The document provides an overview of the history and development of primary health care in Nepal. Some key points: - Nepal has focused on primary health care since signing the Alma Ata Declaration in 1978, establishing programs like FCHVs and integrating vertical health programs. - The constitution now guarantees every citizen the right to free basic health services. Responsibilities are divided between the federal, provincial, and local governments. - Currently, Nepal faces challenges in ensuring universal access to quality health care, adequate health financing and insurance coverage, and addressing health issues in rural areas. But initiatives continue to strengthen the primary health care system.

1. Primary Health Care in
Nepal
Umesh Chandra Ghimire
Roll Number 207
SPH & CM, BPKIHS

2. • As a signatory of Alma Ata declaration of 1978, Government of
Nepal (GoN) continued adherence to the Primary Health Care
(PHC) approaches for the development of quality health care
services both in rural and urban areas.
• Major principles of this declaration are:
• a. Universal Accessibility
• b. Community Participation.
• c. Inter-sectoral coordination
• d. Appropriate technology.
2

3. Emergence of district health system in
Nepal
• In Nepal, Primary health services started since 1933 starting with
establishment of Department of Health Services (DoHS).
• Government hospitals and Ayurvedic hospitals were set up gradually.
During the 50s,
• First Five Year Development Plan (1956-61) was developed and, as
a consequence, Malaria Eradication Program came in existence in
1958 however later in 1978 program was modified for malaria
elimination program.
• More vertical projects were implemented in1960s, which are
FP/MCH, Small pox Eradication and the Central Health Laboratory.
• With more emphasis on curative service during the Second Plan
period (1962-65) emphasis was placed in preventive and curative
medicine. 3

4. • In 1971 vertical programs were integrated to provide services
under one door policy, in one district followed by full integration
of all vertically run health programs in 6 more districts.
• Integrated Community Health Service Development Project
established by the Ministry of Health (MoH) was made
responsible to integrate all vertical health programs and ran
under one umbrella as District Health Office.
4

5. Human resource and community
participation
• The Fourth Plan (1970-75) focused more on preventive and human
resource development and preventive cure got priority.
• Institute of Medicine (IoM) was established under Tribhuvan
University to train mid-level health service providers
• During 5th Plan (1995-1980) Alma Ata declaration was made and
Nepal signed in it.
• Nepal commited itself to provide basic health care services
(preventive, promotive, curative and rehabilitative health care
services using Primary Health Care approach) with gradual
integration of vertically rum programs with slogan of health for all by 5

6. • For community participation in 1988 Nepal launched FCHV
program efforts were targeted to increase community
participation and selected FCHV were trained and enabled to
provide health care services
• Female community health volunteers were the excellent
example of community workforce with success stories of
Vitamin A, polio and immunization, anti Helminthes drug
distribution, also managing some cases of ARI, distribution of
ORS .
• This was another example of community participation as they
were selected from the local area itself
6

7. • Nepal has other health workers called as Village Health Worker
(VHW), who was responsible for immunization, and now they
are replaced by AHW
• Maternal and Child Health Worker (MCHW) responsible for
MCH services, who are selected from their own locality now
they are trained to become Auxiliary Midwifes and new
recruitment is done from ANM
7

8. Beginning of strategic thinking
• The First Long Term Health Plan (1975-90) was developed with an
objective to ensure consistent and proper functioning of the health
services
• Accordingly, the Fifth Plan (1975-80) fully integrated vertical
programs into a health infrastructure capable of providing effective
services to the people
• Emphasis was put on regulating population growth through
promotion of family planning, and expansion of maternal and child
health services
• The Sixth Plan period broke health sector isolation emphasizing
inter-sectoral coordination with food supply, safe drinking water etc. 8

9. • The Seventh Plan (1985-90) witnessed an organizational
integration.
• The Department of Health Services was dissolved and the
Regional Health Services Directorate in five development
regions was created in the spirit of decentralization
• Ministry of Health created two new departments for Department
of Ayurved and Department of Drug Administration.
9

10. First National Health Policy 1991
• In 1991, the National Health Policy was implemented with objective
of upgrading the health standards of the majority of the population by
extending the PHC services up to the village level.
• The policy addressed the issue of preventive, promotive, curative
and basic primary health services
• In this regard PHCC, HP, SHP and Out-Reach Clinics were
established. The policy also aims to provide opportunity to the rural
people to enable them to obtain the benefits of modern medical
facilities by making these accessible to them
• It has also set up one health facility (at least a Sub Health Post) in
every village development committee and a Primary Health Care 10

11. Second Long term health plan 1997-2017
• The Ministry of Health of His Majesty's Government of Nepal
developed a 20-year Second Long-Term Health Plan (SLTHP)
for FY 2054-74 (1997-2017).
• The aim of the SLTHP is to guide health sector development in
the improvement of the health of the population, particularly
those whose health needs are not often met
11

12. The aims of the SLTHP
• To provide a guiding framework to build successive periodic
and annual health plans that improve the health status of the
population;
• To develop appropriate strategies, programmes, and action
plans that reflect national health priorities that are affordable
and consistent with available resources;
• To establish co-ordination among public, private and NGO
sectors and development partner
12

13. Millenium Development Goals
• Nepal also signed MDG in September 2000 which is an
international time-bound commitment to reduce poverty and
advance other social development targets by 2015
• Nepal has committed to work on all 8 goals of MDG and has set
up targets indicators for each goals to achieve by 2015
• However due to some constrains country failed to achieve all
targets of MDG
13

14. Primary Health Care Revitalization
• Nepal Established Primary Health Care Revitalization
Division in 2009 under Department of Health Services
• The division was mantle to revitalize PHC in Nepal by
addressing emerging health challenges in other divisions
and different supporting actors
• The division was to make inroads stipulated
• The division is also expected to make inroads into
translating the constitutionally stipulated fundamental roghts
af basic free health care into practice addressing the
disparities in health services
14

15. The PHCRD was established to address shift of PHC
movement globally
Early Attempts to Implement PHC Current Concerns of PHC
Extended access to a basic package of health
interventions and essential drugs for the rural poor
Transformation and regulation of existing health
systems, aiming for universal access and social
health protection
Concentration on mother and child health Dealing with the health of everyone in the
community
Focus on a small number of selected diseases,
primarily infectious and acute
A comprehensive response to people’s expectations
and needs, spanning the range of risks and illnesses
Improvement of hygiene, water, sanitation and
health education at village level
Promotion of healthier lifestyles and mitigation of
the health effects of social and environmental
hazards
Simple technology for volunteer, nonprofessional
community health workers
Teams of health workers facilitating access to and
appropriate use of technology and medicines
15

16. Early Attempts to Implement PHC Current Concerns of PHC
Participation as the mobilization of local
resources and health-centre management
through local health committees
Institutionalized participation of civil society in
policy dialogue and accountability mechanisms
Government-funded and delivered services with
a centralized top-down management
Pluralistic health systems operating in a
globalized context
Management of growing scarcity and downsizing Guiding the growth of resources for health
towards universal coverage
Bilateral aid and technical assistance Global solidarity and joint learning
Primary care as the antithesis of the hospital Primary care as coordinator of a comprehensive
response at all levels.
PHC is cheap and requires only a modest
investment.
PHC is not cheap: it requires considerable
investment, but it provides better value for
money than its alternatives.
16

17. Initiation of PHCRD working modality in
Nepal
• In 5th April 2010 there was a high level workshop finalized the
working modality of PHCRD in Dhulikhel.
• The participants of workshop mainly focused in following areas and
modality was finalized
1. Social and Health Protection
2. Environmental Health
3. Municipal Health
4. Disability and Community Rehabilitation
5. Extending PHC Services
17

18. History of Public Health Programs in
Nepal
• Malaria Eradication Program 1958 – First Public Health Program
of Nepal
• However this program was converted to malaria elimination program in
2078
• Now we are at end game strategy for malaria elimination in country
• Family Planning Program - 1959
• Initiated with vasectomy with the objective to control population
• FPAN established to takeover the program in same year
18

19. • Safe Motherhood Program- 1959
• Started with establishment of district health system
• The Safe motherhood policy introduced in 1998
• FCHV Program 1988
• Initiated in 1988 as a part of principle for community participation of
ALM ATA declaration
• Now more than 52000 FCHV are working countrywide
• PHC/ORC Program 1994
• Initiated in 2051 BS to increase accessibility of unreached population
• The health service center in VDC (current ward) provides health service
once a month in fixed place
19

20. • Safe Abortion Services – 2002
• Abortion was legalized in Nepal since September 2002 with the
implementation of Safe abortion policy
• There is safe abortion law in existence in the country
• Adolescent Sexual and Reproductive Health Service
• With the endorsement of National Adolescent Health and Development
(NAHD) Strategy in 2000. An implementation guideline on Adolescent
Sexual and Reproductive Health (ASRH) was developed in 2007
• Now ASRH program is implemented countrywide in all health facilities.
20

21. • CBIMNCI Program (History)
• Control of Diarrhoeal Disease Program 1983
• Control of ARI program 1987
• CB-ARI Program – 1995
• CB- ARI and diarrhoea program – 1997
• CB-IMCI – 1997
• CB-NCP 2007
• CBIMNCI – 2014
• National Immunization Program – 2034 BS
• Started with 4 antigens BCG and DPT
• Now GoN is providing 14 antigens as vaccine against 13 disease
21

22. • National Nutrition Program
• Started with unicef GOBI-FFF strategy of child health
• Currently we have nutrition programs have 15 programs to address
different issues of nutrition
• Kala-azar control Program
• The world health assembly in 2005 formalized the memorandum of
understanding for kala azar elimination
• Strategy was defined in three phases
• Preparatory Phase 2005- 2008
• Attack Phase 2008-2015
• Consolidation Phase 2015 onwards
22

23. • Filariasis Control Program
• LF mapping in 2001 and 2005 re-mapping in 2012 revealed the
prevalence od 13% of lymphatic filariasis in country
• To address this issue Nepal Satarted MDA program in targeted districts
with prevalence of > 1%
• Still 14 districts are failed to eliminate filariasis despite of continuous
MDA program
• Dengue Control Program
• National Vector borne disease control program is umbrella program for
control of Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya,
Kala-azar and Lymphatic Filariasis.
• The earliest case of dengue was detedctd in 2005 in a tourist
• Sporadic outbreaks observed in 2006 2009 and 2010 initially most
cases were observed with the travel history of India
• Since then every year sporadic outbreaks are onserved
23

24. • Zoonotic Disease Control Program
• This program manages the dog bite and snake bite
• Leprosy Control Program
• Initiated in 1966 with dapsone monotherapy
• Since 2010 Nepal is declared elimination of leprosy from country
• National Tuberculosis Control Program
• Launched in Nepal in 1962
• The national TB Prevalence Survey 2018-19 estimated there are 17000
TB related death each year in the country
24

25. • HIV/AIDS and STC Control Program
• The program is managed by NCASC under DOHS
• First case of HIV in Nepal 1988
• At District level there ART centers to enroll HIV infected persons for
staring and continuation of ART
• Epidemiologic and Outbreak Surveillance Program
• The program in managed by EDCD
• There are sentinel sites all over country to report any kinds of outbreak
through EWARS system
• Disaster Management Program
• The program in managed by EDCD
• The overall objective of this programme is to enhance the capacities of
health sector in emergency preparedness and response by focusing on
disaster preparedness, disaster risk reduction and response
25

26. • Non Communicable Disease and Mental Health
• PEN Package
• Community Mental Health Program
26

27. Current Status of Primary Health Care
Service in Nepal
Key Facts of Primay Health Care System in Nepal
• The healthcare system in Nepal is a combination of public and
private healthcare services, with the majority relying on the
public system.
• Nepal faces numerous public health challenges, including low
health expenditure, limited healthcare access, poor healthcare
quality, insufficient health insurance coverage, and inadequate
healthcare infrastructure and services.
• Only 60% of the population in Nepal has access to basic
healthcare services, and rural areas have limited access to
healthcare services and poor quality of care due to inadequate
infrastructure and shortage of healthcare professionals.
27

28. • Healthcare financing and health insurance in Nepal is a
significant challenge, with the country spending only 4.3% of its
GDP on healthcare and limited health insurance coverage for
the population.
• Rural health, maternal health, child health, and infectious
diseases are major public health challenges in Nepal.
• Non-communicable diseases are a growing public health issue
in Nepal, with a significant impact on the population.
• The government of Nepal and non-government organizations
are taking various initiatives to address the public health
challenges in the country, including the launch of the "Healthy
Nepal" campaign, investment in healthcare infrastructure and
services, and improving access to care.
• Continued effort and investment are needed to improve the
healthcare system in Nepal and meet the health needs of all 28

29. Health in Constitution
• Country have transformed itself in federalism so the
transformation of health service.
• Constitution of Nepal 2072 in article 35 have mentioned
about righrs relating to health
• Every citizen shall have the right to free basic health
services from the State, and no one shall be deprived of
emergency health services.
• Every person shall have the right to get information about
his or her medical treatment.
• Every citizen shall have equal access to health services.
• Every citizen shall have the right of access to clean
drinking water and sanitation.
29

30. • Nepal’s Constitution have defined the responsibilities of
there tier government for provision health care services
• Federal Government have the responsibility of
preparing Health policies, health services, health
standards, quality and monitoring, national or
specialized service providing hospitals, traditional
treatment services and communicable disease control
• Provincial Government have responsibility to run
hospitals 50 beds and above
• Vast majority of primary health services in responsibility
of local government
30

31. Tertiary Level
Hospitals/
Specialized
Hospitals
Secondary Level Hospitals
Primary Level Hospitals
Health Post / BHSC/ UHC
Current Structure of Health Service
Centers in Federalism
Federal Government
Province Government
Local Government
31

32. • In Nepal various health workforce is providing primary
health care services includes doctor’s paramedics nurses
and FCHVs
• The health system operates in four tiers with the first and
basic tier composed of a massive network of the FCHVs.
• Second tier is primary health care centers where network of
PHC includes BHSc Health Posts ORC
• Third tier is Primary Hospitals at municipal level and District
Hospitals
• Fourth Secondary A and secondary B level hospitals and
Current Primary Health Care System in
Nepal
32

33. Current Primary Health Care System in
Nepal
• Federal Government
• Federal government mainly involves in policy formulation and strategy
preparation and setting country targets and launching new programs
• Federal government also have the responsibility of providing
specialized services
• Central Hospitals more than 100 bed, specialized hospitals and
academic institution cum hospitals are supervised by federal
government
• Health Workforce Planning
• Provincial Government
• Provincial government have responsibility to provide health services
through 50 bed district hospitals and upto 200 bed provincial hospitals
• Provincial Government have another responsibility of supervise and
support local government for provision of basic health services 33

34. • Local Government
• Operation of Major Public Health Programs and
provision of basic primary health services are
responsibility of local government
• Local Government have 5-15 beded primary hospitals
• Health Posts and Basic Health Service Centers
• PHC/ORC
• Immunization Clinics
• However at service provision level federal and provincial
government are also playing major in primary health
services 34

35. Challenges in Primary health care in
Nepal
• Nepal has made significant progress on health indicators over
the past several decades despite of this the challenges exist in
the country
• Country has recently adopted federalism and primary health
care system has been disturbed,
• Local level government are given responsibility of primary
health care but it has been least priority of LLGs
35

36. • Shortage of Health workforce in government system has been
challenge since long. There are more than 30000 sanctioned
post of health worker but only 19000 have been fulfilled
• Disparities in primary health in rural and urban population is
another challenge to address
• For instance, only 61.8% of the households have access to
health services within 30 min, with the gap between urban
(85.9%) and rural (59%)
• Political reformation to federal governance, primary health care
services have been further muddled due to a lack of clarity on
devolution, responsibility distribution, and coordination 36

37. • Poor management are reflected in various epidemic
management, for instance recent measles outbreak in different
districts and current dengue outbreak has been ineffective and
random
• Lack of coordination among three tier government is another
issue in primary health care which has been
• Current dispute in health workers salary and posting is also
another challenge now and in future
37

38. 38

39. • Globalization and health have integral impact and
warrants a need to transform the health system which
can be achieved through re-strengthening primary
health care
• Immediate implementation of policies for clarity in
distribution of responsibility, and accountability to all
governance structure (federal, province and local) is
critical.
• Strengthening of social health security system with
improved quality of Universal Health Coverage (UHC)
through multi-sectoral collaboration and public-private
partnership needs prioritization.
• Improvement of quality of existing primary health care
services based on community health worker
39

40. Models of Health Care in Nepal
• Beverage Model –Basic Primary Health Care Services
• Bishmark Model – Social Security Insurance
• Health Insurance Model – Health Insurance Scheme
• Out of Pocket Expenditure Model – Private and other
secondary and tertiary health are Services
40

41. Basic Essential Health Care Service in Nepal
• Basic health service" means promotional, retributive, diagnostic,
remedial and rehabilitative service easily and freely available
from the state for the sake of fulfillment of health need of
citizens generally, pursuant to sub-section (4) of Section 3 –
Nepal Public Health Service Act
41

42. • Every citizen shall have the right to obtain free basic health services under
the following headings, as prescribed:
• (a) Vaccination service,
• (b) Motherhood, infant and pediatric health service such as integrated
infant and pediatric disease management, nutrition service, pregnancy,
labor and child birth service, family planning, abortion and reproductive
health,
• (c) Service relating to communicable disease,
• (d) Service relating to non-communicable disease and physical disability,
• (e) Service relating to mental disease,
• (f) Service relating to elderly citizen's health,
• (g) Service of general emergency condition,
• (h) Health promotion service,
• (i) Ayurveda and other accredited alternative health service,
• (j) Other services prescribed by the Government of Nepal by a notification
in the Nepal Gazette. 42

43. • Basic Health Services are free of cost for every citizen
• Beside listed basic health services in public health service act
2075 three tier government can provides additional services for
free of cost
• To fulfil the basic health services of Nepalese citizen federal
government provides budget to provincial and local
governments
• The services that are not covered under basic health services
are addressed through health insurance scheme
43

44. Basic Health Services and universal
Health Coverage
44

45. Basic Health Services and Sustainable
Development Goals
• Sustainable Development goal is the worldwide agreement of
countries that imagines to eliminate all kinds of poverty,
equitable development of earth and mankind that creates a
world with justice and safety
• SDG have 17 goals of which 3rd goal is good health and well
being. Under this goal the target 3.8 has ensured about getting
health services without economic hardship to increase universal
health coverage
45

46. Rational for BHSP
• Constitution of Nepal has ensured basic health service as right
of every citizen
• To ensure the resources to provide basic health services by
government
• To categorize the service centers according to their capacity so
it helps government to plan resources accordingly
• To provide information and health service to every citizen
• To decrease the economic hardship of every citizen
46

47. Government investment modality in
Primary Health Services
Primary Health Care Services
Free Health Service
Health Insurance
Social Security
47

48. The services under BHS package
1. Immunization Service
2. Maternal New Born and Child Health
1. Management of Neonatal and Childhood Illness
2. Nutrition Services
3. Pregnancy Delivery and Post Natal Services
4. Family Planning, Safe Abortion, ASRH Services and prevention and
treatment of cancer in women
5. Referal Service
3. Curative Services
1. Communicable Diseases
2. Non Communicable Diseases
3. Mental Health Service
4. Geriatrics Service
5. Emergency Services
6. Referal Service
4. Health Promotion Activities
5. Ayurveda and other traditional Services
48

49. Nepal Key Achievement in Primary
Health Care
• Eradication of Small Pox 1978
49