This is part 2 of historical development of health care services in Nepal.

1. HISTORY OF
HEALTH SYSTEM
DEVELOPMENT
(PLANNED PERIOD)
By:
Vijaya Laxmi Shrestha
(MPH, M. Phil.)

2. 1st Five Year Plan (1956-1961)
 More emphasis was given on the curative
services.
 Nepal Malaria Eradication Organisation
(NMEO) programme in Chitwan reached to the
peak of eradication of malaria and resettlement
of the hill people in the Terai region.
 Organisation of Ministry of Health took place in
1956.
 The first intake of girls in Bir Hospital Nursing
School took place in 1956 and 13 nurses were
produced in 1960.

3. Contd….
 HA school was started in 1955 to provide
basic health care in rural areas.
 Training of Assistant Nurse Midwives
(ANM) in Bhartatpur for providing service
in rural areas was started.
 Prasuti Griha (the first maternity hospital)
was established in Thapathali in 1959
 Only 7% of the people were being served
by Health facilities.
 At the end of this period, there were 34
hospitals with 160 doctors and 24 health
posts.

4. 2nd Plan Period (1962-1965)
 At the start of this period in 1962, the total
population was 9.8 million with life expectancy
of 33 years.
 With the continuous emphasis on curative
services, more focus was on the preventive
aspects.
 Smallpox survey was started in 1962.
 Leprosy control project was started in 1963.
 Tuberculosis control project was started in
1965.
 Royal Drug Research Laboratory was
established in 1964.

5. Contd….
 ANM training was later conducted by
Nepal Rajkiya Ayurved Vidhyalaya, Civil
Medical School, HA Training School
(HATS) & AHW School.
 In 1965, 102 Health Posts & 36
hospitals were in existence.

6. 3rd Plan Period (1965-1970)
 Though the stress was still on the curative
aspects, necessary of preventive services
was accepted.
 32 Districts health centers were divided into
two groups; Type A & Type B
 In16 Type A, there was provision of 2
medical officers, of which one would be
female.
 There would be only one male medical
officer in remaining 16 districts.

7. Contd……
 The concept of provision of rural health
services led to more health posts.
 The building of additional new health
posts in 1970 resulted in a total of 113
at the end of this period.
 Establishment of vertical projects:
◦ Leprosy eradication project in 1965
◦ Smallpox eradication project in 1967
◦ FP/MCH Project in 1968
◦ Starting of Central Health Laboratory in

8. 4th Plan Period (1970-1975)
 The life expectancy was increased to 42.3
years and IMR had come down to
157/1000 live births
 Production of middle & basic level health
workers was shifted from HMG Nepal to
IOM, TU in 1972
 A pilot programme on Integrated Basic
Health Service was launched in Bara in
1971 and in Kaski in 1972.
 With the success of these projects, the
HPs were converted to integrated HPs
providing preventive, promotive & curative
services.

9. Contd….
 Nepal had been classified as non endemic for
small pox eradication since 1973 but the last
case was found in 1974.
 Community Health and Integration Division
(CHID) was set up to reduce duplication &
make health programs effective.
 The population had gone up to 12.9 millions in
1975 which emphasized on population control

10. contd...
 Till date, there were 348 physicians, 900
nurses by 1975.
 A total of more than 1000 basic and middle
level health workers were trained by IoM.
 DoHS trained VHWs & Panchyat based
health workers (PBHW)
 62 hospitals with 2174 beds, 33 health
centres, 351 health posts & 82 Ayurvedic
aushadhalayas were in place at the end of
this period.
 At the end of this period, a 15 year long
term health plan was about to come.

11. 5th Plan Period (1975-1980)
 1st long term health plan (1975-1990)
was formulated.
 IoM increased its effort in Health
Manpower production.
 Nepal had signed the HFA by 2000
document in Alma Ata in 1978.
◦ PHC was accepted as an effective method
by which essential health care services
were to be provided to the community.

12. contd....
 Population increased to 13.9 millions
in 1978 and to estimated 14.0 millions
in 1979.
 Life expectancy had gone up to 46
years and IMR had been reduced to
145/1000 live births.
 Further steps were taken to integrate
vertical programmes.

13. Contd…..
 At the end of this period, there were
◦ 1000 VHWs
◦ 450 FP/PBWs
◦ 2000 middle level workers at HPs &
hospitals
◦ 457 Physicians
◦ 69 hospitals
◦ 483 HPs, of which 233 had been
integrated

14. 6th Plan Period (1980-1985)
 Stress was given on food supply and
provision of clean drinking water
 Concept of Basic Minimum Health Needs
as COMBINA
◦ Child spacing
◦ Oral Rehydration Therapy
◦ Maternal and Child Health
◦ Basic Natal Care
◦ Immunization
◦ Nutrition
◦ Acute Respiratory Infection control

15. Contd….
 A total of 745 HPs, of which 450 were
integrated.
 Health care at the grassroots level
was to be provided by VHWs, be they
integrated or static.
 Still there were 18 districts without a
hospital
 Discussions were made for “attracting
private investors in the development of
rural and urban health services”.

16. contd...
 International Drinking WAter and
Sanitation Decade (1981-1990)
 Life expectancy at birth was estimated
to be 53 years for men and 50 for
women

17. 7th Plan Period (1985-1990)
 Organizational integration had been
completed more or less by 1987 at
peripheral level & by 1990 at central
level
 Reporting system had also been
integrated in 27 districts
 National Health Information System
was being developed by HMG with
WHO collaboration since 1988

18. Contd….
 Type & Number of Health Institutions
◦ Health Posts 745
◦ Health Centers 26
◦ District Hospitals 44
◦ Zonal Hospitals 9
◦ Central Hospitals 5
◦ Other Hospitals 23
 Emphasis was on Basic Minimum Health
Needs of the people including PHC &
Sanitation.
 Bed : Population ratio was 2.4 beds for
every 10,000 population.

19. Contd…
 In 1986, DoHS was dissolved and Ministry
of Health saw the formation of 10 Divisions &
2 Departments of Ayurved & Drug
Administration.
 By this time, 5 Development Regions had
Regional Directorates of Health Services to
provide BMHNs to all people by 2000.
 The provision of 9 Ilaka HPs in each districts
under the responsibility of DHO was made &
additional static HPs were also available as
per need and quota.
 Concept of Sub Health Posts was developed

20. 8th Plan Period (1992-1997)
 Its objective appeared to continue to the
orientation of National Health Policy 1991
 New organizational set up of the MoH
came into effect in 1993
 With this implementation, the intention
was to
◦ Involve lower level in planning and delivery of
health services, supervision and monitoring
◦ Give further efforts to the integration process

21. Contd….
◦ Provide a combined preventive and
curative package at the district level
◦ Bring about more efficient
management by combining functions
of finance, logistics, training, IEC and
MIS.
◦ Have a more compact working force
by eliminating development staff
positions
◦ Budget allocated for health was 5% in

22. 9th Plan Period (1997-2002)
 Focused on poverty alleviation
 Specific and annual plans had been
made according to context of national
needs
 2nd Long Term Health Plan (1997-2017)
was prepared
 Essential Health Services at District
Level
 Increased role of Private and NGO
sectors

23. Contd…
 Traditional health system; Ayurvedic,
Homeopathic, Unani & Naturopathy
 Government budget was to shift its
focus from tertiary to primary level
 Organization & management on the
basis of decentralisation
 Intersectoral Coordination
 Health Research
 Targets on various indicators were set
including MDGs

24. contd...
 Some of the Medical College and Teaching
Hospital were established during this period from
private sector providing secondary and tertiary
medical care services and education.
◦ Bharatpur Medical College Teaching Hospital (1998),
◦ Universal College of Medical Science &
Teaching Hospital (1999),
◦ Kathmandu Medical College & Teaching
Hospital (2000), and
◦ Nepalganj Medical College & Teaching Hospital
(2002)
24

25. 10th Plan Period (2002-2007)
 Focused on Poverty alleviation
 Self reliance
 Decentralization
 Gender awareness
 Mobilization of government, NGOs &
private sectors
 Effective and efficient management
 Strategies were developed to meet
MDGs

26. Policies
(a) Making essential health care services
(EHCS) available to all people,
(b) Establishing decentralized health
system to encourage peoples’
participation,
(c) Establishing Public-private –NGO
partnership in the delivery of health care
services, and
(d) Improving the quality of health care
through total quality management of
human, financial and physical resources

27. Strategies:
 Essential health care services to
rural/remote population
 Developing & implementation of program for
poor & backward people
 IEC activities especially focusing on non
communicable diseases
 Decentralization on planning, decision
making & management of health facilities
 Participation of stakeholders in
planning/policy/program formulation
 Strengthening two way referral system

28. Contd.....
 Promotion of alternative medicine
 Ensure quality of drugs
 Awareness on rational use of drugs
 Hand over health facilities to local bodies
 Promote participatory planning process,
gender balanced
 Proper supervision, monitoring &
evaluation of health services
 Mobilizing government, NGOs & private
sector for HR production

29. Programmes and their priority
The health service programmes are prioritised
on the following bases in the Tenth Plan:
1. Burden of diseases,
2. Implementing capacity,
3. Equity,
4. Programmes targeted to the poor, the
oppressed and those devoid of
opportunities,
5. Programmes contributing to poverty
eradication,
6. Availability of resources

30. The programmes in first priority (P1)
1. EPI and National Polio Eradication
Program
2. Control of Acute Respiratory Infection
3. Control of Diarrhoeal Diseases
4. Nutrition
5. Safe motherhood
6. Family planning
7. Reproductive health of the
adolescents
8. Female community health volunteers
and sudenis (trained traditional birth
attendants)

31. …..in first priority (P1)
9. Epidemiology and control of diseases
(malaria, TB, Leprosy, Kala-azar, HIV/AIDS)
10. Training
11. Community Drug Programme
12. Natural disaster management
13. Health information, communication and
education
14. Drugs & medical equipment supply
15. Health insurance
16. Health Information System management
17. Health research

32. The programmes in second priority
(P2)
 Tertiary level hospital services
◦ Bir Hospital
◦ Shahid Shukraraj Tropical and
Infectious Disease Hospital
◦ Kanti Children’s Hospital
◦ HRH Indra Rajya Laxmi Maternity
Hospital
 Laboratory services
 Strengthening supervision, monitoring
and evaluation systems
 Maintenance of physical infrastructure

33. The programmes in third priority
(P3)
Speciality hospital services
 Nepal Eye Hospital
 Netrajyoti Sangh
 BP Koirala Memorial Cancer Hospital
 BP Koirala Health Science Foundation,
Dharan
 Shahid (Martyr) Gangalal National Health
Centre
 Dental care service
 Alternative medicine
 Hospital development and expansion
 Drug abuse control program

34. Challenges of 10th Plan
The plan was severely under resourced
 Severe gap in political commitment and
implementation
 Lack of specific strategies to change the
attitude of health personnel towards the poor
and marginalized groups
 Availability of EHCS in one-hour walking
distance was unrealistic
 Handing over the management responsibility of
the health facilities to the local bodies in the
ongoing conflict situation was over ambitious
 Not sensitive to the ongoing conflict in the
country

35. 11th Plan
Three Year Interim Plan
(2007-2010)

36. Context and Rationale
Developed after end of conflict
 Programmes to operationalize
constitutional provision of “Free Basic
health service” to all
 Starting with poor, socially excluded, 22
low HDI districts, women, disabled
 Deal with problems of conflict victims

37. Long Term Vision
 To establish appropriate conditions of
quality health services delivery,
accessible to all citizens, with a particular
focus on the low-income citizens and
contribution to the improvement in the
health of all Nepalese citizens

38. General Objectives
 To ensure citizens’ fundamental right
to have improved health services
through access to quality health services
without any discrimination by region,
class, gender, ethnicity, religion, political
beliefs and social and economic status
keeping in view the broader context of
social inclusion.

39. Contd….
 The constituent elements of such
an objective are:
◦ To provide quality health services
◦ To ensure easy access to health services to
all citizens
◦ To ensure enabling environment for utilizing
available health services.

40. Specific Objectives
• Operationalize Free Basic Health services
• Redesign health system.
• Health professional education
• Strengthen Nepal Health Sector Program
(NHSP)
• Provide EHCS to achieve MDG
• Ensure availability of Essential drugs
• Strengthen Health research
• Improve hospital and referral services
• Develop Ayurvedic, alternative medicine
• Public Private Partnership
• Urban health ,NCD, Health of Elderly

41. POLICIES:
◦ Essential and basic health services
◦ Health Sector Reform & Infrastructure
Development
◦ Public Private Partnership
◦ Decentralization of Health Institution
Management
◦ Drug Production & Community Drug Program
◦ Health Research
◦ Health Service Technology

42. Strategies
 Necessary policies and statutes will be
developed to operationalize the
Constitutional provision of Free Basic Health
Services
 Abolition of user fee at HP/SHP/PHC,
District Hospital OPD
 Free Essential drugs at HP/SHP
 Charter of Patient Rights at Health
institutions
 Social Support Programme at Hospitals
 Mobile health camps with specialized

43. Contd…
 Upgrading of SHPs to HPs &
establishment of PHC
 Public health promotion will be focused
through public health education
 Special attention will be given to health
improvement of the economically &
socially disadvantaged people &
communities.
 Ayurvedic & other alternative medicines
will be developed
 Tele-medicine service will be established &

44. Contd…..
 Strengthening of ongoing efforts to treat
conflict victims in collaboration with
professional societies and NGOs
 Include inpatient, emergency and referral
into EHCS up to district level
 Management of human, financial &
physical resources
 Decentralization process will be
strengthened
 Communicable disease control programs
will be continued with emphasis to drug
addiction, HIV/AIDS control etc.

45. Contd…..
 Non communicable diseases prevention
& control
 Amendment of National drug policy,
manufacturing quality and GMP
certification
 PPP including corporate social
responsibility
 Health research system and Health
research strategy

46. Programs
 Special Health Services Program
◦ Free indoor & emergency services
◦ Social help program
◦ National rehabilitation center
◦ Health service camps with free of cost
◦ Seti Zonal Hospital will be upgraded to a
regional hospital.
◦ Uterus prolapse control program will be
launched.

47. Contd…….
◦ Program of blindness & sight deficiency:
Vision 2020: “Right to Sight.”
◦ Community based rehabilitation program
◦ Local persons will be trained as ANM for
Karnali region
◦ Community health insurance program
◦ Community Drug Programs
◦ Grants of Rs 50,000 for FCHV Fund

48. contd...
◦ Open bridge course for ANM, AHW, Staff
nurse
◦ Tele –medicine in the district hospitals
◦ Road Traffic Accidents prevention
program
◦ A National Health Development Council
will be formed
◦ Programs for senior citizens

49. Contd….
 Regular Program:
◦ Safe motherhood
◦ New-born Child health program
◦ Child Health Program
◦ Newly emerging Infectious Disease Control
Program
◦ School Health Program
◦ Oral Health Services
◦ Implementation of Integrated Health
Information System

50. Contd…..
 Health Research
 Laboratory, X-ray/Imaging & Blood
Transfusion Services
 Family Planning
 Nutrition
 Natural Disaster Management
 Mental Health
 Public health Promotive program through HE
 Improvement in financial administration &
proper mobilization of resources

51. Contd…..
 Production of essential human
resources
 In service training & career
development
 Decentralization
 Management of health institution
wastes
 Urban health promotion
 Participation of private sector in Health
 Ayurved & alternative medicine

52. 12th Plan
Three-Year Interim
Plan
(2010/11 - 2012/13)

53. Long-Term Vision
 The long-term vision of the Plan is to
create a prosperous, peaceful and just
Nepal through transforming Nepal
from a least developed country (LDC)
into a developing nation within a two-
decade period.

54. Goal
 The goal of the Plan is to improve
the living standards of all Nepalese
people, reduce poverty to 21 percent,
and achieve MDGs by 2015 through
sustainable economic growth,
generating dignified and gainful
employment opportunities, reducing
economic inequalities, achieving
regional balances, and eliminating
social exclusions.

55. Objective related to Health
Sector
 To increase the utilization of quality
health service by ensuring availability
and accessibility of health services to
the citizens of all class, region and
society.
 To improve public health and
increase living standard of the
people by providing safe and
sustainable drinking water and
sanitation facilities.

56. S.No. Indicators Situation in FY
2009/10
Three Year Plan's
Target
1. Economic growth rate (%) 4.4 5.5
2. Population living below poverty
line (%)
25.4 21
3. Employment growth rate (%) 3.0 3.6
4. Delivery attended by trained
health workers (%)
29 60
5. Contraceptive prevalence rate
(%)
50 56
6. Total fertility rate (women of 15-
49 year age group) (%)
2.9 2.6
7. Maternal mortality ratio (per 100
thousand)
229 170
8. Neo-natal mortality rate (per
1000 live birth)
20 16
9. Infant mortality rate (per 1000
live birth)
41 36
10. Child mortality rate (per 1000
live birth)
50 40

57. Strategy
 Develop physical infrastructures, increase the
capacity of health organizations and their
human resources and manage medicine and
equipment effectively for the strengthening
health service system.
 Provide comprehensive health services
effectively from central to local levels even in
reconstructive, disastrous and emergency
areas.
 Make health services fast, people-oriented,
integrated and decentralized by improving
management process and developing
suitable referral system.

58. contd....
 Encourage PPP for the development of human
resources, expansion of services
 Improve the quality of free basic health services
to deliver to every level of society.
 Make easy access of the services to the people
by integrated development and expansion of
Ayurvedic and other alternative health services.
 Solve the problem of malnutrition
 Provide reliable drinking water and sanitation
services to all by 2017 by gradually increasing
in the quality and service standard of the
drinking water.

59. Problems of health sector
 Lack of human resources and
equipments for qualitative services in
health organizations.
 Centralized System
 Inadequacy of necessary equipments
and medicines, and their unmanaged
supply
 Weak supervision system
 Lack of repair and maintenance of
physical infrastructures

60. contd....
 Lack of basic services and facilities for
the health worker
 Unaffordable health services provided
by the private hospitals to the general
public
 Inability of the poor people to meet
expenses of treatment in serious
diseases

61. 13th Plan
Three Year Interim Plan
(2013-2016)

62. Background
 The third interim plan plan is an
overarching national development
plan set by the National Planning
Commission (NPC).
 It has a long-term a vision of
graduating Nepal from Least
Developed Country (LDC) category to
a developing country status by 2022
within the next ten years.

63. contd.....
 The main strategy of the plan is improving
the living standard of the people with a goal
of reducing the number of people under the
poverty line to 18 per cent from the existing
24 per cent.
 Nutrition is incorporated twice under the
headings of sectoral development policies -
'food security and nutrition' under
'agriculture, irrigation, land reforms and
forests' plus 'health and nutrition' under
'social development.'

64. Strategies
Improve access to and the quality of free
and basic health services.
 Include preventive, curative, promotional
and rehabilitative health services among
primary health services.
 Expand treatment services for
communicable and non-communicable
diseases.
 Improve the nutritional status of vulnerable
citizens by implementing multi-sectoral
nutrition programmes. 64

65. 15th Five Year
Development Plan
(2019/20-2023/24)

66. Background
 As per the constitution’s sole and
shared right, the responsibility of
health has been given to federal,
provincial and local level government
with the activities including health
policy, guideline development,
quality assurance, monitoring,
conventional medicine, control of
communicable diseases placed in
the jurisdiction of the federal
government.

67. contd...
 Vision
 Healthy, productive, responsible and
happy citizens
 Goal
 To ensure access to quality health
services at the population level by
strengthening and expanding health
system at all levels.

68. Objectives
 Develop and expand all types of health
services equitably in central, province and
local level.
 Enhance the government’s responsibility and
effective regulation for ensuring accessible
and quality health services; transform health
sector from pro-profit to service sector.
 Increase access to and utilization of health
services through multi-sectoral coordination
and collaboration; make service providers
and service users more responsible and
promote healthy lifestyle.

69. Strategies
1. Ensuring access to quality basic and
specialized health services
2. Develop and expand Ayurvedic, natural
medicine and other complementary
medicines in a planned way.
3. Address health needs of population of
all age groups based on life cycle
approach with more focus on maternal
and child health, adolescent health and
family management services.

70. contd...
4. Develop and expand health facilities
based on population distribution and
geography; and build technically sound
and social responsible health workforce
5. Increase government financing in
health and build sustainable health
financing system.
6. Management and regulation of
cooperation and collaboration between
public-private and non-government
sector.

71. cont...d
7. Regulation of production, import,
storage, distribution and utilization of
medical equipments, drugs and
supplies.
8. Implement integrated measures for
control of communicable and non-
communicable diseases as well as for
disaster preparedness and response.
9. Increase use of evidence based
decision making by strengthening

72. contd...
10. Expand working area of Nepal health
Research Council to province level.
11. Develop measures to prevent and
manage the public health threats of
imported cases.
12. Effective implementation of multi-
sectoral nutrition plan through
coordination and collaboration.
13. Incorporate health in all policies
through multi-sectoral coordination.