Public Policy and Health Policy

MPH 2nd Year
Prabesh Ghimire
Public Policy and Health Policy

Public Policy and Health Policy MPH 2nd
Year
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TABLE OF CONTENTS
UNIT 1: INTRODUCTION TO PUBLIC POLICY AND HEALTH POLICY...................................................4
Concept of Public Policy and Health Policy ..............................................................................................4
Role of Public policy to influence public's health ......................................................................................6
Policy Formulation Process in Nepal ........................................................................................................8
Brief History of Health Policy Development in Nepal................................................................................9
Key Players in policy development ...........................................................................................................9
Policy Evaluation.....................................................................................................................................10
Coordinating areas of health policy with other public policies ................................................................12
Public Policy Reviews .............................................................................................................................12
UNIT 2: THEORY AND PRACTICE OF HEALTH POLICY.......................................................................14
National Health Policy 1991 and New Health Policy ..............................................................................14
Health and Health Related Acts and Regulations...................................................................................17
Globalization and its Effects in Health Policy..........................................................................................19
National commitment on health in periodic plans ...................................................................................21
Pay for Performance Concept.................................................................................................................23
Universal Health Coverage .....................................................................................................................25
UNIT 3: HUMAN RESOURCE MANAGEMENT POLICY..........................................................................26
Human Resource Management Policy ...................................................................................................26
Evolution, External Influences, Trends and Issues in Human Resource Policy .....................................29
Human Resource for Health (HRH) planning, projection, production and utilization Policy...................32
Personnel Policy .....................................................................................................................................32
Supervision, Capacity Building, Career Development and Quality Assurance Policy............................34
Policy for delivery and utilization of human resources............................................................................37
UNIT 4: EDUCATION IN HEALTH AND CURRICULUM DEVELOPMENT POLICY ...............................38
Education in Health and in Different Universities/ Councils in Nepal......................................................38
Curriculum Development Policy of MOE, Universities/ Institutes and Councils .....................................40
Health Professional Councils, their Policy and regulations.....................................................................40
UNIT 5: TRAINING POLICY.......................................................................................................................44
Introduction to National Health Training Policy.......................................................................................44
UNIT 6: REVIEW OF HEALTH POLICIES IN NEPAL...............................................................................45
Long Term Health Plans and Policies.....................................................................................................45
Fourteenth Periodic Plan of Nepal (2073/74-2-075/76)..........................................................................46
Nepal's Health Sector Strategy (2015-2020) ..........................................................................................47

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Health Related Policies of Nepal ............................................................................................................49
Health Care Financing and Expenditure Policy ......................................................................................49
National Drug Policy, 1995......................................................................................................................50
National Ayurveda Health Policy, 1996...................................................................................................51
Safe Motherhood Policy..........................................................................................................................51
Policy on Skilled Birth Attendants (2006)................................................................................................52
National Safe Abortion Policy- 2002 .......................................................................................................53
National Health Insurance Policy............................................................................................................54
Health Insurance Act 2017......................................................................................................................55
Health Sector Information Strategy.........................................................................................................56
International Health Regulations.............................................................................................................57
Disaster Management Policy ..................................................................................................................59
Vital Registration Act 2033 (1976) ..........................................................................................................60
UNIT 7: HEALTH SYSTEM AND POLICY RESEARCH ...........................................................................61
National Health Research Policy ............................................................................................................61
Local Government Operation Act............................................................................................................63

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UNIT 1: INTRODUCTION TO PUBLIC POLICY AND HEALTH POLICY
Concept of Public Policy and Health Policy
Policy
Policy is a set of decisions with intentions or purposes to achieve goal that benefits a group or population.
In other words, policy is a decision making framework or conscious course of action used to achieve a
Broadly speaking, a policy is a principle or a plan to guide decisions, actions and outcomes.
- Policies can be laws, documents, and procedures, guiding principles, statements of intent or working
frameworks.
- Policies may be written documents or unwritten practices. Policies can be implicit or explicit, formal
or informal.
Purpose of policy
- It provides a frame for strategic plans and courses of action (What should be done and how?)
- It provides guidance on what to do and what not to do
- It explains who is responsible for implementation of a policy.
- It guides further series of subsequent decisions (strategies, plans, guidelines, targets) to implement
including legal provisions.
Scope of policy
i. Micro Policy
- Such policies are implemented at small-scale and only limited number of specified population are
affected by its decisions.
- E.g Policies developed by business house, civil societies or similar organization.
ii. Macro Policy
- Such policies are implemented in a wider scale and affects larger population.
- E.g State (public) policies
Public Policy
The term public policy always refers to the actions of government and the intentions that determine those
actions. (Clarke E. Cochrane et al.)
Public policy consists of political decisions for implementing programs to achieve societal goals. (Chalres
L. Cochrane and Eloise F. Malone)
From these definitions, it is clear that public policy is a state policy developed and implemented by
government. In other words, public policies are governmental decisions and are actually the result of
activities which the government undertakes in pursuance of certain goals and activities.
Key attributes of Public Policy
- Public policy is made on the behalf of public (entire citizens or targeted groups).
- Policy is oriented towards a goal or desired state, such as solution of a problem.
- Public Policy is ultimately made by governments, even if the idea comes from outside government or
through the interaction of government and non-governmental actors.
- Policy is made within the constitutional framework of the country. i.e. Public policy is guided by the
mission of the state.

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- Public policy is universal. It is interpreted and implemented by public and private actors who have
different interpretations of problems, solutions, and their own motivations.
- Policy is what the government chooses to do or not to do.
- Public policy is positive in the sense that it depicts the concern of the government and involves its
action to a particular problem on which the policy is made. It has the sanction of law and authority
behind it.
- Public policy has cross border implications
Examples of various public policies related to Health in Nepal
 Alcohol Control Policy
 Civil Service Act
 Consumer Protection Act, 1996
 Disaster Control Act, 1975
 Domestic Violence Act, 2009
 Environmental Protection Act, 1997
 Food Regulations. 1996
 Higher Education Policy, 2015
 Human Rights Commission Act, 1996
 Human Trafficking Control Act, 2014
 Labour Act, 1992
 Local Self-governance Act, 1999
 National Center for Educational Development Policy 2005
 National policy for Drugs Control, 2006
 Solid Waste Management Act, 2011
Health Policy
- Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health
care goals within a society.
- An explicit health policy can achieve several things: it defines a vision for the future which in turn
helps to establish targets and points of reference for the short and medium term.
- Health policies are part of the larger process that aims to align country priorities with the real health
needs of the population, generate buy-in across government, health and development partners, civil
society and the private sector, and make better use of all available resources for health- so that all
people in all places have access to quality health care and live longer lives as a result.
Fundamental considerations in Policy Formulation
i. Demographic trends
- Information on population trends, with gender and geographical disaggregation, is basic to policy
planning. E.g. mortality and morbidity data are central to building healthy policy.
- In addition, ethnicity is becoming an increasingly important dimension in some countries where some
ethnic groups are disproportionately represented in poor and marginalized communities, and it is
important to consider how inclusion can be adequately addressed in policy documents.
ii. Economic trends
- All those involved in the policy processes should understand the government's financial position and
the estimates of expenditure required to execute the policy.
- Knowledge of the budgetary situation is an essential item in the armory of everybody involved in the
health policy process.

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iii. International or regional commitments
- All countries are likely to have a number of bilateral or international commitments, In some cases,
such agreements are directly related to health, such as the International Health Regulations or the
FCTC.
- A growing number of these commitments are also related to trading relationships such as GATT,
TRIPS etc. which require opening up the health sector to competition from foreign investors, or patent
protections.
- It is important that policy makers know about relevant current and potential future commitments, as
these commitments can constrain or enable the policy choices that may be available.
iv. Constitutional provisions
v. Political mandates
Role of Public policy to influence public's health
i. Public policy influences social determinants of health
- Public policy can be seen as one influence upon community health that can impact all other factors
that influence overall health.
- Public policy affects housing, education, income, access to food, the availability and quality of health
care, and the environment in which we live; for example:
 Public housing standards ensure that safety and public health issues (e.g., lead paint exposure,
overcrowding) are addressed.
 The minimum wage law guarantees that people can earn an adequate salary for the work that
they perform.
 Indoor Air Quality Standards ensures that humans (preferably women and children) are not
unduly exposed to smoke in their places of residence and work.
 GESI policy ensures that women and marginalized groups have equitable access to health care.
ii. Regulatory roles of policies
- The traditional role of a public policy, especially a law, is to regulate, control and/or penalize people,
groups or organizations for certain forms of conduct.
- Tobacco control act forbids the use of tobacco in public places and also bans tobacco promotion and
advertising in any forms of media.
- Food act safeguards the health and well being of the consumers by preventing adulteration of food
stuffs and controlling on the production, sale and distribution of misbranded and adulterated food
products.
- Pesticide act regulates the import, export, production, distribution and use of pesticides.
iii. Protective roles of Public Policy
- Another important role of public policies is to protect the health of individuals or groups of people.
- Example: HIV/AIDS and STI policy ensures the protection of confidentiality for people infected with
STI.
- Environment Protection Act deals with prevention and control of pollution and makes provision for
Environmental Impact Assessment (EIA) to be carried out by projects prior to its implementation.

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iv. Instrumental roles
- The public policies can also help to change values and patterns of social interaction in ways that
might reduce the risk of adverse effects on public health.
- Example: Policies that have an impact on the way in which sexuality is taught to children in schools,
or how condoms are advertised, are likely to have a long-term impact on sexual interactions in
adulthood.
v. Public Policies directly or indirectly impact health sector
- Various public policies are either directly or indirectly concerned with improving the health and well
being of the public.
- Public policies are inter-connected to health sector in many ways and numbers of considerations of
health are made on various public policies such as
 The policy and the Agriculture Development Strategy place an emphasis on mainstreaming food
and nutrition security.
 Various education policies of Nepal recognize the importance of health in curricula for various
regular and vocational trainings program.
 Monetary policy of Nepal also influences health and well-being of public E.g. of the health tax on
tobacco, 75% goes to Cancer Hospital and 25% for prevention of tuberculosis and other
diseases.
 Labour policies addresses health promotion program for employees for prevention of
occupational hazard and safety.
Importance of health policy
i. Health policy facilitates planning
- Policies help to develop a vision of the future, to define short-, medium- and long-term references, to
determine objectives, to set out priorities, to delegate roles and to define means of action and
institutional arrangements.
ii. Policy can support decision-making
- Policy can support decision-making in a context of greater public awareness of the harmful effects of
incoherent policies and of greater public scrutiny of decision-making regarding the costs and benefits
of proposed options.
iii. Health policy provides a framework for evaluating performance
- By setting expectations, objectives, priorities and strategies and the resources required to achieve
them, policy simultaneously sets out criteria on the basis of which actions can be evaluated while
providing a frame of reference that may be used by health professionals at different levels to
understand their responsibilities.
iv. Health policy can help to rally professionals and other sectors around health problems and to
legitimize actions
- When it is part of a judicious planning of change, the development of health policies provides a
unique opportunity for building consensus around health issues and for allowing citizens to voice their
opinion, thus giving a greater degree of legitimacy to actions that will be proposed later.
- Critical and difficult decisions, such as new allocation of resources or rationing services, may be
made more acceptable to interest groups if they are taken in the context of a political process that has
brought the main players together.

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Conditions for success of public policy
- Institutional/technical capacities
- Political feasibility
- Social acceptability
- Affordability
Policy Formulation Process in Nepal
Public policies in Nepal are initially formulated by the line ministries rather than by a central planning
agency. Ideally, these line ministries seek inputs from civil society when preparing policy proposals. The
approval of all major policies is centered on the Cabinet of Ministers as the principal decision-making
body.
The Nepalese health policy formulation involves the following processes
i. Problem identification and policy analysis
- The sectoral ministry identifies problem in the respective public sector.
- The problem is often defined and articulated by institutions such as interest groups, political parties,
mass-media, business organizations, etc.
- Another important source for problem identification could be the findings from national studies.
- After indentifying the problem, the first question to ask are:
 Does the issue require a new policy to be developed, or can it be dealt with by other means (e.g.
political or administrative decision)?
- If it is decided that the issue can be dealt only by developing a new policy, the next step is to decide
on the scope of new policy and the level at which it will eventually have to be approved.
 Is cabinet submission required to enable policy approval?
 Does new policy lies within the discretion of Ministry of Health under existing legislation?
ii. Policy development phase
- The ministry develops a policy agenda and consults with relevant stakeholders, other supporting
ministries (such as Ministry of Finance and Ministry of Law) and agencies (such as National Planning
Commission).
- Sometimes technical assistance is sought from development partners and other stakeholders for
policy analysis.
- The ministry also holds meeting to discuss with representatives of other ministries that may be
affected by proposed new policy.
- The representatives provide information relevant to policy issue and/or required to make informed
policy recommendation.
- After several discussions, meetings and necessary preparations, the inter-ministerial committee
provides recommendation on policy direction.
- The ministry drafts Cabinet Memorandum (policy proposal for cabinet's review and decision) and
submits to the cabinet for consideration.
iii. Policy decision making/ policy adoption phase
- The policy proposal is debated and discussed in the appropriate cabinet committee or cabinet of
ministers.
- Based on the discussions, cabinet decides on whether to endorse or reject the policy proposals.
- Sometime, the policy proposal may be sent back to respective ministry for amendments of particular
sections which the cabinet may find inappropriate for approval.

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iv. Implementation, monitoring and evaluation
- The respective ministry implements the policy decision after approval. For this, the ministry may
develop necessary strategies, guidelines and manuals to facilitate the implementation process.
- Sometimes, new institutional arrangements may also be developed by the ministry to execute policy
decisions.
- If necessary, other ministries affected by the policy also coordinate the implementation of decision.
- The ministry is also responsible for monitoring, and evaluation of the impact of the policy.
Critics of health policy formulation in Nepal
- Ideally, all health policies would be developed from evidence-based research. In the real world, health
issues often arise unexpectedly with very little time for analysis or for the development of a
considered policy response based on research.
- Evidence informed policy decisions are not a common practice.
Brief History of Health Policy Development in Nepal
- Policy development existed in many forms in the historical ages.
- Five year plan, first initiated in 1956 marks the formal start of policy development process in Nepal.
- First Long-Term Health Plan was developed in 1975 with major emphasis on checking population
growth and popularizing family planning plus maternal and child health.
- First National health policy was formulated in 1991. With the implementation of this policy, the major
emphasis was to involve lower levels e.g. regional and district in planning and delivery of health
services and provide a combined preventive and curative package at the district level.
- In 1997, Second Long-Term Health Plan was initiated in 1997 with a vision of an integrated health
system in which there is equitable access to health care.
- The Nepal Health Service Act was also authenticated in 1997 to regulate Nepalese health services.
This act was later amended for five times. The latest amendment was made in 2010.
- Taking into considerations the recent changing national and international contexts of health, National
health policy of 1991 was abolished and new health policy was formulated in 2014 with greater
emphasis on universal health coverage.
Key Players in policy development
Policy process encompasses an intricate series of smaller processes. Consequent upon the intricacies
involved, specific crucial actors play roles in the policy development process. These players include:
i. Legislators
- Legislators are members of parliament, for example house of representatives in Nepal.
- These legislators possess direct constitutional authority to initiate and formulate policies.
- As elected law makers, they are expected to collate the views, interests, demands and problems of
their constituents, harmonize them and translate them into policy proposals for the legislature.
- Such policy proposals are subjected to the entire legislative processes of reading, debating and
scrutiny.
- Legislators do not generate and develop policy proposals from their people only. They also develop
draft policies from their fellow legislators and the executive.

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ii. Political parties
- As the political parties pursue their primary interest of gaining governmental power, they play
prominent roles in the policy process.
- A political party that controls the lever of power tends to influence their members in government to
formulate policies that will protect their party programs and manifesto.
iii. Non-government stakeholders
- Non-government stakeholders (I/NGOs) are also the key actors that substantially influence policy
processes in the form of advocacy, representation in government bodies, consultation, technical
assistance and policy dialogue.
- Over the last few decades, family planning, reproductive health, safe motherhood, HIV/AIDS and
range of other health sector policy making involves prominent engagement of non-government
stakeholders
iv. Administrators
- Administrators work directly under the executive arm of government as they are implementers of
public policy.
- Administrator's skills training, competence and experience in governmental tasks have put them in a
vantage position to tackle policy issues.
- Political office holders continuously depend on administrators that have skills, competence and
adequate information necessary in the policy process.
- In this circumstance, administrators will continue to wield considerable influence and apply their
discretions in the policy process.
v. Interest groups
- These are associations of individuals who share common interests, beliefs and aspirations regarding
their demands.
- They are civil society organizations and advocate their interests and demands with a view to
influencing the policy process.
- The interest group may include professional associations (e.g. Nepal Public Health Association,
Nepal Doctor's Association), human rights group (e.g. Nepal Human Rights Commission), business
organizations (e.g. Surya Nepal influencing Tobacco policy), etc.
- Interest groups submit memoranda and draft policy proposals to the legislature. They also mobilize
the public to support their advocacy on particular policy proposals.
Policy Evaluation
Policy evaluation uses a range of research methods to systematically investigate the effectiveness of
policy interventions, implementation and process. It is the activity through which we develop an
understanding of the merit, worth, and utility of a policy.
Purpose of policy evaluation
Policy evaluation, like all evaluation, can serve important purposes along the entire chain of the policy
process, including
- Documenting policy development
- Documenting and informing implementation
- Assessing support and compliance with existing policies
- Demonstrating impacts and value of a policy

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- Informing an evidence base
- Informing future policies
- Providing accountability for resources invested
Types of policy evaluation
Evaluation is an integral part of each step in the policy process. There are three main types of policy
evaluation and each focus on a different phase of the policy process:
i. Policy content evaluation
- Policy content evaluation examines the substantive information and material contained within a policy
in relation to the policy’s requirements, its similarity to other policies, the context in which it was
developed, or some combination of these.
- Some of the key policy content evaluation questions are:
 Does the policy clearly state the goals or objectives?
 Are the evidence based components of the policy clearly articulated?
 Are the requirements for implementation clearly stated in the policy?
 Are the requirements feasible given available resources?
 Does the policy articulate the mechanism for monitoring implementation?
 Does the policy identify indicator for assessing program success?
 How is the content of the policy similar to or different from that of other policies?
ii. Policy implementation evaluation
- Policy implementation evaluation examines the inputs, activities, and outputs involved in the
implementation of a policy.
- The implementation of a policy is a critical component in understanding its effectiveness.
- It can provide important information about the barriers to and facilitators of implementation and a
comparison between different components or intensities of implementation.
- Some of the questions that guide policy implementation evaluation are
 Was the policy implemented according to the policy requirements?
 What inputs and resources were required to implement the policy? Were all these inputs and
resources available?
 What key activities were completed during policy implementation?
 Did the activities result in the anticipated outputs?
 What factors influenced the implementation?
iii. Policy impact evaluation
- Policy impact evaluation examines changes in key indicators that have occurred since the
implementation of a policy and the extent to which changes can be attributed to the policy.
- It identifies the relative cost-benefit or cost-effectiveness of a policy
- Some of the policy impact evaluation questions are:
 Was there a change in the outcomes and impacts of interest?
 Did the policy contribute to a change in the outcomes and impacts of interest?
 Did contextual factors influence the level of impact?
 What was the economic impact of the policy (cost-effectiveness or cost-benefit?

©Prabesh Ghimire
Methods of Policy Evaluation
 Cost-effectiveness evaluation
 Cost-benefit evaluation
Coordinating areas of health policy with
Public sectors
Local development
Urban Development
Water supply and sanitation
Education
Women, children and social
welfare
Finance
Home Affairs
Public Policy Reviews
Review of sectoral policies
i. Policies of Ministry of Education
- The topics of health promotion, communicable and non
health including family planning are included in the school curricula as well in the teachers training
curriculum.
- School health and nutrition program is a joint program between Ministry of Education and Ministry of
Health.
of health policy with other public policies
Coordinating areas in health policy
Strengthening health system Addressing determinants of
health
Policies for financial and
management support at the local
level health facility level
Policies on infrastructure
development (e.g. health
facilities)
Policy on drinking water and
sanitation
Policies on ho
management , safe drinking
water supply
Policies on NCD control
Policies on water and sanitation
Policies on HRH production and
development
Policies on Curriculum
development
Policies on nutrition education,
NDC awareness and health
promotion
Policy on gender based violence
Financing and expenditure policy Taxation policy on harmful
products
Disaster Management Policy Policies on gender based
violence, road safety, substance
abuse
Policies of Ministry of Education
The topics of health promotion, communicable and non-communicable diseases and reproductive
and nutrition program is a joint program between Ministry of Education and Ministry of
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Addressing determinants of
Policy on drinking water and
Policies on housing, waste
management , safe drinking
Policies on NCD control
Policies on water and sanitation
Policies on nutrition education,
NDC awareness and health
gender based violence
Taxation policy on harmful
Policies on gender based
ence, road safety, substance
communicable diseases and reproductive
and nutrition program is a joint program between Ministry of Education and Ministry of

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ii. Policies of Ministry of Environment and Population
- Environmental Protection Act mentions that clean and healthy environment will be maintained and
significant adverse health impacts on local people and environment will be prevented by
implementing IEE/EIA.
- Under, National Adaptation Program of Action (NAPA) 2010 nine integrated projects have been
identified as the urgent and immediate national adaptation priority. One of these projects is related to
adapting climate challenges in public health.
- Environment ministry has initiated to develop ambient air quality standard, indoor air quality standards
and noise pollution standards.
iii. Policies of Ministry of Federal Affairs and Local Development
- Local self-governance act makes provision of financial and managerial support to the health facilities
at local level.
- In scope of work of local bodies, there is a provision for working through multi-sectoral coordination
and collaboration with line agencies including health.
iv. Policies of Ministry of Agriculture Development
- The policy and the Agriculture Development Strategy (ADS) (2015-2035) emphasizes on food and
nutrition security.
- Multi-sectoral nutrition plan of which Ministry of Agriculture is a part, emphasizes on multi-sectoral
coordination for nutrition and food security in Nepal.
- Food act regulates production, sales, distribution and import of adulterated and misbranded food
products.
- Dietary supplement guidelines 2072 makes special provisions for formulation, production, sales,
distribution and import of dietary supplements.
v. Policies of Ministry of Finance
- Finance sector policies makes VAT exemption on health commodities such as vaccine,
contraceptives, nutritional formulations, drugs and equipment used in cancer management.
- Of the health tax on tobacco, 75% foes to Cancer hospital and 25% for prevention of tuberculosis and
other diseases.
- The policy makes age bar of 18 years to buy alcohol and cigarettes.
vi. Policies of Ministry of industry
- Industrial policies have provision for accreditation of private health institutions (hospitals, nursing
homes and health club).
vii. Policies of Ministry of commerce
- Quarantine policy restricts the goods and subjects, which are harmful for health of the people and
environment.
- Standards are set for storage of medical equipment (x-ray machine, lab equipment, etc.) at custom
office.
- Policy provisions to monitor and seize substandard products (such as food) from the market that are
harmful to public health.

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UNIT 2: THEORY AND PRACTICE OF HEALTH POLICY
National Health Policy 1991 and New Health Policy
New Health Policy 2014
New Health Policy 2014 (2071 BS) is a replacement of the previous policy to address current and newly
emerging health challenges through mechanism of universal health coverage and accountable health
system.
Vision: All Nepali citizens have the physical, mental, social and emotional health to lead productive and
quality lives.
Mission: Ensure citizen’s fundamental rights to stay healthy by utilizing available resources optimally and
fostering strategic cooperation between service providers, service users and other stakeholders.
Goal: To ensure health for all citizens as a fundamental human right by increasing access to quality
health services through a provision of just and accountable health system.
Objectives:
- To provide free basic health services
- To establish an effective and accountable health system
- To promote people’s participation in extending health services.
Principles
‐ Health as a fundamental right of citizen
‐ Right to information
‐ Equity and social justice
‐ People’s participation
‐ Participation of private sectors
‐ Resource mobilization (internal and external)
‐ Regulated health service network
‐ Accountable health system
Policies
The National Health Policy includes 14 policies covering broad range of health service provisions.
1. To make available in an effective manner the quality health services, established as a fundamental
right, ensuring universal health coverage and provision of basic health services at free of cost.
2. To plan produce, acquire, develop, and utilize necessary human resources to make health services
affordable and effective.
3. To develop the Ayurvedic medicine system as well as safeguarding and systematic development of
other existing complementary medicine systems.
4. To aim at becoming self- sufficient in quality medicine and medical equipment through effective
importation and utilization with emphasis on internal production.
5. To utilize in policy formulation program planning, medical and treatment system, the proven
behaviors or practices obtained from researchers by enhancing the quality of research to
international standard.

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6. To promote public health by giving high priority to education, information, and communication
programs for transforming into practice the access to information and messages about health as a
right to information.
7. To reduce prevalence of malnutrition through promotion and usage of quality healthy foods.
8. To ensure availability of quality health services through competent and accountable mechanism and
system for coordination, monitoring and regulation.
9. To ensure professional and quality service standard by making health related professional councils
capable, professional, and accountable.
10. To mainstream health in every policy of state by reinforcing collaboration with health-related various
stakeholders.
11. To ensure the right of citizens to live in healthy environment through effective control of environmental
pollution for protection and promotion of health.
12. To maintain good governance in the health sector through necessary policy, structure and
management for delivery of quality health services.
13. To promote public and private sectors partnership for systematic and quality development of health
sector
14. To increase the investment in the health sector by state to ensure quality and accessible health
services and to provide financial security to citizens for medical cost and as well as effectively
utilize and manage financial resources obtained from private and non-government sector.
Strengths
- Recognizes health services as a fundamental right of citizens by providing basic health services free
of cost.
- Focuses poor, marginalized and vulnerable communities of both rural and urban areas based on
equality and social justice through universal health coverage.
- Availability of doctor, nurse and health technicians in each VDC and midwife in each ward.
- Aims to establish at least one health institution in each village within 30 minutes distance. One PHCC
for every 20 thousand population and one 25-bedded hospital for every one hundred thousand
population.
- Provisions for one doctor along with 23 health workers for every 10 thousand population.
Weaknesses
- Gender issues in health are not adequately addressed by this policy.
- This policy is silent regarding the emerging double burden of diseases.
- The policy seems over-ambitious regarding distribution of health workers (e.g. one doctor/VDC) and
health institutions with no particular road map and resources to achieving them.
Discuss on the need for new health policy in the changing context
The need for new health policy or update in the existing health policy of Nepal can be justified in the
following grounds
i. Restructuring in federal context
- National Health Policy 2014 was formulated based on the spirit of people's movement 2062/63 and
10 point approach paper. However, with the promulgation of constitution of Nepal 2072, Nepal has
recently entered into the federalism.
- Therefore, there is a need to reform and restructure the existing health system in the federal,
provincial and local level based on the power entrusted by the constitution of Nepal.

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ii. Adjusting to shift from MDG to SDG:
- With the significant achievements in health related millennium development goals, Nepal is now
committed to achieving the Sustainable development Goals. Therefore adjustment of health related
sustainable development goals into the national health policy is deemed essential.
iii. Establishing health as a broader development agenda
- Where many international studies have confirmed significant contribution of health sector investment
in the overall economic development of the country, it is deemed necessary to translate into practice
"health as a broader development agenda" through development of evidence informed policy.
iv. Addressing new health challenges
- In the context where Nepal is transitioning from the state of political disturbances to stability, it is
equally important to address existing and new challenges in the health sectors and establish health
as a human right as envisioned in the constitution of Nepal.
- This should be guided by health policy.
Existing health sector challenges/ Areas where new health policy needs a focus
- How to restructure and reform health system at federal, provincial and local levels as per the
provisions in the constitution of Nepal.
- To date many citizens have not been able to effectively utilize health care services. Establishing
health system that ensures health care rights of every citizen as provisioned in the Constitution of
Nepal remains a challenge.
- Nepal's health sector is highly dependent on donor funds. Establishing self-sustained health care
financing in health sector through widespread community participation is another challenge.
- While infectious diseases still constitute a major public health problem, the growing prevalence of
chronic diseases has put Nepal into the double burden of disease. At the meantime, number of
deaths from accidents and injuries are also on rise. There is a challenge in resource allocation to
control infectious as well as chronic diseases.
- Addressing the health of urban poor
- Addressing the relative imbalances/deficit in the production, and utilization of HRH, brain drain,
problems related to security of HRH are important challenges that need to be addressed.
- Increasing investments for addressing the health of the disabled and mentally ill.
- There is no adequate coordination in the institutions responsible for production and utilization of HRH.
- There is also a challenge for effective regulation and implementation of prevalent health related acts.
- Addressing human health problems arising from climate change, growing food insecurity and
disasters also requires multi-sectoral responses
Guiding principles for new health policy
i. Universal health coverage
ii. Health in all policies
iii. Health as a broader development agenda- Increasing investment in health sector
iv. Quality health service
v. Evidence based health planning
vi. Equity and Social inclusion

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Health and Health Related Acts and Regulations
SN Acts/ Regulations Description
1 Health Service Act, 2053 and
Regulation 2055
2 Tobacco Product (Control and
Regulatory) Act, 2011
3 Health Worker and Health
Institution Security Act, 2066
and regulation 2069
- Prohibit assaults to health workers and padlock, fire and/or
vandalization of health institutions
- Makes provision for security requests for health workers and
health institutions in case of security threats.
4 Drug Act, 2035 - Regulates manufacture, sale, distribution, export and import of
drugs.
- Makes provision for compensation in case of death or injury
due to unsafe drugs.
- Prohibits misuse and abuse of drugs
- Prohibits false or misleading advertisement of drugs
5 Breastfeeding substances
(sales and distribution control)
Act, 2049 (1992)
- Permits the Ministry of Health to disseminate public
educational and informational materials about baby food.
- Prohibits manufacturers and distributors from advertising and
promoting substitutes for breast feeding. Manufacturers and
distributors are also forbidden from distributing product
samples or promoting products in health care agencies.
- The act also details provisions covering the certification of
substitute breast milk products.
- It also sets quality control measures, covers inspections and
suspension of licenses, details penalties and liabilities for
violation of act.
6 Iodized salt (production, sale
and distribution) Act, 2055
(1998)
- Prohibits on import, purchase and sale of iodine free salt.
- Makes provision for obtaining the permit to produce, import,
supply, sell and distribute iodized salt.
7 Social Health Insurance Act,
2073
7 Nepal Medical Council Act
2020
(Discussed in Unit 4)
8 Nepal Nursing Council
Act,2053
9 National Health Professional
Council Act, 2053
10 Nepal Pharmacy Council Act,
2057

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Other Health Related Acts
12 Food Act, 1965 - Prohibits the production, sale, export and import of any
adulterant and on the sale of falsely stated or misbranded
products.
- Regulates licensing for manufacturing, selling, distributing,
storing or processing of food.
- Makes penal provisions for the violation of act.
13 Environment Protection Act,
1996
‐ Requires certain persons/bodies to conduct EIA or IEE
‐ Deals with ‘Prevention and Control of Pollution’ and restricts
pollution that will have adverse effects on environment and
public health.
‐ It also has a provision for the appointment of Environmental
Inspectors to carry out inspection and examinations and stop
activities that cause pollution.
14 Pesticide Act 1991 and
Regulation 1993
‐ Regulates the import, export, production, distribution and use
of pesticides.
‐ Makes provisions for pesticide board and pesticide registration
office for certification and licensing of pesticide production and
trade.
Tobacco Product (Control and Regulatory) Act, 2011
The Tobacco Product (Control and Regulation) Act, 2010 is the primary law governing tobacco control in
Nepal
Major Provisions of the Act include:
i. No person shall be allowed to smoke or consume tobacco in public places.
ii. No person shall be allowed to smoke in private house or on transportation in a way that may affect
other person.
iii. The manufacturers shall mention the label and trademarks, details of manufacturer and amount of
nicotine contained as well as hazardous constituents on the packet or wrappers of the tobacco
product.
iv. The manufacturers shall print and indicate clear and visible warning messages and hazards,
colorful picture of harmful effect due to consumption of tobacco products covering at least 75% of
packet, wrappers or packaging of parcel and should label outer side in Nepali language with details
like tobacco products are injurious to health.
v. No person including the manufacturer shall be allowed to advertise and promote or release or
sponsor any program, news or information about tobacco products through newspaper and
electronic media like radio, television, FM, internet , hoarding board, wall painting or any other
media.
vi. No person shall be allowed to sell and distribute or provide the tobacco products for free to a
person below the age of 18 and to the pregnant woman.
vii. Government of Nepal shall establish a Health Tax Fund for controlling smoking and tobacco
products consumption and to the prevention and control of diseases caused by consumption of
such products.

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Globalization and its Effects in Health Policy
Concept of Globalization
It implies a free flow of information, ideas, technology, goods and services, capital and even people
across different countries and societies. It increases connectivity between different markets in the form of
trade, investments and cultural exchanges.
The concept of globalization has been explained by the IMF (International Monetary Fund) as ‘the
growing economic interdependence of countries worldwide through increasing volume and variety of
cross border transactions in goods and services and of international capital flows and also through the
more rapid and widespread diffusion of technology.’
Features of Globalization:
Economic relationships have been the fundamental driving force behind the overall process of
globalization over the last two decades. A present day globalization is the outcome of the two principal
features
i. Free trade
- Free trade is a policy followed by some international markets in which countries' governments do not
restrict imports from, or exports to, other countries.
- Free trade is exemplified by the European Economic Area and the North American Free Trade
Agreement, which have established open markets.
a. Deregulation
- Deregulation involves removing government legislation and laws in a particular market.
Deregulation often refers to removing barriers to competition.
a. Economic liberalization
- Economic liberalization is the lessening of government regulations and restrictions in an economy
in exchange for greater participation by private entities.
- When it means, government has liberalized trade, it mean it has removed the tariffs, subsidies
and other restrictions on the flow of goods and services between countries.
- It promotes globalization through unregulated access to markets.
Principle features of economic liberalization that has promoted globalization:
- Removal of restriction on the movement of goods and services.
- Reduction in tax rates and lifting of unnecessary controls over economy.
- Simplifying procedures for imports and exports
- Abolishing licensing requirement for establishment of industries.
ii. Free market (Privatization)
- Privatization helps establish a free market creating spaces for private sectors.
- It means transfer of ownership and/or management of an enterprise from the public sector to the
private sector.
- Free market promotes globalization by drawing private sectors from the world to participate in a
competitive market.

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Framework for analysis of impact of globalization in health policy
Various frameworks can be used for understanding and analyzing the economic aspects of globalization
and their impacts on health policy.
The impacts of globalization on health policy are manifested through various ways and there is
interdependence between health sector, economy and social dimensions.
1. Impact through health sector
2. Impact through social sector

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3. Impact through economic sector
National commitment on health in periodic plans
1. First five year plan (1956-61)
- Nepal Malaria Eradication Organization (NMEO) Program in the Chitwan valley started in full swing
geared towards the eradication of Malaria.
- In 1956, an organization of MOH was done.
- First maternity hospital (Prasuti Griha) in Thapathali was established in 1959.
2. Second plan period (1962-65)
- The preventive aspects were stressed by a small-pox survey conducted in 1962 with objectives of
eradication.
- Soon after that pilot projects for control of two other major diseases (TB and Leprosy) were started.
- By 1965, vertical projects covering such as malaria, small-pox, leprosy, TB and MCH/FP services
were already in place.
3. Third plan period (1965-70)
- The third plan place more emphasis on preventive health care.
- The concept of provision of health services led to expansion of health posts.
4. Fourth plan period (1970-75)
- The training of various categories of health personnel was shifted to Institute of Medicine (IOM) under
TU.
- In 1971, a pilot project was started in Bara district and in Kaski district in 1972 under the name of
Integrated Basic Health Services.
5. Fifth plan period (1975-80)
- The fifth plan aimed to provide minimum health care to the maximum number of people
simultaneously promoting regional balance in health care.

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- In 1978, Nepal closely aligned with health for all strategies as declared in Alma-Ata conference and
stepped ahead to expand and strengthen the integrated approach through PHC.
- The First Long Term Health Plan (1975-90) was developed.
6. Sixth plan period (1980-85)
- Focused on decentralization under sectoral policy on development administration.
- Idea of COMBINA was mooted as the Nepalese version of Basic Minimum Health Needs.
7. Seventh plan period (1985-90)
- Some organization integration took place by 1987 at the peripheral level and by 1990 at the central
level.
- National health information system was developed in 1988.
8. Eighth Five Year Plan, 1992-97
The health part of the eighth five year plan called for attaining the highest level of health for all Nepalese
people and spelled out the need to:
‐ improve the health of the people in order to provide healthy people for the country’s development;
‐ extend basic and primary health services to rural areas to improve the health of rural people;
‐ extend family planning and maternal and child health services to the local level; and
‐ develop specialized health services accessible throughout the country.
9. Ninth Five Year Plan, 1997-2002
This plan emphasized:
‐ improving the health status of the people and supporting poverty eradication;
‐ mobilizing the private and non-government sectors for quality health services and human resource
development;
‐ improving the cost-effectiveness of health service provision;
‐ developing policies to solve problems related to the environment of professional health care;
‐ promoting people's participation, inter-regional coordination and decentralization; and
‐ exploring alternative means of health care financing.
10. Tenth Five Year Plan, 2002-07
The Tenth Plan, also known as Nepal’s Poverty Reduction Strategy Paper, focused on poverty alleviation
and called for:
‐ making essential health care services available to all;
‐ establishing a decentralized health system;
‐ establishing public-private-NGO partnerships to deliver health care services; and
‐ improving the quality of health care through total quality management of human, financial and
physical resources.
11. Eleventh Plan, 2007/8-2009/10
This plan established the right of citizens to free basic health care and said that preventive, promotive and
curative health services shall be implemented as per primary health services. The plan focused on:
‐ laying a foundation for economic and social transformation;
‐ adopting an inclusive development process and carrying out targeted programs while focusing on
excluded groups; and

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‐ establishing the right of all citizens to free basic health care services without any discrimination by
region, class, gender, ethnicity, religion, political belief or social and economic status, keeping in view
the broader context of social inclusion.
12. Twelfth Plan, 2009/10-11/12
The twelfth plan also calls for quality health care services for all by:
‐ encouraging partnerships between public and private organizations, NGOs and communities;
‐ developing appropriate referral systems; and
‐ controlling and treating non-communicable diseases like cancer, heart diseases, mental health
problems, diabetes and hypertension.
13. Thirteenth Plan, 2013/14-2015/16
The thirteenth interim plan places an emphasis on equitable health services by
‐ Improving access to the quality health services
‐ Managing all necessary human, financial and logistical resources and developing institutional
capacity.
‐ Enhancing collaboration across government, private and other sectors.
14. Fourteenth Plan, 2017/18-2019/20
The fourteenth plan seems much like a continuation of thirteenth plan. The plan aims to
- Provide effective health services to everyone for ensuring easy access to quality health services.
- Increase awareness regarding nutritious food and increase access of people to its services.
- Reduce neonatal, infant and child mortality rate and increase average life expectancy.
- Provide emphasis on local production of quality drugs and health commodities.
- To increase involvement of co-operative and non-governmental sectors in health sector and manage
investments from these sectors.
- To develop Ayurvedic Medicine System by utilizing and managing herbs available in the country and
also protect and manage other alternative medicine.
Pay for Performance Concept
Pay for performance (P4P) is an approach used to provide incentives to physicians and health care
provider organizations to achieve improved performance by increasing quality of care or reducing costs.
‐ In this sense, P4P differs from the predominant fee-for-service (FFS) payment system that provides
incentives for producing defined health care services.
‐ A common criticism of FFS, which P4P is intended to address is that FFS rewards providers for
producing higher volumes of health care services without direct assessments of the effect on quality
of care or overall costs of the health care system.
‐ The main definition of P4P include the following
 Pay for quality
 Pay for reporting
 Pay for efficiency
 Pay for value
Purpose of pay for performance
‐ To reward the delivery of specific services
‐ To encourage higher coverage
‐ For better quality or improved health outcomes

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Pay for performance in Nepal
‐ The Ministry of Health had introduced a health worker's performance model known as performance
based management system to improve health worker's performance. The main thrust of the
application of PBMS was to link financial incentives with the employee's performance in an
organization.
‐ The component of performance based management system included
 Setting of goals, objectives and targets
 Work performance evaluation/ performance appraisal
 Performance based financial incentives
 Performance improvement plan
‐ The performance based management system included six key result areas with 23 performance
based indicators
 Planning and programming (5 indicators)
 Maternal and neonatal health and family planning services (6 indicators)
 Child health services (6 indicators)
 Tuberculosis control (2 indicators)
 Curative services (3 indicators)
 Health education activities (1 indicator)
Limitations of Pay for Performance
i. Lack of valid, reliable and important indicators
‐ Measuring performance in health care can be quite difficult. Quality of care for, for instance is
influenced by many physician, patient and health care system factors.
‐ Available performance indicators are often driven administrative data that are collected for purposes
other than measuring performance. These data may lack the clinical detail necessary to measure the
quality of care adequately.
ii. Lack of comprehensive performance indicators
‐ Comprehensive performance measurements are not possible in health care or may be too costly to
obtain.
‐ If such measurements are not comprehensive, health providers may focus on imporving their
performance in the areas that can be measured and neglect areas that are not examined or
rewarded.
iii. Lack of flexibility of performance measures
‐ The performance measurement approach may be overly prescriptive and may intrude on provider's
autonomy, flexibility, and ability to use professional judgements to decide the best course of care in
particular situations.
iv. Lack of cost-effectiveness
‐ P4P programs may impose large costs on provider organizations. Simply reporting performance
measures may be quite expensive.
‐ Providers may need to purchase and implement complex information systems and collect and
validate expensive data.

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v. Unintended consequences
‐ P4P incentive payment may have unintended consequences that could be detrimental in several
ways.
‐ Once concern is that health providers may begin to avoid taking on more 'difficult' patients so that
they can avoid scoring poorly on quality or efficiency.
Universal Health Coverage
WHO defines universal health coverage as:
…access to key promotive, preventive, curative and rehabilitative health interventions for all at an
affordable cost, thereby achieving equity in access. The principle of financial-risk protection ensures that
the cost of care does not put people at risk of financial catastrophe. (WHO 2005)
- This definition of UHC embodies three related objectives:
 equity in access to health services - everyone who needs services should get them, not only
those who can pay for them;
 the quality of health services should be good enough to improve the health of those receiving
services; and
 people should be protected against financial-risk, ensuring that the cost of using services does
not put people at risk of financial harm.
‐ UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right
and on the Health for All agenda set by the Alma Ata declaration in 1978.
‐ UHC cuts across all of the health-related Sustainable Development Goals (SDGs) and brings hope of
better health and protection for the world’s poorest.
GON approaches for achieving equity and Universal Health Coverage
‐ Free Health Care Program was adopted in 2006
‐ Aama Program/ Safe Delivery Incentive Package
‐ Universal free treatment services for Uterine Prolapse
‐ Reaching the unreached strategy.
‐ Social health security Program
‐ Referral support Program with cash incentives upto NPR 8,000.
‐ Cash support of NPR 50,000 for treatment of cancer, heart, Alzheimer’s and Parkinson’s diseases

©Prabesh Ghimire
Figure: Three dimensions of universal health coverage
Challenges to achieving equity and universal health coverage in Nepal
i. Availability and accessibility
‐ Stock out of drugs at basic health facilities
‐ Although increment of service utilization by poor, it is still low.
‐ Geographical location and terrain: Distance, high transportation cost
ii. Lack of clear entitlement and procedures
‐ Poor targeting mechanisms: verification mechanisms to identify poor and ultr
‐ People younger than 75 years are not entitled for treatment benefits.
‐ Ambiguous procedures for entitlement of medical benefits to the poor and victims of conflicts.
iii. Insufficient financial protection
‐ There is no scheme to provide protection in the c
‐ Social health security Program enrolled in few districts but process is too slow.
‐ Provision of benefits of NRP 50,000 in case of cancer, kidney, heart and other chronic disease does
not adequately cover treatment costs.
iv. Unregulated private sectors
‐ Growing private sector contributing to high out
‐ Diversion of public funds to private sector through unjustifiable referring of patients to private facilities.
UNIT 3: HUMAN RESOURCE MANAGEMENT POLICY
Human Resource Management Policy
‐ Overall process of human resource management includes three major activities
 Need Assessment
 Human Resource Development
 Human Resource Utilization/ Management
‐ It is necessary to have policies for all three elements.
Figure: Three dimensions of universal health coverage
Challenges to achieving equity and universal health coverage in Nepal
Stock out of drugs at basic health facilities
Although increment of service utilization by poor, it is still low.
Geographical location and terrain: Distance, high transportation cost
Lack of clear entitlement and procedures
Poor targeting mechanisms: verification mechanisms to identify poor and ultra poor
People younger than 75 years are not entitled for treatment benefits.
Ambiguous procedures for entitlement of medical benefits to the poor and victims of conflicts.
There is no scheme to provide protection in the case of catastrophic illness.
enrolled in few districts but process is too slow.
Provision of benefits of NRP 50,000 in case of cancer, kidney, heart and other chronic disease does
not adequately cover treatment costs.
Growing private sector contributing to high out-of pocket expenditure.
Diversion of public funds to private sector through unjustifiable referring of patients to private facilities.
UNIT 3: HUMAN RESOURCE MANAGEMENT POLICY
Resource Management Policy
Overall process of human resource management includes three major activities
Human Resource Development
Human Resource Utilization/ Management
It is necessary to have policies for all three elements.
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Ambiguous procedures for entitlement of medical benefits to the poor and victims of conflicts.
Provision of benefits of NRP 50,000 in case of cancer, kidney, heart and other chronic disease does
Diversion of public funds to private sector through unjustifiable referring of patients to private facilities.

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Policy of human resource needs assessment
‐ Need assessment should address three major questions
a) What types of human resources are needed?
b) Where are the human resources needed?
c) How many HRH for each category are needed?
‐ The answers for these questions should be addressed in need assessment policy.
‐ However, there is a policy gap to guide the need assessment of HRH.
a) What types of human resources are needed?
‐ The type of human resources needed for health sector may be classified in different basis
i. On the basis of service sector: management/administration and technical
ii. On the basis of levels of HRH: Manager/officers, mid-levels and support
‐ Although government of Nepal has made some attempts to specify how many doctors and health
workers are needed at each level, this is not sufficient.
‐ Who are the human resources for health is not clearly specified in the policy and there is a clear
policy gap regarding which human resources are needed for health sector.
b) Where are the human resources needed?
‐ The required type of human resources may be required either to fulfill regional needs or to fulfill
national needs as a whole.
‐ Regional need for HRH may arise when new program or launched or for other reasons
‐ National need may arise during reforms or introduction of national programs.
‐ Policy on need assessment should address whether it is for national or regional need.
c) How many HRH for each category are needed?
‐ There are different approaches to estimate the number of HRH required for health sector.
‐ In Nepal, these estimations are guided by some traditional practices. However, there are no
concrete policies.
Approaches for Need Assessment
i. Structure based approach
‐ This is a mathematical method for estimating human resource requirements based on
 Numbers of positions sanctioned
 Numbers of filled position
 Required number of particular HR
‐ This approach is not in fact guided by policy.
ii. Population based approach
‐ This approach determines the required number of HRH based on proportionate of the population. E.g.
number of doctors per 10,000 population.
‐ However, the basis for determining the population is complex.
‐ There are no national policies addressing population based approach in determining HRH
requirements.
iii. Problem based approach
‐ This approach is based on the prevalence or burden of disease in the region. E.g. no. of experts
required to address a given problem.
‐ E.g. SBA training, Abortion training to ANM.

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Possible outcomes of need assessment
‐ Increase the pool of existing HRH
‐ Impart additional skills among the existing HRH
‐ Develop new category of HRH with new skills
Policy on Human Resource Development
‐ Human resource development policy is closely linked to need assessment policy.
‐ Purpose of human resource development is to
 Increase the pool of existing HRH
 Impart additional skills among the existing HRH
 Develop new category of HRH with new skills
‐ Various institutions are involved in the process of HRH development
 Universities
 Academia
 Government and private training institutes
‐ Therefore, there is no single policy for HR development. It is a set of different policies.
i. Policy of institutions on HRH development
‐ Each institution has its own policy on development of HRH which may include:
a. Policy on types of HRH to develop
‐ For example: IOM has its policy to train and develop more than 48 types under different
categories of HRH while School of Health and Allied Sciences under Pokhara university has a
policy to develop 11 types of HRH.
‐ Such policy is guided by demand from the state, capacity of institution and cost-effectiveness.
b. Policy on quality of training
‐ Every institution has a policy to select best candidates through competitive processes.
‐ Policy for quantification of faculties. How many faculties are required for development of each
category of HRH?
‐ Policy for curriculum development
‐ Policy for evaluation and certification
‐ Policy for number of intake for production
ii. Policy of authority body (professional councils)
‐ This policy is concerned about competency of concerned human resources.
‐ Policies of authority body reflects the state policies
‐ These policies include policies on competency such as
 Training pre-requisites (such as infrastructures, no. faculties and their qualification, etc.)
 Policy for periodic inspection of training institutions
 Policy for licensing and certification

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Evolution, External Influences, Trends and Issues in Human Resource Policy
Evolution and Trends in HRH Policy
a. Early efforts
‐ The review of health policies and plan of Nepal reveal that the introduction of integrated community
health Programs of 1974 is one of the initial efforts made to systematize the training process with the
aim of developing health personnel on integrated care.
b. First Long-term health plan
‐ The First long term health plan 1974, there was chapter on health workforce.
‐ This plan identified the institute of Medicine (IOM) as a major producer of health workers. This
envisioned that there should be special health care regulation for effective management.
‐ However, this plan was mostly limited to the shortage of mid and lower level technical health
professionals.
c. Formulation of National Health Policy 1991
‐ In 1991, National Health Policy was developed. This policy emphasized the cooperation for the
development of the major academic institutions (IOM, CTEVT, NHTC, RHTC) to raise HRH
production capacity.
‐ Moreover, the policy aimed to encourage HRH to work in remote areas, plan out-transfers and pursue
promotion and career development procedures for HRH working at various levels.
d. Development of HRH Master Plan
‐ The first national HRH master plan (1993-1995) was prepared by MOHP with the aim of producing
technically competent HRH and their distribution across the country.
‐ This plan also talked about the recruitment, deployment and supervision mechanisms, This further
emphasized on the updated HRH inventory.
e. Development of Second Long-Term Health Plan
‐ The second long-term health plan (1997-2017) also aimed to provide technically competent and
socially responsible health personnel in appropriate numbers for quality health care throughout the
country, particularly in underserved areas. It has given emphasis on HRH management.
f. Formulation of Strategic Plan for HRH
‐ In 2003, a strategic plan for HRH (2003-2013) was developed, which focused on three strategic
objectives, including:
 specifying the direction of development of HR,
 defining HR objectives for the medium term, and
 identifying short-term policy actions for MOHP so that the system gets ready for more challenging
reforms.
g. First Nepal Health Sector Plan
‐ Nepal health sector plan (2004-2010) aimed to develop clear, effective and functional human
resource development policies, planning systems, and Programs.
‐ It also emphasized a range of implementation interventions in order to address HRH challenges.
These included:

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 Two-year compulsory service scheme for medical doctors who studies under the government's
scholarship scheme.
 Fulfillment of vacant posts by contract staffs
 Formulation of SBA policy and long term plan and initiation of SBA training
 Training of all health personnel including FCHVs on IMCI
h. Nepal Health Sector Plan II
‐ Further, Nepal Health Sector Plan II (2011-2015) recognized that there are HRH challenges, including
shortage of health workers, low motivation and poor retention, incomplete human resource
information and poor skill mix. Various actions were outlined to tackle these challenges:
 Scientific and robust projection of HRH
 Coordination with medical schools/ academia and training centres for production and supply of
critical HRH
 Upgrade and update provider skills to enhance quality of care
 Performance based and retention based payment systems
 Strengthening HURIS
 Multi-year contract provisions
i. Development of HRH Strategy
‐ Further, HRH strategy developed for 2011-2015 was aligned to support the implementation of HRH
strategies contained in the NHSP-II. It included future human resource requirements and supply, and
examined their implications for training and training institutions.
j. HRH Policy today
‐ At present, the HRH policy of Nepal is guided by National Health Policy 2014 and Health Sector
Strategy (2015-2020) which puts much emphasis on HRH education as well as rural retention.
External Influences
i. Global Priorities and Health Agendas
‐ Global priorities determine the overall HRH policy directions to meet the standards and goals. Some
of the examples include
 Sustainable Development Goals
 WHO global code of practice on the international recruitment of health personnel
 Global Strategy on HRH Workforce and
 The Kampala Declaration and Agenda for Global Action Health Worker for All and All for Health
Workers, 2-7 March 2008.
 Global policy recommendations on 'increasing access to health workers in remote and rural areas
through improved retention.
ii. Government Policy and regulations
‐ With the introduction of new HRH policies and strategies, HRH policy is liable for constant
development, update and revisions to comply with these policies:
 National Health Policy 2014:
 Nepal Health Sector Strategy 2015-2020
 National HRH Strategic Plan 2003-17

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iii. Regional commitments
‐ In 2014, member states of WHO South-East Asia Region agreed to the “Decade for Strengthening
Human Resources for Health in SEA Region 2015-2024”.
‐ The member states including Nepal are recommended to develop priority actions for HRH
strengthening with a focus on rural retention and transformative education.
iv. National Contexts
‐ Mathema Report 2015 and subsequent cabinet decisions for improving medical education are likely
to influence HRH planning and production in HRH policy of health sector.
‐ Government decisions such as guideline for mobilization of Scholarship doctor and health personnel-
2071.
v. Economic Conditions
‐ One of the biggest influences is the shape of the current economy. Staff salaries alone consume 60-
80% of the government’s recurrent health budget in most countries.
‐ HRH policy in any country depends not on the need for their services but on the resources available
to support them.
vi. Technological advancements
‐ New information technologies and telecommunications have a high potential for improving
productivity, by allowing health professionals to exchange clinical data over a distance in real time or
to have immediate access to new knowledge. E.g. telemedicine
‐ At the same time, policies to introduce technology may eliminate job, impose new skill requirements
and require new investment in terms of training.
vii. Workforce mobility and brain drain
‐ In developing countries like Nepal, the mobility of HRH particularly highly qualified HRH have often
taken the form of a more brutal exodus of skills, depriving countries of rare resources crucial for
development of health systems.
‐ As the job market is rapidly changing, HRH policies must cope with difficulties of retaining personnel
who are attracted by better offers outside the public health system.

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Human Resource for Health (HRH) planning, projection, production and utilization Policy
Personnel Policy
Various policies, plans and strategies have spelled out the provisions relating to human resources for
health in Nepal.
i. National Health Policy 2014
‐ National Health Policy aims to plan, produce, retain and develop skilled human resources to deliver
affordable and effective health services.
‐ This policy guarantees the opportunity for higher education, trainings within service duration and
participation on profession related studies and researches to doctors and health workers.
‐ Emphasis has also been laid on master planning of HRH development, unified curriculum
development as well as achieving skill mix of HRH at all areas.
ii. Health Service Act (1994)
- The major policy document governing the employment of health sector staff is the health services act
1994.
- This act makes provision for the management of health workers employed by the MOHP and
provides guidance on the recruitment, deployment, transfer, promotion, and discipline of health
workers.

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- Amongst many other things, the act also allows for a change from rank system of posts to a grade
system.
- Five amendments have been made to this Act till date.
iii. The 2003-2017 Strategic Plan for HRH
- The 2003-2017 strategic plan was intended to
 Specify the direction and growth of human resource growth
 Outline human resource objectives for the medium term, and
 Identify short-term policy actions for the MOH.
- It includes future human resource requirements and supply and examines their implication for training
and training institutions.
- The plan, which was formally adopted, projected a 71% increase in the public sector workforce by
2017.
iv. National HRH Strategic Plan (2011-15)
- In 2011, Ministry of Health and Population developed the 2011-2015 HRH Strategic Plan.
- This plan aimed to ensure equitable distribution of appropriately skilled human resources for health
(HRH) to support the achievement of health outcomes in Nepal and in particular for the
implementation of the Nepal Health Sector Program.
- HRH Strategic Plan (2011-2015) contained a range of strategies and activities to achieve this aim and
the following planned outputs:
 Appropriate supply of health workers for labour market needs;
 Equitable distribution of health workers;
 Improved health worker performance; and
 Effective and coordinated human resource planning, management and development across the
health sector
v. Second Long-Term Health Plan (1997-2017)
- The Second Long-Term Health Plan planned the following activities regarding HRH:
 Decentralization of HRH planning within the national guidelines of the “HRH Master Plan”
 Conducting periodic assessment of the need to supply of health personnel in coordination with
relevant sectors, ministries, organizations and professional bodies.
 Production of HRH based on projected needs rather than capacity of training institutions.
- Provision of subsidies in pre-service education to candidates from remote areas and to promote
gender equity.
vi. Thirteenth Periodic Plan
- The thirteenth periodic plan of Nepal places management of human resource as one of the major
policies.
vii. NHSP-III Strategic Plan (2015-20)
- The NHSP-III strategic plan has defined nine outcomes for the health sector of which strengthening
HRH is one among the first outcomes.
- There are two outputs concerning HRH for achieving the outcome of strengthening HRH.
 Output 1a.1: Improved staff availability at all levels with focus on rural retention and enrollment
 Output 1a.2: Improved human resource education and competencies

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Supervision, Capacity Building, Career Development and Quality Assurance Policy
Capacity Building and Career Development Policy
Various health related policies and documents such as National Health Policy 2014, Second Long-Term
Health Plan (1997-2017), Nepal Health Sector Strategy (2015-20), Strategic Plan for Human Resource for
Health (2003-2017), etc. clearly state the need for career development of HRH in Nepal
In Nepal, the formal provisions covering career development and capacity building opportunities,
including postgraduate study, in-service training and national or international study tours, are given by the
Health Service Act. The Act dictates a range of criteria according to which such opportunities are to be
made available to health workers, including:
• Relevance of the training to the employee’s work;
• Marks in educational qualifications;
• Seniority;
• Experience of service in geographical region;
• Work performance evaluation; and
• Age (in cases of training that culminates in an educational degree, candidates must be under the age
of 45).
The major provisions for career development and capacity building of human resources for health in
Nepal include the following:
i. Performance Rewards
- Performance rewards for health workers are formally governed according to the Health Service Act
(1997).
- The Act includes provisions covering a range of reward mechanisms, including salary increments, the
upgrading of positions and promotion.
- Employees receiving excellent marks on annual work performance evaluations and who have
completed the minimum service period required for promotion but have not been promoted receive a
performance reward of five salary grade increments.
- This depends on nomination by the health facility officer in-charge or the DHO, with the final decision
by the relevant head of department in MoH, who will also provide a letter of appreciation.
ii. Participation in study or training Program
- A provision for sanctioning leave for up to four to six years, in the case of advanced degrees has
been provisioned for participation in study or training Programs.
- For nominating employees for study, training or study tour, the Ministry shall make nomination from
amongst the HRH in the ministry and its sub-ordinate offices based on the following grounds:
• The subject of study, training or study tour is useful and necessary for the group or sub-group for
which the concerned employee is serving.
• Nomination for study scholarship, training or study tour, based on priority from amongst the HRH
who secure higher marks for educational qualifications, seniority, experience of service in
geographical region and work performance evaluation.
• Those that have not crossed the age of Forty Five years in the case of study of bachelor, master
or any educational degree.

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iii. Upgrading of Health Workers
- Upgrading of a health worker’s position, based on years of service in the original position,
performance evaluations from the period of work in that position and the successful completion of any
training required for the post to which the worker is to be upgraded, is listed among the potential
rewards for health workers.
- For example, an ANM may be upgraded to a senior ANM (equivalent to a staff nurse) and an
assistant health worker (AHW) may be upgraded to a senior AHW (equivalent to a health assistant).
iv. Promotion
- In order to be a candidate for promotion, an employee must have completed the service period of
Three years in the post that is one below the class of the post to which promotion is made
- An employee who has completed Ten years in the Fifth level may be a candidate for promotion
despite that the employee does have the educational qualification prescribed for the Fifth level.
- An employee must have worked in the remote area for at least Two years in order for the employee to
be a candidate for promotion.
- If an employee who has been upgraded to the Eighth level has already worked for two years in the
level that is one level below that in the remote area, then the employee shall be considered to have
served in the remote area for promotion to the Ninth level.
v. Linking remoteness to career development
- Since the promulgation of The Health Service Act in 1997, government health workers must have
worked in a remote area for at least two years in order to be a candidate for promotion, and those
health workers with experience in different geographical regions are to given priority in nomination for
scholarship and training opportunities.
- This incentive for taking on remote postings is applicable to all technical officials, including nurses.
Limitations in career development opportunities in Nepal
Various studies suggest that there are several limitations within the existing provision of career
development opportunities for HRH in Nepal. Some of these limitations have been highlighted below:
• Studies reveal that in practice, performance assessment tends to be highly subjective rather than
being based on the regular assessment of clearly defined criteria.
• Due to the inability of GON to increase the number of sanctioned positions, in practice health workers
may be compelled to continue working in their original position without being upgraded.
• Some qualified health specialists for whom posts are not provided in remote district health facilities,
are unable to achieve promotion.
Quality Assurance Policy for HRH Management
In order to ensure the quality of health care services, the National policy on quality assurance has made
provisions for the following:
 Establishment of quality assurance steering committee at the central and QA working committee at
the district level to oversee, coordinate and monitor the policies and strategies related to quality of
health care services.
 The QA steering committee at ministerial level is chaired by chief specialist of curative division under
MOH and the QA working committee will be chaired by chief of DHO/DPHO.
 Establishment of QA section at DOHS as a focal point for quality assurance activities.
 Development for standards, guidelines and clinical protocols for major components of essential health
care services.

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In addition to this, The GON has established various professional councils for the quality assurance in
HRH production. These include:
i. Nepal Medical Council
ii. Nepal Nursing Council
iii. Nepal Health Professional Council
iv. Nepal Pharmacy Council
These councils are guided by respective acts and are responsible for the quality assurance in the
following ways:
• Determining the qualification for accreditation of respective health professionals (medical doctors,
public health professionals, paramedics, pharmacists, nurses, etc.)
• Conducting licensing examination for newly produced health professionals.
• Providing recognition to training institutions for providing formal medical education and training.
• Formulating code of conduct for maintaining professional ethics in health practice.
Professional bodies/
councils
Scope Policies for Quality Assurance
Nepal Health
Professional Council
Public health
professionals and
Mid-level health
workers
Examination of application and registration of
health professionals with required minimum
qualifications, Revocation of certificate of
frauds, Recognition to educational qualification
Nepal Medical Council
(NMC)
Medical doctors Formal permission, , regular supervision of
medical colleges, quality standardization,
examination and certification of medical doctors,
etc.
Nepal Nursing Council
(NNC)
Nurses and
ANMs
Formal permission, standardization of quality,
quality control, certification and accreditation of
nurses.
Nepal Pharmacy
Council (NPC)
Pharmacists Standardization of pharmacy colleges,
monitoring and supervision, quality control,
certification and accreditation of pharmacy
professionals.
Council for Technical
Education and
Vocational Training
(CTEVT)
Basic and Mid-
Level Para-
professionals
Examination, Certification and accreditation
Policy on Quality Assurance of Health Services
Policy on Quality Assurance of Health Services was developed by GON in 2007.
Goal:
• To ensure the quality of services provided by Governmental, non governmental and private sector
according to set standard.
Policies
• Quality assurance will be developed as integral part of essential health care services delivery system.

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• A coordination mechanism will be developed among NGOs, private sector and local community to
ensure quality health services delivery.
• A sustainable standard will be developed from central to district in order to monitor the QA services
Strategies
i. A QA Steering Committee will be formed at central and district level to oversee, coordinate and
monitor the policies and strategies related to quality of health care services.
ii. A QA Section will be established at Management Division under Department of Health Services
which will be developed as a focal point for quality improvement.
iii. In the first phase, standards, guidelines and clinical protocols will be reviewed and/or developed for
four major components of EHCS which include: Reproductive health, child health, communicable
disease control and OPD services. Emphasis will be given on proper implementation of these
standards, guidelines and protocols through routine monitoring and supervision.
iv. Local community will be involved in improving management of health institution to provide quality
health care services by mobilizing local resources.
v. Performance of quality of care activities carried out at different levels will be reviewed by integrating it
with existing performance review system and monitored on regular basis.
vi. Medical and death audit system such as maternal death audit or new born death audit will be
established up to the PHCC level in a phase wise manner. The District level QA committee will be
responsible to carry out the auditing.
vii. Social audit to assess client satisfaction and bring beneficiary's perspective in design and
improvement of health policies and Programs and health services will be initiated.
viii. Regular monitoring will be carried out from Quality Assurance Section at all level of government, non-
government and private sector health institution and necessary support will be provided.
Policy for delivery and utilization of human resources
National Health Policy
- The National Health Policy aims to adopt following strategies to plan, produce, retain and develop
skilled human resources to deliver affordable and effective health services
 A doctor and 23 health workers per ten thousand of population will be gradually ensured.
 Special provision will be made for the utilization of HRH in remote and mountainous areas.
 Skilled manpower working for the private sectors will be utilized in the civil services as per
necessity.
National Abortion Policy
- In order to utilize appropriate HRH for expanding standard safe abortion services and increasing
abortion awareness, the National Abortion Policy adopts following policies:
 The appropriate human resources required for the provision of CAC services will be identified and
orientation and competency-based skill training will be conducted.
 CAC curriculum for different levels of health service providers will be incorporated in to the pre-
service and in-service training Programs.
National SBA Policy
- With the purpose of providing skilled care at every birth, the National SBA Policy has taken up
following policies in terms of delivery and utilization of HRH
 Each health post will be staffed by two ANMs and a staff nurse

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 As a part of decentralization, any additional requirement for SBAs will be addressed locally to
ensure round the clock (24 hours a day) provision of delivery services.
 A new cadre of professional mid-wife will be initiated as a crucial human resource for safe
motherhood.
 Number of new accredited training sites will be expanded to ensure production of competent
SBAs.
UNIT 4: EDUCATION IN HEALTH AND CURRICULUM DEVELOPMENT POLICY
Education in Health and in Different Universities/ Councils in Nepal
i. Tribhuwan University/ Institute of Medicine
‐ The Institute of Medicine (IOM) was established in 1972 under Tribhuwan University with the
mandate and the responsibility of training all the categories of health manpower needed in the
country.
‐ The institute consist a total of 12 campuses scattered over the country out of which 3 campuses are
in Kathmandu and 9 campuses are outside the Kathmandu Valley.
‐ IOM is the largest institute in the country implementing wide range of academic programs related to
health which includes
 11 programs at Bachelor level
 26 programs at Postgraduate level
 11 programs at Doctorate level
ii. Pokhara University
‐ Health and health related academic programs in Pokhara University are operated under the School of
Health and Allied Sciences.
‐ The education programs for health sciences were started in Pokhara University since 1997.
‐ The school runs two years Master and four years Bachelor programs.
‐ The courses use a variety of learning methods including seminars, extensive practical sessions and
field visits.
‐ The health related academic programs run under Pokhara University includes the following:
 7 programs at Bachelor level
 4 programs at Postgraduate level
iii. Purbanchal University
‐ Purbanchal University offers academic programs in health through its College of Medical and Allied
Sciences (PUCMAS) as well as its affiliated colleges.
‐ PUCMAS has been established as a central institute of medical and allied sciences at Purbanchal
University and offers four academic programs.
 Post Basic Bachelor of Nursing (PBBN)
 Bachelor of Science in Nursing (BSN)
 Master in Public Health (MPH)
 Master in Pharmacy (M. Pharmacy)
‐ In addition to above programs, other affiliated colleges of Purbanchal University offer varieties
educational programs on health which includes:
 Bachelor of Public Health (BPH)

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 Bachelor of Pharmacy
 Master of Science in Nursing
 Bachelor of Medicine and Bachelor of Surgery (MBBS)
 Bachelor of Homeopathic Medicine and Surgery (BHMS)
iv. Kathmandu University (KU)
‐ The School of Medical Sciences under Kathmandu University offers number of health related
academic programs through its constituent and affiliated colleges.
 DM/M.Ch programs
 MD/MS/MDS programs
 Master in Pharmacy
 Bachelor of Medicine and Bachelor of Surgery (MBBS)
 Bsc. Nursing
 Bachelor in Dental Surgery
 Bachelor in Physiotherapy
 Bachelor of Pharmacy
 Bsc. Human Biology
 Diploma in Medical Imaging
 Certificate in Nursing
v. CTEVT
‐ CTEVT through its constituted and affiliated technical colleges and institutes offer proficiency/diploma
level, technical school leaving certificate and short-term vocational and skill training.
‐ In brief, the existing health related academic programs offered by CTEVT includes the following
a. Certificate/Diploma level programs (3 years program)
‐ CTEVT offers 8 different diploma level courses in health which includes
 Proficiency Certificate in General Medicine
 Proficiency Certificate in Nursing
 Proficiency Certificate in Medical Lab Technology
 Proficiency Certificate in Radiography
 Proficiency Certificate in Ayurvedic Science
 Diploma in Pharmacy
 Diploma in Dental Science
 Diploma in Ophthalmic Science
b. TSLC programs (15 and 18 months program)
‐ Five types of TSLC courses are available under CTEVT
 Community Medical Assistant (CMA)
 Auxiliary Nurse Midwife (ANM)
 Auxiliary Health Worker (AHW)
 Dental Hygienist
 Lab Assistant

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Curriculum Development Policy of MOE, Universities/ Institutes and Councils
Institute of Medicine
‐ The National Centre for Health professions Education (NCHPE) has been designated the
responsibilities in the design and review of (Certificate, Undergraduate and Postgraduate Level)
curricula of various Programs of the IOM.
‐ The curriculum development policy emphasizes the concepts of primary health care and community
orientation in line with the recommendations on Reorientation of Medical Education (ROME) launched
by the WHO, South East Asia Region.
‐ IOM has a provision of curriculum development and evaluation committee comprising of five
members including coordinator, member secretary and three members.
Pokhara University
‐ Curriculum Development Center established under section 19 of the Pokhara University Act 2053
functions to develop, update and revise curriculum as per the national and international need.
Health Professional Councils, their Policy and regulations
Nepal Health Professional Council Act, 2053 (1997)
A Nepal Health Professional Council Act was enacted by the parliament in 1997 AD. This act paved the
way towards establishment of Health Professional Council for systematic operation of health services and
registration of health professional according to their qualifications.
The act also guides the formation of the council and sets out functions, duties and power of the council as
follows:
‐ To make necessary policies for smoothly operating the health profession related activities.
‐ To determine the curricula, terms of admission and policies on examination system of educational
institutions imparting teaching and learning on health profession and evaluate and review the related
matters.
‐ To determine the qualifications of health professionals and to provide for the registration of the names
of health professionals having required qualifications.
Some of the major provisions in the act are
i. Application for registration of name in register
‐ A health professional possessing minimum prescribed qualifications has to make an application to the
Council for getting his/her name registered in the register.
ii. Examination of Application
‐ The council shall inquire the application as to whether the qualifications certificate and degree are
recognized ones or not and whether the application meets the requirements.
‐ Based on this inquiry report, the council shall make decision to or not to register the name of
applicant in the register.
iii. Deletion of name form register and re-registration
‐ Council may issue an order to delete the name of a registered health professional from the register in
the following circumstances:
 where he/she has been punished by a court in a criminal offense

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