This document provides a summary of the primary health care system in Nepal. It discusses the background and principles of primary health care in Nepal since adopting the Alma Ata Declaration in 1978. It then summarizes the progress made in key primary health care indicators from 1980 to 2005 across several components, including health education, nutrition, maternal and child health, immunizations, control of endemic diseases, treatment of common illnesses, essential drugs, water and sanitation. Overall, it shows improvements across many health indicators and the strengthening of primary health care services nationwide over the past few decades in Nepal.

1. PRIMARY HEALTH CARE
SYSTEM IN NEPAL
PRESENTER: RAJAN CHAUDHARY
BDS, 3RD YEAR, VTH BATCH
CMS-TH , BHARATPUR

2. CONTENTS
1. BACKGROUND
2. PRESENT STATUS OF PHC
2.1 Health Education Program
2.2 Nutrition
2.3 Water and Sanitation
2.4 FP/MCH
2.5 Expanded Program of Immunization
2.6 Control of Locally Endemic Diseases
2.7 Treatment of common illness
2.8 Essential drugs

3. 1. BACKGROUND
General
As a signatory of Alma Ata declaration of 1978, Government of Nepal (GoN) has fully realized the
importance of continued adherence to the Primary Health Care (PHC) approaches for the development of
coordinated quality health care services for the people living both in rural and urban areas.
Major principles of this declaration are:
a. Universal accessibility to available resources and services in order to provide adequate coverage of
the most essential health needs of the population.
b. Community and individual involvement and self-reliance.
c. Inter-sectoral action for health
d. Appropriate technology and cost-effectiveness, i.e., allocation of resources in such a manner as
to yield the greatest benefits, withbenefits measured by the extent to which health need of
large number of people can be met.

4. PRESENT STATUS OF PHC
The PHC service including curative health services has been provided since 1978 through a network
of district and below the district level health care service delivery network. The lowest level of health
facility is Sub Health Post. In order to provide basic health services nearly 50,000 Female Community
Health Volunteers are mobilized throughout the country. In each of the PHC components, following
progress have been realized during the period 1980-2006:

5. Indicator 1980 1990 2000 2005
1. Health Education
2. Nutrition
a. Stunting
b. Wasting
a. 51.8%
b. 42.0% (NNS, 1975)
a. 52.2%
b. 49.9% (CBS, 1984)
a. 49.0%
b. 60.2%
(NMIS, 1998)
a. 57.0%
b. 43.0%
(DHS, 2001)
a. 49.0%
b. 39.0%
(DHS, 2006)
3. MCH
a. ANC 1st visit
b. ANC 4th visit
c. % of births attended by
SBA
d. FP acceptance rate
e. CBR
e. 43 per 1000
(CBS, 1978)
a. 15.5% of expected
pregnancy (CBS, 1994)
c. 3.1%
d. 26% (CBS, 1987)
e. 41.6 per 1000 (CBS,
1987)
c. 13%
d. 35%
(2001)
a. 72% expected
pregnancy from SBA
c. 19% attended by
trained health worker
d. 44% (2006)
4. Water and Sanitation
a. Population with access
to safe drinking (piped)
water
b. Population with access
to basic sanitation
a. 33% (total)
6% (rural)
a. 34% (rural)
b. 19.8% (1991)
22.5% (1996)
a. 71% rural
76% urban
5. Immunization
a. BCG
b. DPT3
c. Measles
d. Polio
a. 32%
b. 16%
c. 2%
d. 1%
a. 68%
b.
c. 63%
d. 30%
a.
b. 71%
c. 92%
d. 71%
a. 83%
b. 89%
c. 85%
d. 85%
Milestones of Primary Health Care in Nepal

6. INDICATORS 1988 1990 2000 2005
6. Control of Endemic
Diseases
a. Diarrhoea % of children
affected
b. ARI % of children
affected
c. Malaria positive cases
d. Leprosy
e. Tuberculosis care rate
1.99/1000 2.7/1000(1987)
85 %
4/1000(1997) 11.9 %
7. Treatment of
Common
Illnesses and Injuries
8. Essential Drugs
Availability
Excellent 2007

7. 2.1 Health Education Program
Health Education was being run through a section in DoHS, which was converted into an
autonomous institution in 1998 as a National Health Education, Information And
Communication Centre (NHEICC) with an objective to raise health awareness of the people as
means to promote health and prevent diseases through full utilization of community resources.
The Centre has developed and disseminated audio-visual aids, media program, TV spots,
calendars with health messages flip charts and many other materials to prevent communicable
diseases, water borne diseases, feco-oral diseases, TB, Leprosy, and promotion of healthy
behavior, use of family planning and safe motherhood.

8. 2.2 Nutrition
Nutrition section was established in DoHS as early as in 1970 to promote and train health
workers in nutrition education, prevention and treatment of Protein, Energy Malnutrition;
micro-nutrients, Vitamin A and Iodine Deficiency order.The nutritional surveys carried out in
different years revealed that nutrition is one of the common problems in Nepal particularly
among lactating mothers and children less than five years of age. DoHS is involved in a lot of
activities to improve nutritional status of the children forging coordination with Agriculture,
Education, Women Development and Poverty Alleviation programs.

9. 2.3 Water and Sanitation
Water and sanitation promotion program was launched by separate departments outside the
MoH. The main actors providing safe drinking water and improved sanitation in the country are:
Ministry of Local Development, Ministry of Housing and Physical planning and Department of
Drinking Water and Sewerage. As water and sanitation has been identified as one of the basic
needs, the GoN has launched special program in 1987 with assistance from Asian Development
Bank and World Bank involving local community as water users committee. Nepal observed the
International Drinking Water Supply and Sanitation Decade (1981-90) at the callof United
Nations.
In the 1980s domestic water supply situation was poor to the extent that covered only 6 % of
rural population which has gone up to 71 % by the year 2000. Over the last decade there has
been increasing awareness about the need to improve sanitation situation in Nepal. The overall
sanitation coverage increased from 19.8 in 1991 to 22.5 in 1996.

10. 2.4 FP/MCH
Since the early 1980s Family Planning and Maternal Child Health Care service was given utmost
priority in delivery of health services though public health facilities. PHC services are provided at
District Health Office clinics and Primary Health Care Centre (PHCC), Health Post (HP) and Sub
Health Post (SHP) level facilities by basic and grass-root level health workers. At household level
Female Community Health Volunteers (FCHVs) provide counseling to mothers and distribute
condom, pills, folic acid, Vitamin A and oral rehydration packets. The Maternal and Child Health
Worker (MCHW) position was created and trained to provide ANC, delivery, post delivery care
from SHP as well as making home visits. They were also trained to give first aid treatment to
complicated obstetric cases before referring to appropriate service center. An Emergency
Obstetric Kit box (EOC Kit) with life saving obstetric medicines was given to them. MoHP is
working towards better access and higher quality service to improve maternal health. A
Maternal Incentive Scheme has been adopted since 2005 to increase demand for maternity
services along with a focus on improving access to such services.

11. One of the objectives of Primary Health Care Outreach service was to provide ANC, FP, basic
health care for minor ailments and health education at the door steps. Over the decade (1980-
90) tremendous progress has been observed in contraceptive acceptors, safe-motherhood
services and awareness about FP and MCH services. As a result, total fertility rate (TFR)
declined from 6 (mid-1970s) to 3.1 per women in 2006.
The Contraceptive Prevalence Rate in Nepal has also gone up to a very satisfactory level from 3
% in 1976 to 44% in 2006. On the safe motherhood side, the ANC 1st visit,4th visit and home
delivery by trained health workers has been increasing each year. However, the gap between
1st and 4thANC visit needs to be improved.

12. 2.5 Expanded Program of Immunization
Expanded Program for Immunization (EPI) was launched in 1978 following the success of
smallpox eradication program which started intensively to reduce morbidity and mortality from
vaccine preventable disease of children less than 5 years of age. It covered vaccination to
prevent from diseases like Polio, Tetanus, Measles, TB, Diphtheria and Whooping Cough. Grass-
roots level health workers (VHW/MCHWs) provided vaccines from PHC service delivery network.
Immunization coverage improved from BCG - 32%, DPT3 – 16 % and measles – 12% in the year
1980 to 83 %, 89 % and 85 % respectively in the year 2005 which is due to PHC approach.

13. 2.6 Control of Locally Endemic Diseases
The DoHS put great efforts in controlling diarrhoeal diseases among children of under 5 years of
age through national Control of Diarrheal Disease (CDD) Program. During 1986, 45,000 children
died of diarrhea. National program has highly emphasized to bring down the diarrheal
morbidity and mortality and as a result the incidence of diarrhea has been drastically reduced
among children under 5 years’ of age. The programs introduced were distribution of oral
rehydration solution, establishment of ORT corners and massive health education. The
proportion of severe diarrhea has fallen from 10% to 4% in the last 5 years and case fatality rate
has decreased and is decreasing each year.
Similarly Acute Respiratory Infection (ARI) Program was also introduced targeting to reduce
mortality among children due to ARI. The community based ARI management program relies
heavily on the knowledge and skill of health workers. The case fatality rate of severe pneumonia
has fallen down from 13 to 4 per 1000 in the last 5 years. Infant mortality rate (IMR) has
declined by 41% over the 15 years period. Similarly under 5 mortality has gone down by 48% -
from 117 deaths per 1000 live births to 61.5

14. Malaria program was launched to control malaria. The target was to bring down Malaria Incidence Rate below 4.0
per 1000 population by 1997 and to further bring down to 2 per 1000 population by 2000 AD. Annual Parasite
Incidence rate was 1.99% in l982, 4.54% in 1985 and 2.71% in 1987. Similarly slide positivity rate was 1.12% in
l982, 2.74% in l985 and l.94% in 87. All these efforts are not adequate and in recent years it is speculated that
malaria is rolling back. The Global Fund for Malaria with adequate fund could be targeted more comprehensively
to address the roll back malaria problem. Tuberculosis Control Project was established in 1965 and worked till
1972 and converted into a regular program later on. This was put under PHC service delivery package and the
activities were case finding, treatment, case holding and health education. Target was to achieve 85% cure rate of
all diagnosed new smear positive cases by the year 2000. The Directly Observed Treatment Short Course (DOTS)
was introduced, during late 1990s to accomplish 85% cure rate.
Established in 1978, Leprosy Control Project introduced case holding, treating, monitoring and training to health
workers for preventive, curative and rehabilitative services. Now leprosy control program runs through the regular
PHC service delivery system. Multi drug therapy treatment was introduced in 1980s to eliminate leprosy from
Nepal by the year 2000. However, the elimination target has to be accomplished yet.

15. 2.7 Treatment of common illness
MoPH has structure from SHP level to tertiary care facilities to provide treatment of common
illness and injury. Private sector providers basically the new medical colleges have developed
huge infrastructure for this beside private nursing homes in the urban centres. NGO sector has
been helpful to provide service in the remote areas. Injury has been a serious dimension of
health care due to difficult geography. General practitioners with bone setting skill are posted in
the remote districts. A trauma centre is under development for referral purpose. Exact number of
OPD attendants covering health and other GON hospitals and private sector needs to be
compiled as regular HMIS activity.

16. 2.8 Essential drugs
Reports have shown that, the availability of drugs and other health commodities has improved
over the years. Recently concluded Joint Annual Review of NHSPIP in its Aide-Memoire
remarked that in the area of drugs procurement, logistics and availability, progress is
encouraging but the free care policy will test the system’s solidity. Implementation of the “Pull”
system has shown encouraging preliminary results and should be accelerated to ensure the
availability of drugs in all facilities when services become free and demand increases.

17. THANK YOU!