector, and other stakeholders all involved together.
Decentralisation is one of the
priority issues in the health sector of Nepal. The Ministry of Health, in
coordination with the Ministry of Local Development, has taken initiatives
from the lowest level i.e. the Sub-Health Posts, for handing over their
financial and administrative management to the respective Village Development
Committees. District offices are given fund for mounting health promotional
activities. The initial problems were:
i. Policy making process which needs to be looked
into its context, objectives, stakeholders and consultation with them,
legislative compatibility and monitoring mechanism
ii. Organising the structure at different levels with
appropriate responsibility and authority
iii. Clear-cut
policy on resource generation and allocation; thus avoiding the burden on to
the poor
iv. Appropriate
and efficient planning of health suitable to the local need
v. Resource
management
vi. Coordinating
with the national policy and spirit, and
vii. Capacity
building at the local level along with development of a Public Private
Partnership (PPP) spirit.
More frequent and intense monitoring of the system would
be necessary to identify the initial hiccups and take remedial measures in
time.
Health System
5.3 Managerial
process
Steering Committees have been formed for various
programmes like for GAVI (Hepatitis B)/Polio eradication, HIV/AIDS, leprosy,
family planning, IMCI and others at the central level.
5.4 Health
information system
Routine monitoring system has much improved over the
years. Various mini surveys are frequently being carried out, especially for
vitamin A and child survival and epidemiological programmes. The management
information system in the form of Health Management Information (HMIS),
Logistics Management Information System (LMIS) and Fiscal Management
Information System (FMIS) has also been developed quite well during in the
last 10 years with the help of organisations like
the WHO and the UNFPA. To start with, the FP and MCH, Child Health,
Epidemiology and other programmes had their own separate forms (all together
more than 130) for reporting of their activities and findings. At present all
health related activities are recorded and reported right from the lowest
health unit i.e. SHP to district hospitals.
Besides the HMIS, there are also other sources of
infrequent, frequent or regular information of individual programmes like
child health, epidemiology, leprosy, tuberculosis, public health laboratory
and others depending on the nature of their activities. Such information may
be in the form of general or specific monitoring visit reports or
surveillance reports as in HIV/AIDS in every six months or evaluation
reports.
The LMIS has been developed mainly to assess the storage
situation (depletion level), forecast the need and plan for the supplies to
reach at a certain time and at a certain institution. It is being done by
using some particular forms, designed for this purpose, and by receiving
reports regularly from all health institutions at the Logistics Division of
the DHS (Demographic Health Survey). This has saved health workers worries of
supplies going out of stock. The USAID is the main partner in this endeavour.
The FMIS is one of the very recent developments in the
DHS. It is one of the most difficult problems technically and so far even
regular efforts from time to time have failed to improve the fiscal
management system at different levels. Since the initiation of FMIS, the
staffs working in the area of fiscal management have been trained, forms are
designed and reporting made strictly regular. This new arrangement has
considerably improved the fiscal discipline and the management system.
i. Vertical and horizontal flow of data in the system is shown in the flow
chart given here:
Information
Flow Chart
The design of the HIMS for capturing the data and building
data bases is given below:
HMIS Design and Development
2. Dissemination through the MoH
publication
a. National Health
Bulletin : irregular
b. Annual Report of DoHS: This
publication is being regularly published since 1994, capturing most of the
health service from the government health infrastructure directly below the ministry -– PHCs,
HPs and SHPs, Government
Hospitals and some of Non- Government hospitals.
The problem of this publication is that it only captures
about 25 percent of the existing health services, not capturing the private
health services coverage, and the monthly timely coverage report only less
than 70 percent.
Hospital reporting is reflected on the basis of in-patient
discharge and classified according to ICD-10. Patients admitted at the emergency
department were not reflected in the annual report. The basic hospital
statistics such as Bed Occupancy Rate, Length of Stay, Turn
Over Interval are also not covered for district hospitals. Bed occupancy Rate
is reported for the central hospital only.
There are opportunities to improve the quality of the
publication for improvement of health services at national and district
level. There should be more relevant information in logistics, finance and
personnel aspects of health services, especially to improve essential health
service coverage.
5.5 Emergency
preparedness
A Disaster Health Working Group has been formed and it has
produced an inter-agency action plan for emergency preparedness and disaster
response plans for the health sector in Nepal which will help tackle all
the health aspects of major hazards including epidemic outbreaks in the
country EHA- WHO/SEARO Health
Action Crisis- WHO/HQ EHA
2- WHO/SEARO
5.6 Health research
and technology
Produced
and disseminated IEC materials including a CD ROM on HIV/AIDS
Supported
Epidemiology and Disease Control Division to develop guidelines on Emergency
Preparedness and Disaster Management for hospitals in Nepal.
Supported
operational research studies on:
 ‘The
influence of REFLECT on changes in consciousness concerning selected topics
of reproductive health’
Rapid
Situational Analysis on ARH in HSSP working districts
EOC
Needs Assessments for the Bardiya, Achham and Dhading districts
hospitals
Improvement
of Midwifery Services at the Doti District Hospital (Ministry of Health, Annual
Report 2002/2003).
Related Links Ministry of Health and Population Research-
WHO/SEARO Research-WHO/HQ MDG Progress report - 2005
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