History of Development of Public health in Nepal and different approaches

Historical Development of Public
Health Services and Health Care in
Nepal and Different Approaches of
Health care delivery system
Presenter:
Jagat Prasad Upadhyay
Muskan Pudasainee
MPH (PHSM) 3rd Semester
School of Health and Allied Sciences
(SHAS)
Pokhara University

Presentation Outline
• Historical Development of Public Health Services and Health Care in Nepal
• Different Approaches of Health care delivery system
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Public health services
• Public health services refer to the collective efforts and initiatives undertaken by government
and non-governmental organizations to protect, promote, and improve the health and well-
being of the general population.
• These services aim to prevent disease, prolong life, and promote overall health through
various strategies, interventions, and programs. Public health services encompass a wide range
of activities and functions that address both individual and community health needs.
• Some key components of public health services include disease prevention and control, health
education and promotion, environmental health, health policy and planning, emergency
preparedness and response and access to healthcare.
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Type of Health Care Services in Nepal
• The health care services of Nepal categorized as follows
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Health care services in Nepal
Modern Healthcare system
Traditional health care system
Private sector;
Non-profit,
Profit.
Public sector
MoHP
With formal system:
Ayurveda, Homeopathy,
Unani, Naturopathy.
Without formal
system:
Dhami, Jhankri,
Gurau, Jharphuke,
Gubaju, Tantrik, Lama

History of Public health development in Nepal
Historians have divided Nepalese history into;
• Ancient era (first century to 879 AD),
• Medieval era (879 AD to till control of the Kathmandu by King Prithvi Narayan
Shah–1768 AD) and
• Modern era Nepal from 1769 AD onwards.(but the modern era for health is
considered from 1889 AD)
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History of Public Health Development in Nepal
During Ancient Era
• During Lichchhavi period in the reign of Anshu Verma (605-620 AD), one of the
historical document has mentioned about Aarogyashala.
• There was the practice of separation of baby from mother’s uterus in case of
maternal death during the time of Narendra Dev.
• Lastly, cutting umbilical cord immediately after the baby is born and not to wait
till the placenta is expelled (Anshu Verma).
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During Medieval Era
• In the Malla period the King of the Kantipur, Pratap Malla (1641-1674 AD)
established a traditional medicine (Ayurvedic) dispensary for common people at
Royal Palace complex in Hanumandhoka, Kathmandu.
• It is widely believed that the current Singh Darbar Baidyakhana is the continuity
of the dispensary established earlier by the King Pratap Malla.
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Before Prithvi Narayan Shah
• Rana period, which lasted for 104 years; is the important era of health and hospital
development in Nepal.
• In this period, several hospitals and dispensaries were established in both the modern medicine
and traditional medicine as a state initiative.
• Khokana Leprosy Asylum was the first health institution established by the state in 1857 AD
to isolate the leprosy patients.
Bir Shamsher (1885-1901 AD): Introduction of Hospital Services
• Bir hospital: 1947 BS /1889 AD.
• Cholera Hospital in Teku.
• Leprosy Hospital in Tripureshwar.
• Prithvi-Bir group of hospitals in Birganj, Jaleshwar, Hanuman Nagar, Taulihawa and
Nepalganj.
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Chandra Shamsher (1902-1929 AD): National Network of Hospitals and Dispensaries
• Chandra Lok Hospital in Bhaktapur in 1903 AD.
• Prithvi-Chandra Hospitals in Palpa, Palhi (Parasi), Doti, and Ilam.
• Tribhuvan-Chandra Hospitals established in Dhankuta, Bhadrapur, Sarlahi, and Rangeli.
• In 1925 AD Tri-Chandra Military Hospital in Kathmandu.
• Nar Devi Ayurvedic Hospital in 1918 AD.
Prime Minister Bhim Shamsher 1929-1932 AD
• He established Tri-Bhim Hospitals in Bhairahawa, Butwal and Bahadurganj.
• Ramghat dispensary at Pashupati was inaugurated in 1929 AD.
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Prime Minister Juddha Shamsher 1932-1945 AD
• Tri-Juddha group of hospitals in 1931 AD in Dharan and in 1940 in Bhimphedi,
Bardiya, and Kailali.
• Tokha Tuberculosis Sanatorium came in operation in 1935 AD.
• Leprosy department and treatment center was established at Pachali in 1937 AD.
Prime Minister Padam Shamsher (1945-1948 AD) and Mohan Shamsher (1948 –
1951 AD)
• One health center was established in Sankhu in 1949.
• Homeopathic dispensary was opened and a chest clinic (1951) was started in Bir
Hospital.
• School health program initiated during this period.
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After Democracy (1951 onward)
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First Five-Year Plan (1956-1961)
• More emphasis on curative health services
• Nepal malaria eradication organization was in full swing
• MoH was established in 1956
• First intake of girls in Nursing Training School at the Bir Hospital in 1956
• Health Assistant Training School established in 1955
• Training of Assistant Nurse Midwives for services in rural areas
• Upgrading and modernization of existing hospitals
• Construction of the first maternity hospital (Prashuti Griha) in 1959
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Second Three-Year Plan (1982-1965)
• Emphasis on curative aspects
• More stress was laid on the preventive aspects of health, small pox survey started
in 1962, leprosy control in 1963 and TB control in 1965
• Establishment of Royal Drugs Research Lab in 1964
• Train for Human Resource for Manpower Development
• National Health Survey was done in 1965 and shown that 36 Health Posts
established till date was very worthwhile
• Running of vertical projects: malaria eradication, TB/Leprosy control project,
FP/MCH projects.
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Third Five-Year Plan (1965-1970)
• It was accepted that more focus on prevention was very important
• Stress on establishment of vertical projects i.e. Leprosy Eradication Project 1965,
Small Pox Eradication Project 1967, FP/MCH project 1968
• Starting of the Central Health Laboratory in 1967
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Fourth Five-Year Plan (1970-1975)
• More emphasis was laid on preventive aspects of health care
• Integrated basic health services was started in 1971
• Community Health and Integrated Division was set up to reduce duplication and
to make health program cost effective
• IoM trained Health Workers for the basic level and middle level
• DoHS trained VHWs and Panchayat Based Health Workers (PBHW)
• Contemplation of a Long Term Health Plan of 15 years
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Fifth Plan Period (1975-1980)
• Integration of vertical programs into health infrastructure
• IoM increased its effort on HRH production to meet the increasing demand
• Nepal had signed the Alma-Ata Declaration in 1978 and adopted PHC for achieving HFA
2000
• Small pox eradication in 13 April 1977 AD from Nepal.
Sixth Plan Period (1980-1985)
• It real intention was Nepalese should not live by health alone
• It stressed on increasing food supply and provision of clear drinking water
• Up to this time, there were still 18 districts without hospital. By the end of this period, 26
Health Centers were to be upgraded to hospitals or downgraded to health post or even phased
out as per the Long Term Health Plan
• Idea of COMBINA was mooted. COMBINA corresponded to a Nepalese version of Basic
Minimum Health Needs (BMHN)
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Seventh Plan Period (1985-1990)
• Organizational integration had been completed more or less in 1987 at the peripheral level and
by 1990 at the central level
• A national health information system was being developed by HMG with WHO collaboration
and has been functioning since 1988
• Emphasis was on Basic Minimum Health Needs
• In 1986, the DoHS was dissolved and there was the formation of 10 Divisions and 2
Departments (Ayurveda and Drug Administration)
• By this time, as per the decentralization act 1982, the five development regions had Regional
Directorate of Health Services functioning
• Guidelines had been formulated for the establishment of HPS:
• Walking distance
• Settlement and Population concentration
• Accessibility
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National Health Policy of Nepal 1991
• The elected Nepali Congress government brought the National Health Policy 1991
• The primary objectives of the Health Policy are to upgrade the health standards of
the majority of the rural population by extending Basic Primary Health Services
up to the village level and to provide the opportunity to the rural people to enable
them to obtain the benefits of modern medical facilities by making the facilities
accessible to them.
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Eight Plan Period (1992-1997)
• Budgetary allocation for the health sector in 1994 was 5% of national budget
• Organogram of DoHS was developed in 1993
• Integration of the delivery of health services and hospital services by combining
DPHO and medical services under DHO
• Establishment of Nepal Health Research Council (NHRC) in 1995
• Special committee was set up to look at Post Graduate Medical Education in this
country
• The organogram of 1993 was revised in 1995
• MoH committed to give more stress to the Ayurvedic system of medicine
• Nepal Public Health Association was formally established since 1990
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Ninth Plan Period (1997-2002)
• Enhancing the access of integrated health services
• Mobilization of private and non-government sectors,
• Medium-term Strategic Plan
• National reproductive health and safe motherhood plan and polices have been
prepared.
• Reproductive health clinical protocol was prepared.
• National financial policy is formulated and implemented.
• List of essential medicines (for sub health post to district hospitals) was prepared
• The Human Organ Transplantation Act, 1998 and a draft of Antibiotic Policy,
1997 have been prepared.
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Tenth Five-year plan (2002-2007)
• Additional contribution to health services is also being made by the private and non-
government sectors.
• Management of 1,433 health agencies (sub-health posts, health posts and primary health
care centers) of 28 districts have been handed over to the local bodies.
• National capacity to produce health human resources at all levels has been developed.
• The financial and technical contribution of the donor community has played a positive role
in the development of the health sector.
• In the field of child nutrition, significant results have been achieved. Between 2001 and
2007, the percentage of stunting children decreased from 57 percent to 49 percent, and that
of wasting (weight to age) dropped from 43 percent to 39 percent, as did the infant mortality
rate.
• Average life expectancy has increased. Despite this positive picture on the whole, health
conditions of the people of remote districts, those living below the poverty line and
marginalized groups, are less positive.
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After Tenth Five-year plan (2002-2007)
• After tenth five year plan different plan/policies were made that aims to prevent the disease,
promote the health and prolonging the life of the people
• Development of Nepal Health Sector Program (NHSP 2004-2009) guided by National Health
Policy 1991, Second Long term Health Plan 1997-2017 & Health Sector Strategy
• Extension of NHSP-I to Nepal Health Sector Program II 2010-2015, with greater emphasis on
partnership, accessibility, equity, inclusion, local governance and decentralized service delivery,
• Development of Nepal Health Sector Strategy (2015-2020) and NHSS-Implementation Plan 2016-
2021 based on expanded policy and monitoring framework of National Planning Commission
(NPC), focuses on multi-sectoral collaboration.
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Policy, regulatory and strategic documents
developed during that Period
• Immunization Act 2016
• National Strategy on Reaching the
Unreached, 2015-2030
• National e-Health Strategy 2017
• Health Insurance Act 2017
• Disability Management (Prevention,
Treatment and Rehabilitation) Policy 2017
• The Right to Safe Motherhood and
Reproductive Health Act 2018
• Disaster Risk Reduction National Strategic
Plan of Action, 2018
• Social and Behavior Change Communication
Strategy 2018
• Public Health Service Act 2018
• National Health Policy 2019
• National SMNH Roadmap 2015-2030
• Public Health Service Regulation 2020
• National Adolescent Health and
Development Strategy 2020
• National HRH Strategy 2020/21
• National Health Financing Strategy
• UHC; Strategic Framework (Draft)
• National Health Care Quality Assurance
Framework 2022
• IHMIS Roadmap 2022
• Nepal Health Sector Strategy 2022-2030.
MoHP Nepal
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Fifteenth Five-Year Plan (2019/20-2023/24)
• The plan aims to:
1. To achieve balanced development and expansion of all sorts of health services at the
federal, provincial, and local levels.
2. To transform the profit-oriented health sector gradually into a service-oriented sector by
increasing government responsibilities and effective regulation for easily accessible and
quality health service.
3. To promote a healthy lifestyle by making health service providers and service seekers more
responsible for increasing the citizens' access to health service through multi-sectoral
coordination and partnership.
The FYP also includes a number of other health-related initiatives, such as:
• Strengthen the health workforce
• Reduce maternal and child mortality
• Improve access to quality healthcare services
• Promote healthy lifestyles
• Strengthening the public health system.
• Addressing the health needs of women, children, and adolescents.
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Nepal is signatory to difference conference, charter, declaration related to health
• Health promotion related conference (Ottawa charter to Astana declaration)
• SDG
• NCD, Nutrition, Environmental health
• Global/international Health
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Different Approaches of
Health Care Delivery System
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Approaches in Public Health
• Epidemiological Approach: It plays a crucial role in understanding patterns of
disease occurrence, identifying risk factors, and informing public health interventions.
The epidemiological approach in public health involves the following key elements,
Surveillance, Study design and data collection, Data analysis and interpretation, and
Identification of risk factors.
• Biostatistics Approach: Biostatistics plays a crucial role in public health research,
program evaluation, and evidence-based decision-making. The key aspects of the
biostatistics approach in public health are Study design, Data collection and
management, Statistical analysis, Data interpretation, Data modeling and predictions,
Meta-analysis, and systematic review.
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Approaches in Public Health
• Behavioral Science Approach: The behavioral science approach in public health
focuses on understanding and influencing individual and collective behaviors to
promote health and prevent disease. It draws upon principles and theories from
psychology, sociology, anthropology, and other behavioral sciences to inform
public health interventions.
• Health Promotion and Education Approach: The health promotion and
education approach in public health focuses on empowering individuals and
communities to take control of their health and make informed decisions to
promote well-being. It involves providing education, raising awareness, and
implementing interventions that encourage healthy behaviors and create
supportive environments for health.
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Approaches to Health Care Delivery System
• A healthcare delivery system refers to the network of organizations,
institutions, resources, and individuals involved in providing healthcare
services to individuals and communities.
• It encompasses all the components and processes involved in delivering
medical care, preventive services, and promoting overall health.
• A healthcare delivery system typically includes several elements:
Healthcare providers, Healthcare facilities, Health insurance, Public
Health organizations, Health information system etc.
• These elements work together to provide medical care, preventive
services, health promotion, and disease management to individuals and
communities.
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Approaches to Health Care Delivery System
• The goal of a healthcare delivery system is to improve health
outcomes, enhance access to care, ensure quality and safety, and
address the health needs of the population.
• The specific structure and functioning of the system can vary between
countries and regions based on factors such as governance, cultural
norms, funding mechanisms, and health policies.
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Different Approaches of Health care
delivery system
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1) Public:
The public approach to healthcare delivery refers to a system in which the government
plays a significant role in ensuring the provision of healthcare services to its citizens.
This approach is characterized by government funding, regulation, and management of
healthcare facilities and services.
Some key features and examples of public healthcare delivery systems are:
A) Healthcare delivery systems
B) Universal Healthcare Coverage
C) Government Funding
D) Publicly Owned Facilities
E) Regulation and Quality Control
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Public Approach in Nepal
• Health care system of Nepal formally began from the Alma Ata declaration which
focuses on primary healthcare and basic health service free of cost.
• Nepal's Health system is managed by the Ministry of Health (MOH). MoH is
responsible for making necessary arrangements and formulation of policies for the
effective delivery of services like Curative services, Disease prevention, Health
promotion, and the Primary health care system.
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Healthcare System of Nepal – A Quick Overview
11/11/2023 34

2) Private
• The private approach to healthcare delivery refers to a system in which healthcare
services are primarily provided by private entities, such as privately owned
hospitals, clinics, and healthcare professionals.
• In this model, the government's role is generally limited to regulation and
oversight.
• Private healthcare delivery systems offer benefits such as shorter wait times for
procedures, access to advanced treatments, and a wider range of healthcare
options.
• However, they can also lead to higher costs, inequitable access for those who
cannot afford private insurance, and fragmentation of care.
• Regulation and oversight by the government are essential to ensure patient safety,
maintain quality standards, and address disparities in access to care.
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Key features of private healthcare delivery systems:
• Privately owned facilities
• Fee-for-services model
• Health insurance
• Focus on Efficiency and Profitability
• Specialization and Technology
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Private Approach in Nepal:
• In 1990 there were only 16 private hospitals in Nepal, a number that had soared to 301 in 2014.
The private sector has over two-thirds of the hospital beds in Nepal and 60% of Nepal’s doctors
work in this sector.
• The government plays a regulatory role in overseeing the quality and standards of private
healthcare services to ensure patient safety.
• However, there is a lack of routine monitoring by regulatory bodies and insufficient institutional
structure or resources to monitor the sector and guide it toward achieving government policy.
• Overall, the private healthcare sector in Nepal supplements the public healthcare system and
provides additional options for individuals seeking healthcare services.
11/11/2023 37

3) Public-Private Partnership:
• Public-Private Partnership (PPP) in health refers to collaborative efforts between the
government and private entities to address healthcare challenges and improve the
delivery of healthcare services.
• PPPs bring together the strengths of both sectors to achieve common healthcare
goals.
Here are some key aspects and benefits of public-private partnerships in health:
A) Resource Sharing and Cost efficiency
B) Service Delivery in an effective manner
C) Infrastructure development
D) Innovation and technology
E) Accountability
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Objectives of PPP
• Improving accessible and affordable services at all places
• Improving quality service available
• Monitoring the growth of the private sector and directing its contribution toward
service delivery
• Mobilizing additional response
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The guiding principle of PPP in Health
• Public Interest and Public Health Focus
• Clear Goals and Objectives
• Transparency and Accountability
• Value for Money
• Quality and Safety
• Sustainability
• Community Engagement and Participation
• Knowledge Sharing and Collaboration
• Risk Management
11/11/2023 40

Public-Private Approach in Nepal
Service Contracts
Blood transfusion with NRCS, family planning with FPAN, Safe
abortion with Marie Stopes, Eye service with Netra Jyoti Sangh
Management Contract
Lamjung district hospital, dadheldhura hospital with NGO, Jiri hospital
with local community, Tansen mission hospital, Rukum chaurajahari
hospital, okhaldhunga community hospital.
Build own, Operate and
Transfer
Maternity hospital thapathali by paropakar, phalpu hospital, am pipal
hospital Gorkha, Manipal medical college, Bharatpur medical college,
Lahan hopital, Trisuli hopital, western regional hospital.
11/11/2023 41

Public-Private Approach in Nepal
Joint venture
Nepal eye hospital
Leasing
Pharmacy services in several hospitals
Contracting + pay for performance
Prevention and surgery of uterine prolapsed cases
Contracting via social franchising
Potential model for drug supply management
11/11/2023 42

Social Marketing:
• Social marketing in health is a strategic approach that applies marketing principles
and techniques to promote positive health behaviors, encourage behavior change,
and address public health issues.
• It involves using marketing strategies to influence individuals, communities, and
societies to adopt healthy behaviors and make informed decisions about their
health.
Some key aspects and strategies of social marketing in health:
A) Behavior Change
B) Audience Segmentation
C) Communication and Messaging
D) Marketing Mix (Focusing on 4 Ps: Product, Price, Place, and Promotion)
E) Partnerships and Collaborations
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Community own program:
• A community-owned program refers to a project, initiative, or organization that is
collectively owned and managed by members of a community or a group of
stakeholders.
• In a community-owned program, decision-making power, governance, and
resources are shared among the participants, ensuring that everyone has a voice
and influence over the program's direction.
Some key aspects of a community-owned program
A) An ownership and Governance
B) Participation and Collaboration
C) Resource Sharing
D) Transparency and Accountability
E) Benefits for the Community
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References
• Health Service Management Book
• Periodic Plan of Nepal (first to fifteenth)
• Public Health Approach - Wales Safer Communities
• A Framework for a Systems Approach to Health Care Delivery - Building a Better
Delivery System - NCBI Bookshelf (nih.gov)
• Previous assignments and reference notes from seniors and lecturers
11/11/2023 45

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