Primary Health Care

UNIT 1: PRIMARY HEALTH CARE (PHC)
1.1: Alma – Ata Conference on Primary Health Care

Concept of Primary Health Care
What is Primary Health Care?
PHC is essential health care that is a socially appropriate, universally accessible, scientifically
sound first level care provided by a suitably trained workforce supported by integrated referral
systems and in a way that gives priority to those most in need, maximizes community and
individual self-reliance and participation and involves collaboration with other sectors.
It includes the following:
 Health promotion
 Illness prevention
 Care of the sick
 Advocacy
 Community development
Primary health care (PHC) became a core policy for the World Health Organization with the
AlmaAta Declaration in 1978 and the ‘Health-for-All by the Year 2000’ Program.
Primary Health Care:
The conference defined PHC as "Essential health care made universally accessible to individuals
and families in the community by them and acceptable to them, through their full participation
and at a cost that the community and the country can afford,
Historical background of PHC concept
By the late 1960’s
1. Crisis of the vertical projects.
E.g. Failure of Malaria eradication
Vertical program period (1946-1977)
Selected focused on
 Control of major infectious disease

 Prevention, treatment or eradication of specific targets
Remarkable success
 Eradication of small pox (1977)

 Reduction of polio, measles, tetanus, cholera
Significant failures
 Malaria eradication and malnutrition
PRIMARY HEALTH CARE & INTERNATIONAL HEALTH 1

Limited progress in making basic health care widely available
 Hospital based does not cover the needs of poor's or those in rural areas
2. New studies on community health
 J.Bryant, Health and developing world, 1969 Questioned the hospital-based health care
system
 K.Newell (ed) Health by the people, 1975 Excellence in the community health
 ILLICH Medical nemesis : the expropriation of health, 1976
 McKeown The role of medicine: Dream, mirage or nemesis, 1976. The overall health of
the population bore less relationship to medical advances than to standards of living and
nutrition.
3. New political context (crisis of the cold war)
1974 UN Resolution on the need of a “New International Economic Order” to improve social
conditions in underdeveloped countries
4. Christian movements, NGO’S and alternative experiences
The Luteran Christian medical commission (CMC) emphasized training of village workers.
Red Cross Societies tradition of voluntary work in the community. (Chinese barefoot doctors)

Declaration of Alma-Ata
International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in
the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all
health and development workers, and the world community to protect and promote the health of all the people
of the world, hereby makes the following
Declaration:
I
The Conference strongly reaffirms that health, which is a state of complete physical, mental and
social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human
right and that the attainment of the highest possible level of health is a most important world-
wide social goal whose realization requires the action of many other social and economic sectors
in addition to the health sector.
II
The existing gross inequality in the health status of the people particularly between developed
and developing countries as well as within countries is politically, socially and economically
unacceptable and is, therefore, of common concern to all countries.
III
Economic and social development, based on a New International Economic Order, is of basic
importance to the fullest attainment of health for all and to the reduction of the gap between the
health status of the developing and developed countries. The promotion and protection of the
health of the people is essential to sustained economic and social development and contributes to
a better quality of life and to world peace.
IV
The people have the right and duty to participate individually and collectively in the planning
and implementation of their health care.

V
Governments have a responsibility for the health of their people which can be fulfilled only by
the provision of adequate health and social measures. A main social target of governments,
international organizations and the whole world community in the coming decades should be the
attainment by all peoples of the world by the year 2000 of a level of health that will permit them
to lead a socially and economically productive life. Primary health care is the key to attaining
this target as part of development in the spirit of social justice.
VI
Primary health care is essential health care based on practical, scientifically sound and socially
acceptable methods and technology made universally accessible to individual and families in the
community through their full participation and at a cost that the community and country can
afford to maintain at every stage of their development in the spirit of self-reliance and self-
determination. It forms an integral part both of the country's health system, of which it is the
central function and main focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family and community with the
national health system bringing health care as close as possible to where people live and work,
and constitutes the first element of a continuing health care process.
VII
Primary health care:
1. Reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country and its communities and is based on the application of the
relevant results of social, biomedical and health services research and public health
experience;
2. Addresses the main health problems in the community, providing Promotive, preventive,
curative and rehabilitative services accordingly;
3. Includes at least: education concerning prevailing health problems and the methods of
preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,
including family planning; immunization against the major infectious diseases;
prevention and control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs;
4. involves, in addition to the health sector, all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other sectors; and demands the
coordinated efforts of all those sectors;
5. Requires and promotes maximum community and individual self-reliance and
participation in the planning, organization, operation and control of primary health care,
making fullest use of local, national and other available resources; and to this end
develops through appropriate education the ability of communities to participate;
6. Should be sustained by integrated, functional and mutually supportive referral systems,
leading to the progressive improvement of comprehensive health care for all, and giving
priority to those most in need;

7. relies, at local and referral levels, on health workers, including physicians, nurses,
midwives, auxiliaries and community workers as applicable, as well as traditional
Practitioners as needed, suitably trained socially and technically to work as a health team
and to respond to the expressed health needs of the community.
VIII
All governments should formulate national policies, strategies and plans of action to launch and
sustain primary health care as part of a comprehensive national health system and in
coordination with other sectors. To this end, it will be necessary to exercise political will, to
mobilize the country's resources and to use available external resources rationally.
IX
All countries should cooperate in a spirit of partnership and service to ensure primary health care
for all people since the attainment of health by people in any one country directly concerns and
benefits every other country. In this context the joint WHO/UNICEF report on primary health
care constitutes a solid basis for the further development and operation of primary health care
throughout the world.
X
An acceptable level of health for all the people of the world by the year 2000 can be attained
through a fuller and better use of the world's resources, a considerable part of which is now spent
on armaments and military conflicts. A genuine policy of independence, peace, détente and
disarmament could and should release additional resources that could well be devoted to
peaceful aims and in particular to the acceleration of social and economic development of which
primary health care, as an essential part, should be allotted its proper share.
The International Conference on Primary Health Care calls for urgent and effective national and international
action to develop and implement primary health care throughout the world and particularly in developing
countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It
urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and
bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world
community to support national and international commitment to primary health care and to channel increased
technical and financial support to it, particularly in developing countries. The Conference calls on all the
aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance
with the spirit and content of this Declaration.
The twenty – two recommendations of Alma- Ata Conference
1. Interrelationships between health and development
2. Community participation in PHC
3. The role of national administrations in PHC
4. Coordination of health and health related sectors
5. Content of primary health care
6. Comprehensive PHC
7. Support of PHC within the national health system
8. Special needs of vulnerable and high risk groups
9. Roles and categories of health and health -related manpower for PHC
10. Training of health and health related manpower for PHC

11. Incentives for service in remote and neglected areas
12. Appropriate technology for health
13. Logistic support and facilities for primary health care
14. Essential drugs for PHC
15. Administration and management for PHC
16. Health services research and operational studies
17. Resources for PHC
18. National commitment to PHC
19. National strategies for PHC
20. Technical cooperation in PHC
21. International support for PHC
22. The roles of WHO and UNICEF in supporting PHC.
Elements/core activities of PHC/Component
Easy to remember: Elements

E Education concerning prevailing health problems and the methods of
identifying, preventing and controlling them.
L Locally endemic disease prevention and control.
E Expanded programme of immunization against major infectious diseases.
M Maternal and child health care including family planning.
E Essential drugs arrangement.
N Nutritional food supplement, an adequate supply of safe and basic nutrition.
T Treatment of communicable and non-communicable disease and promotion of mental
health.
S Safe water and sanitation.

Extended Elements in 21st Century
1. Expanded options of immunizations
2. Reproductive Health Needs
3. Provision of essential technologies for health
4. Health Promotion
5. Prevention and control of non-communicable diseases
6. Food safety and provision of selected food supplements
Basic component of Primary Health Care
1. Public education
2. Proper nutrition
3. Clean water and sanitation
4. Maternal and child health
5. Immunization
6. Local disease control
7. Accessible treatment
8. Drug provision
Principles of Primary Health Care
1. Equitable distribution
2. Community participation
3. Intersectoral coordination
4. Appropriate technology
5. Decentralization
1. Equity/Equitable Distribution
The first key principle in primary health care strategy is equity or equitable distribution of health
services. Health services must be shared equally by all people irrespective of their ability to pay
and all (rich or poor, urban or rural) must have access to health services. Currently health
services are mainly in towns and inaccessibility to majority of population in the developing
world.
2. Community Participation
Overall responsibility is of the State. The involvement of individuals, families, and communities
in promotion of their own health and welfare is an essential ingredient of primary health care.
PHC coverage cannot be achieved without the involvement of community in planning,
implementation and maintenance of health services.
3. Intersectoral Coordination
Declaration of Alma –Ata states that PHC involves in addition to the health sector all related
sectors and aspects of national and community development, in particular education,
agriculture, animal husbandry, food, industry, education, housing, public works and
communication. To achieve cooperation, planning at country level is required to involve all
sectors

4. Appropriate Technology
Technology that is scientifically sound, adaptable to the local needs, and acceptable to those who
apply it and those for whom it is used and can be maintained by the people themselves with the
resources of the community and country can afford.
STRATEGIES OF PHC
1. Reducing excess mortality of poor marginalized populations:
PHC must ensure access to health services for the most disadvantaged populations, and focus on
interventions which will directly impact on the major causes of mortality, morbidity and
disability for those populations.
2. Reducing the leading risk factors to human health:
PHC, through its preventative and health promotion roles, must address those known risk factors,
which are the major determinants of health outcomes for local populations.
3. Developing Sustainable Health Systems:
PHC as a component of health systems must develop in ways, which are financially sustainable,
supported by political leaders, and supported by the populations served.
4. Developing an enabling policy and institutional environment:
PHC policy must be integrated with other policy domains, and play its part in the pursuit of
wider social, economic, environmental and development policy.
Obstacles to the implementation of the PHC strategy
1. Misinterpretation of the PHC concept
2. Misconception that PHC is a 2nd rate health care for the poor.
3. Selective PHC strategies
4. Lack of political will
5. Centralized planning and management
The Basic Requirements for Sound PHC (the 8 A’s and the 3 C’s)
1. Appropriateness
2. Availability
3. Adequacy
4. Accessibility
5. Acceptability
6. Affordability
7. Assessability
8. Accountability
9. Completeness
10. Comprehensiveness
11. Continuity

1. Appropriateness
 Whether the service is needed at all in relation to essential human needs, priorities and
policies.
 The service has to be properly selected and carried out by trained personnel in the proper
way.
2. Adequacy
 The service proportionate to requirement.
 Sufficient volume of care to meet the need and demand of a community
3. Affordability
 The cost should be within the means and resources of the individual and the country.
4. Accessibility
 Reachable, convenient services
 Geographic, economic, cultural accessibility
5. Acceptability
 Acceptability of care depends on a variety of factors, including satisfactory
communication between health care providers and the patients, whether the patients trust
this care, and whether the patients believe in the confidentiality and privacy of
information shared with the providers.
6. Availability
 Availability of medical care means that care can be obtained whenever people need it.
7. Assessability
 Assessability means that medical care can be readily evaluated.
8. Accountability
 Accountability implies the feasibility of regular review of financial records by certified
public accountants.
9. Completeness
 Completeness of care requires adequate attention to all aspects of a medical problem,
including prevention, early detection, diagnosis, treatment, follow up measures, and
rehabilitation.
10. Comprehensiveness
 Comprehensiveness of care means that care is provided for all types of health problems.
11. Continuity
 Continuity of care requires that the management of a patient’s care over time be
coordinated among providers.
COMPREHENSIVE AND SELECTIVE PHC
WHAT HAPPEN TO THE ALMA ATA MODEL OF PRIMARY HEALTH
CARE/COMPREHENSIVE PHC

1. Few countries tried to implement comprehensive PHC; with few successes, including
in
 Costa Rica, Cuba, Kerala State (India), Sri Lanka, China
 For a short time, Nicaragua, Mozambique
2. But for most countries
 Strong, sustained political will was lacking for implementation at local levels
 Changing political context reinforced conservative attitudes of health professionals that
PHC
 Promoted non-scientific solutions
 Demanded too many sacrifices
 Was second class medicine
3. Alma-Ata PHC was considered too broad, idealistic, and unrealistic
4. Rockefeller Foundation meeting 1979
• Examined status of health and population programs
• Expressed concern about decreased interest in population control
5. Walsh & Warren; “Selective PHC: An Interim Strategy for Disease Control in
Developing Countries” (NEJM, 301, 1979, 967-974)
• Authors agreed with concepts, yet recommended pursuing selective PHC targets,
especially related to mothers and children, due to inadequate funding for
comprehensive programs
SELECTIVE PRIMARY HEALTH CARE
THE SHIFT TO “SELECTIVE PHC” (1978-1990s)
Most countries shifted to “selective PHC”
 UNICEF (J. Grant) an early ‘adopter’ and promoter
 Easier to train, deploy and manage staff
 Quicker to obtain and quantify results
 Lower program costs
 Easier to justify and obtain donor funds
 Measurable outputs, prompt results, technological solutions, easier accountability, and
time-limited support
UNICEF Declaration of A Children’s Revolution 1982.
Emphasized new technological breakthroughs
SPHC: a package of low cost interventions: GOBI-FFF
GOBI-FFF
Growth monitoring.
For identifying at an early stage children who were not growing as they should, because of poor
nutrition.
Oral Rehydration.

To control diarrheal diseases with ORS, a mixture of water, salt and sugar that could be prepared
by mothers.
Breast feeding
Of infants as a means to prevent diseases
Immunization.
Vaccines, especially against diseases of childhood (measles, diphtheria, tetanus, polio,
tuberculosis and whooping cough)
FFF (Added later)
Food supplementation
Female literacy
Family planning.
Appeared as cost-effective & practical Interventions easy to monitor and evaluate.
SPHC: contradictory experiences and criticism during the 1980s
 Growth monitoring became an end in itself rather than a means to improve the nutrition of
vulnerable children.
 ORS Partial solution when water and sewage systems are contaminated.
 Breast feeding faced the propaganda of powerful food industries.
 Immunization considered a successful program.
 In 1980 only about 5 per cent of children in the so-called third world were immunized against
six diseases (measles, tetanus, whooping-cough, diphtheria, tuberculosis and polio)
 By the end of the 1980s well over half were fully immunized by the time they were only one
year old.
 Most Latin American countries, especially Colombia, achieved high immunization rates.
Some important accomplishments of selective PHC
 80% of children vaccinated for 5 common diseases (DPT, polio, measles)
 1980-93
• Infant mortality reduced by 25%
• Life expectancy increased by at least 4 years
•
 1985-93
• Children under 5 dying of vaccine preventable diseases reduced by 1.3 M deaths/year
• Yet these diseases still cause 2.4 M deaths/year
Models of primary health care
COMPREHENSIVE SELECTIVE MEDICAL MODEL
View of Positive wellbeing Absence of disease Absence of Disease
health

Locus of Communities and Health professionals Medical practitioners
control over individuals
health
Major focus Health through equity and Health through medical Disease eradication
community development interventions through medical
interventions
Health care Multidisciplinary teams Doctors plus other health Doctors
providers professionals
Strategies Multi-sectoral Medical interventions Medical interventions
for health collaboration
Challenges of PHC:
 Inefficient health systems and policy and lack of implementation of policies:  Improper
management and evaluation  Inadequate health education:
 Community participation neglected:
 Party Politics on health of people:
 Equitable distribution:
 Population pressure:
 Emerging and re-emerging diseases:
 Water
 Poverty and its health consequences:
 Challenges of reproductive health:
 Supply of essential drugs:
 Violence, accidents and injuries are increasing at an alarming rate.
 Increased in mental health problems caused by stress-related living.
Concepts of health care
Health care is an act of helpful activity specifically intended to maintain or improve health. It is
defined as a multitude of services rendered to individuals, families, or communities by the agents
of the health services or professions for the purpose of promoting, maintaining, monitoring or
restoring health.
Levels of health care
There are four levels of health care.
1. Promotive
2. Preventive
3. Curative
4. Rehabilitative
Overview of operational aspect of PHC/ Core activities
There is set of core activities which were normally defined nationally or locally according to
1978 declaration of Alma-Ata proposed this activities should include:
1. Education concerning prevailing health problems and the methods of identifying,
preventing and controlling them

2. Promotion of food supply and proper nutrition, an adequate supply of safe water and
basic sanitation
3. Maternal and child health care including family planning
4. Immunization against major infectious diseases.
5. Prevention and control of locally endemic diseases.
6. Treatment of common diseases and injuries.
7. Promotion of mental health.
8. Provision of essential drugs and basic laboratory services.
9. Training of health guides, health worker and health assistant
10. Referral services
11. Mental health services, service to physically handicapped, health and social care of
elderly.
Job description of District Public Health Officer
The job description of District Public Health Officer is summarized in the following heading:
1. Planning
 Prepare the structure of district level health development plan within the budget ceiling as pre-
national policy and directions
 Get the annual district level health plan and program approved by the district assembly and
make arrangement to send it to the regional centre and national center.
 Prepare detail work plan and work calendar for the chief of PHCCs, HPs, SHPs and the
technicians of the public health offices.
 Present timely recommended proposal for other programs, if necessary, in addition to the
regular annual programs of the districts along with the rationales for such programs
Divisions of targets
 Make arrangements to hand over responsibilities of conducting programs for the fulfillment of
various objectives of the districts health services to PHCCs, HPs, SHPs within the district on
the basis of populations.
Collection of information and analysis
 Ensure the regular dissemination of information from various health institutions within the
districts.
 Prepare graphs, charts on the basis of district health profile and display them.
 Identify and priorities the main health problems of the district on the basis of the analysis of
the information collected.
 Identify district level health indicator
 Evaluate the effectiveness of health programs in the district according to the progress towards
fulfillment of the objectives and on this basis recommend employees involved in these
programs for opportunities for career development.
 Disseminate information regularly, send progress reports and provide feedback as directed by
the district public health office.
2. Family Planning Program

 Ensure the family planning services always available in the district through the health
institutions, health workers, and volunteers in the district.
 Make arrangements to provide family planning consultancy services through health
institutions, PHC outreach and health workers.
 Make arrangement to provide vasectomy and laparoscopy, services through institutional
clinics on a regular basis.
 Make arrangements to have in stock contraceptives for four months for regular supply.
 Make arrangements for the follow up on those availing of family planning services and
defaulters.
 Make necessary arrangements to increase the number of those availing of family planning
services in the district and various health institutions.
3. Safe Motherhood
 Ensure that safe motherhood services are being provided by the PHCCs, HPs, SPHPs, PHC
outreach, rural health program, and mother and child health program midwives.
4. Vaccinations Programs
 Ensure the quality vaccination services are regularly being provided by vaccination centers
and health institutions.
 Make arrangements for the regular supply of vaccines and managements of cold chain.
 In case of epidemics like polio, measles and hepatitis make immediate arrangements for the
prevention of their spread and report to the centers.
5. Nutrition Program
 Conduct the survey on nutrition in the community and study or have others study the nutrition
situation of the community.
 Make arrangements of growth monitoring through health institutions and PHC outreach.
 Make necessary arrangements for giving vitamin A capsule to children and distribution of iron
tablets.
 Make arrangements to give iron tablets to the pregnant women.
 Make arrangements for the supply of iodize salt.
6. Diarrheal Diseases
 Monitor the work at all levels for the control of diarrhoeal diseases.
 Make arrangements for the prevention of epidemic of diarrhoeal diseases in the districts.
 Make arrangements to set-up ORT corners in all health institutions.
 Make arrangements for the regular supply of oral rehydration solution at all levels in the
district.
7. Emergencies Respiratory Diseases
 Make arrangements for the prevention and treatment of respiratory diseases by various health
institutions in the districts.
 Make arrangements for the supply of medication for respiratory diseases at health institutions.
 Monitor the work being carried out all levels for the control of respiratory diseases
8. Malaria and Kala-azar
 Make arrangements for the control of malaria in the district on clinical basis
 Make arrangements for the collection of slides of those with fever though the field visit of
rural health worker, outreach clinic and health posts and test them at the district public health
office or in the field as necessary.

 Make arrangement for the complete treatment of all positive cases
 Send proposals with the rational for the spraying of insecticides in areas with malaria and
kala-azar epidemic on the basis of the case load and intensity of the epidemic to the
Epidemiology Division through the Regional Directorate of Health Services.
9. Tuberculosis
 Make arrangements for the collection of sample of the sputum of the suspected TB patient,
its testing and treatment of patient with confirmed cases of the disease  Make
arrangements to look for defaulter patients and treat them again  Make arrangements to
provide information on the prevention of TB.
10. Leprosy
 Make arrangements for the collection of skin smear of suspected leprosy patient, its testing
and find out if arrangements have been made for the treatment of patients with leprosy.
 Make arrangements for the follow-up of patents being treated, tracing of defaulter patients.
 Make arrangements to provide information on the prevention of leprosy.
11. HIV/AIDS Prevention Program
 Identify the target group and make arrangements of the prevention of HIV/AIDS 
Make arrangements of the promotion of condom use.
 Make arrangements for the treatment of sexual diseases.
12. Epidemic Control
 Collect the information on the spread of epidemic in the district and if confirmed immediately
inform the regional health directorate and Epidemiology and Disease Control Division
 Make necessary arrangements for the control of epidemic, supply of medicines, deputation of
health teams, and dissemination of information and mobilization of resources.
 Carry out or have other to carry out preventive measures for possible seasonal epidemics and
make arrangements to stock medicines.
13. Health Education Program
 Find out if public awareness programs about all public health programs being carried out in
the district is being carried out as necessary and if it is not ensure that such awareness
programs are being carried out.
14. School Health Education Program
 Make arrangements to conduct school health programs regularly in all the schools of the district.
15. Female Community Health Volunteer Program

 Make arrangements for FCHV and midwives selection training and refresher review meeting
and conducting of supervision meeting in the district on the basis of population.
 Find out if there are FCHV and midwives training conducted by various NGOs in the district
and coordinate them and make arrangements for the collection of reports and maintaining of
standards.
 Make arrangements to conduct district level review meeting of FCHV and midwives program
in the districts.
 Participate in regional meetings with supervisions on making periodic reports of FCHV and
midwives programs and strengthening the programs.
 Prepare the plans to make the mother’s group active and help in the implementation of the
plans by various organizations.
 Ascertain if the PHC outreach program are being run.

 Make arrangements to conduct district level and VDC level orientation programs.
 Collect monthly progress reports from health posts, and send them to the HMIS section with
analysis and reaction.
16. Simple Treatment and Referral Service
 Assist in the referral of patients who cannot be treated in health institutions and in the process
of ascertaining if s/he is being treated with priority.
17. Community Drug Programme
 Run the community medicine program with the participation of health committees in the
district
18. Budget and Supply of Provisions
 Mobilize budget allocated for various programs
 Ascertain amount of medicines and equipment/instruments needed to run programs and make
arrangements to supply medicines and equipment/instruments requested.
 Make arrangements for the maintenance and utilization of various equipment in the district.
 Ensure that accounts, inventories and records of goods in the store are maintained.
 Ascertain if the allocated budget is being spent and ensures that records are kept.
 Public health officer should ascertain if the public health program are being run and if they
are not assist the chief of the district health office to run them.
19. Monitoring and Supervision
 Monitor all health programs in the district on the monitoring checklist. Prepare or have others
prepare the district profile periodically.
 Have the chiefs of the PHCs, HPs, and SHPs, and technical assistants prepare field
supervision work plan and approve them.
 Prepare the annual plan for the integrated supervision and monitoring of the various health
services in the district, get it approved from the district health chief and make arrangements
for the regular monitoring and supervision of HPs and SHPs by the assistants in the district.
 Study the supervision reports, inform the concerned department on the contents and take
action against employees if the necessary.
20. Conducting Program
 Run or have others run smoothly all public health services related programs in the district
through the PHCs, HPs and SHPs.
 Prepare annual work plan for health programs and training programs.
 Ensure that programs are being run according to the work plan.
21. Administrative Duties
 Make necessary arrangements for day to day administrative work of the public
health office to be carried out smoothly.
 Act as the supervision and evaluate the performance of subordinates.  Evaluate
the performance of the employees and reward or punish them  Be an active
participant in the monthly staff meeting.
22. People’s Participation and Community Mobilization
 Make arrangements for the regular contact with members of the district health and population
committee to establish a relationship with them and make the committee active.
 Make arrangements to mobilize the health committees of PHCs, HPs, SHPs and the
management committee of PHC outreaches.
23. Coordination

 Establish cordial relationships with all governmental and non-governmental organizations
and people representatives in the district.
EFFECTS/CHALLENGES/OBSTACLES OF STRUCTURAL ADJUSTMENT
PROGRAMS ON HEALTH
What are SAPs?
 Structural Adjustment Program is the set of “free market “policy reforms imposed on
developing countries by the Bretton Woods institutions (the World Bank and the
International Monetary fund (IMF)) as a condition for receipt of loans.
 Developed in early 1980’s as a means of gaining stronger influence over the economics of
the debt-strapped Governments in the South.
What are SAPs designed to do?
SAPs are designed to improve a country’s foreign investment climate by eliminating trade and
investment regulations to boost foreign exchange earnings by promoting exports and to ensure
Governments deficits through cuts in spending.
What measures are imposed under SAPs?
 Although SAPs differ somewhat from country to country they include:
 A shift from the production of cash crops for domestic consumption to specialization in the
production of cash crops or other commodities like rubber, cotton, tin, etc for export.
 Abolishing food and agriculture subsides to reduce Government expenditures.
 Deep cuts to social programs usually in the areas of Health Education and housing and
massive layoffs in the civil service.
 Currency devaluation measures which increase import costs while reducing the value of
domestically produced goods.
 Liberalization of trade and investment and high interest rates to attract foreign investment.
 Privatization of Government held enterprises.
Why the need for SAPs?
 It is necessary to bring a developing country from the crisis to economic recovery and
growth. Social wellbeing is not an integral component of SAPs but a hoped for results of
applying free market principles to the economy.
 The process of adjustment is ‘sacrifice’ of ‘present pain for future hope
Policies of SAPs
 Currency devaluation
 Managed balanced of payments
 Reduction of Government services through public spending cuts/ budget deficit cuts
 Reducing tax on high earners
 Wage suppression
 Privatization.
 Lower tariffs on imports and tighter monetary policy.
 Cuts in social spending and business degradation.

 Governments are also encouraged or forced to reduce their role in the economy by
privatizing state- owned industry, including the health sector and opening up their
economics to foreign competition.
SAP in Nepal
Started in Nepal after 1985, more forcefully during the period of Nepali congress government
in1991-94
SAPs Impact on Public Health
Specifically, in health sector SAP means

 A cut in the welfare of investment, leading to gradual dismantling of the private health
services.
 Introduction of services charges in public institution, which has now, making the services
inaccessible to the poor people
 Handing over the responsibility of health services to the primary sector and undermining
the rationality of public health. The private sector on the other hand focused only on
curative care. Nepal, for example, was forced to reduce its public health expenditure in
health and to recover the cost of health services from its users by international banks.
 The voluntary sector, which has also stepped in to provide health services is forced to
concentrate and prioritize only those areas where international aid is made unavailable.
How does SAP affects Women?
Mainly affects the health of women of developing countries: -
 Increased MMR
 Increased child mortality rate
 Halts in women empowerment
 Lack of essential health care
 Anemia and Malnutrition
 Cut spending the financial allocations in women’s health.
Conclusion
 SAPs designed by the IMF and World Bank have been the framework for economic and
social policy in most of the south since the early 1980s. No less than 34 African countries
have implemented SAP.

 Dramatic impact on the status of education, health, environment and women and children.
 SAPs have hurt the poor most.
“Poor countries have become poor and rich have become rich,”
1.2: REVITALIZATION OF PHC
Introduction
In 2009, Ministry of Health and Population (MoHP) constituted Primary Health Care
Revitalization Division (PRD), a new division, under the Department of Health Services
(DoHS). The new division will assume the mantle to revitalize PHC in Nepal by addressing
emerging health challenges in close collaboration with the other DoHS divisions and different
supporting actors.
The division is also expected to make inroads into translating the constitutionally specified
fundamental right of basic free health care into practice by addressing the disparities in health
service delivery and promoting equitable health services
Why revitalization of PHC now?
 Governments and Donors committed to attain MDGs and committed to health sector reforms
 Growing realization that maternal and Neonatal mortality cannot be effectively unless the
health system is capable of managing complications  Role of sustainable health system for
addressing  Other conditions –HIV/AIDs, TB, Malaria.
Evolution in the concept of PHC reform
Rational behind Revitalization of PHC in Nepal

Components of revitalization of PHC
 Free health care service

 Social health protection & insurance
 Urban health
What has happened in Nepal in PHC?
 Human resource training: major progress but deployment and retention still big problem.
 Service delivery infrastructure expanded, still in adequate, quality needs to improve.
 Maternal child health indicators improving
 Efforts at Inter-sectoral actions/healthy public policies minimal
 Community empowerment- some progress
Objective and strategies of Revitalization of PHC
Objective:
Is to strengthen health system of Nepal and attain universal coverage of EHCS
Strategies:
 Increasing access coverage and utilization of quality essential health care and reducing
inequity
 Empowerment of, community leaders in planning and management at all levels
 Promoting Healthy public policy to protect health of people and the communities through
intersect oral actions.
 Human resource development reforms through involvement of academia and public health
institution
Four PHC Reform
1. Public policy reform
2. Leadership reform
3. Universal coverage reform
4. Service delivery reform
1. Public policy reform
 Policies to support universal coverage

 Public health policy to promote continuum of preventive , promotive , curative and
rehabilitative care
 Promote inter-sectoral collaboration
 Ensure that no public policy has deleterious effect on health
2. Leadership reform
Pragmatic leadership in health that is:
 Inclusive
 Participatory
 Negotiation based
 Works with diverse stakeholders
3. Universal coverage reform
 Out of pocket expenditure
 Increasing the range of services in the essential health package
 Cover disadvantaged population groups
4. Service delivery reform
Revitaliz
ation of PHC works mainly on three thematic issues
1. National Free Health Care
2. Social Health Protection
3. Urban Health and Environment
1. National Free Health Care
 According to National Free Health Care Program 32 in items in HP, 35 in PHCC
items/medicine are available for free respectively.
 Apart from that free health service delivery is also targeted for people at extreme poverty,
poor people, physically challenged, senior citizen (above sixty) and FCHVs.
2. Social Health Protection
Social health protection the division is working for pilot testing and networking for
expansion of protection mechanism as outlined in National Health Insurance strategy.
3. Urban Health and Environment
Urban clinic and deploying FCHVs at municipal areas for delivering Essential Health
Care System is the major activities under urban health and Environment program.

Goals of Health Insurance
1. Individuals & families: pooling financial risks and resources
 Access to providers of care
 Protection from exceptional costs
 Pre-payment for routine preventive services
2. Employers: Attracting and retaining workers
3. Providers: Ensuring payments and stable revenue
4. Government: Covering priority populations
 Elderly, disabled, or poor
 Pregnant women and children
Community Health Insurance:
 community health insurance as “any not-for-profit insurance scheme that is aimed
primarily at the informal sector and formed on the basis of a collective pooling of health
risks and in which the members participate in its management.”
 Beneficiaries are associated with, or involved in the management of community-based
schemes, at least in the choice of the health services it covers.
 It is voluntary in nature, formed on the basis of an ethnic of mutual aid, and covers a
variety of benefit packages.
 The main specialty of CHI, the local community takes the initiative in establishing a
health insurance scheme, usually to improve access to health care as well as protect
against high medical expenses.
 The solidarity element is strongest in CHIs as most of the members know each other.
Nepal
 CBHI introduced in 1976 initiated by the United Mission to Nepal as “Lalitpur Medical
Insurance Scheme“ -- first non-profit health insurance schemes in Nepal.
 CBHI scheme were initiated by government and NGOs since 2003 as subsidized insurance
schemes.
 In parallel, some privately-operated CBHI schemes have been established in financial
support of NGOs and Cooperatives.
Advantages of CHI
 Good participation of people. This allows people to involve and contribute in the design
and management of the health insurance scheme and thereby in the delivery of their health
care.
 Their ability to cover the informal sector – the farmers, the peasants, the self-employed and
the landless workers. These sections of society are usually not covered by other forms of
health insurance.
 Their ability to design schemes that meet the people felt needs, keeping the premiums
affordable and the benefit package acceptable.
 The awareness of unity and a willingness to bear its consequences. (Solidarity )

Free Health services and essential health care service in Nepal
The interim constitution of Nepal in 2007 started that every citizen shall have the right to get
basic health services free of cost from the state as provided for in the law. MOH has
implemented policy aimed at providing free health services since December 2006.
In the first phase free essential health care services were offer to poor and vulnerable citizen
attending primary health care Centre (PHCC) and District hospital (up to 25 bedded capacity). In
addition to this in 35 district that ranked lowest in HDI the programme provide additional free
outpatient services to same group in the district facilities.
Since January 2009 under the "New Nepal Healthy Nepal" initiative of the government all citizen
are able to assess District hospital and PHC without having to pay for registration. They are
eligible for free outpatient, emergency and inpatient services as well as essential drugs.
A second universal programme commenced in January 2008 aimed out the provision of free
health care services to all citizen whether poor or not at the health post. There are no charges for
registration for the dispension of 38 essential drug at the health post, 58 at PHC and 70 at district
hospital.
Issues and challenges of free health Services:
1. Limited and donor depending health financing.
2. Current free health provision declaration is not sufficient to ensure universal assess of
health services with desired quality.
3. Human resource crunch is limiting the service delivery.
4. Inadequate policy linkage between health facilities and communities.
UNIT 2: INTERNATIONAL HEALTH 2.1: Introduction of international Health

What is international health?
IH is concerned with health problems, their determinants, and their solutions around the world,
especially those of the low and middle income countries that remain as the world problem. The
issues in IH are mainly Health system/PHC, Globalization, global interest/players and
determinants of Population Health
International health
 Focuses on health issues of countries other than one’s own, especially those of low- income
and middle income
 Development and implementation of solutions usually requires binational cooperation
 Embraces both prevention in populations and clinical care of individuals
 Seeks to help people of other nations
Globalization
 Globalization is the growing integration of economies and societies around the world.
 In this era of rapid globalization where flow of ideas, money and technology is so common,

 The health of individuals is not only dependent on local processes but also on global
processes, for example there are lots of global players and organisations whose agenda
ultimately influence and alter local polices.
 Diseases can be transmitted across the countries.
 International Health is concerned with health problems, disease transmission, health
regulations and health system organisation across the countries in the world.
 It looks at the impact of global players on national health and analyse major global efforts
and initiatives to improve human health.
 Primary Health Care approach has been associated with International Health as an important
international health policy affecting health system organisation and health care provision and
promotion ideology.
Why international health stands for?

World Disparities: Sanitation, education, health status, income, GDP
 The existing gross inequality in the health status of the people, between developed and
developing countries as well as within countries, is politically, socially, and economically
unacceptable and is, therefore, of common concern to all countries. The people have a right
and duty to participate individually and collectively in the planning and implementation of
their health care.
 Emergencies: Tsunami, Earthquake, floods, famines
 Pandemics: SARS, SWINE FLU, bird flu, HIV/AIDS
Why?
 Humanitarian reasons: In 2005, an estimated 2.8 million people died from AIDS, the vast
majority of them in developing countries. More than 15 million children have been orphaned
as a result of AIDS. And more than 3 million people die annually from tuberculosis (TB) or
malaria.
 Equity reasons: Roughly 90 percent of the world’s health care resources are spent on
diseases that affect 10 percent of the world’s population. Working to solve global health
problems will help ensure that money and resources are distributed more fairly across the
globe.
 Direct impact reasons: In an increasingly connected world, diseases can move as freely as
people and products. Infectious diseases can easily cross national borders and pose
immediate threat.
 Indirect impact reasons: rising incidences of diseases like HIV/AIDS, malaria, and TB are
increasing poverty and political instability in many countries. That in turn has political and
economic consequences worldwide.

Issues in International Health
 Determinants of Health and Societal Responses
 Child Survival and Other Vertical Programs
 Primary Health Care
 Essential Drugs
 The Social and Political Context of the HIV/AIDS Epidemic
 Debt, Structural Adjustment, and Health
 International Health Agencies: Multi and Bilateral
 Health Care Reform; Finances and Systems
 Health Care Reform and Human Resources
 Population and Family Planning
 Water and Sanitation
 NGOs and Community Health Workers
 Traditional Practices
 Women health and HIV/AIDS
 Trade Related Intellectual Property Right
 Elderly population health
 Pornography
 Global air travelling
 Girls trafficking
 Foreign employment
 War
 Communicable and non- communicable disease etc….
Roles and contribution of multilateral agencies, bilateral agencies and other health related
international organization in Nepal.
Multi- lateral Agencies
WHO (World Health Organization)
World Health Organization (WHO) is an inter-national specialized agency. It was established in
7th April 1948. It is a multilateral agency.
Goal
The goal of who is the attainment by all peoples of the highest level of health.
Activities of WHO
 Management of health services
 Health information and communication
 Development of human resource for health.
 Quality of Care and health technology rational use of drugs.
 Prevention and control of communicable diseases, like TB, Acute Respiratory diseases and
others.
 Eradication and elimination of endemic diseases like poliomyelitis, leprosy, neonatal tetanus.
 Implementation of Safe motherhood program.
 Implementation of child health and Adolescent health.
 Conduction of Nutritional Program.

 Prevention and Control of non-communicable diseases such as cancer, cardio vascular
diseases, diabetics and COPD.
UNICEF (United Nations International Children’s Fund)
United Nations International Children's Fund (UNICEF) is one of the multilateral agencies
working in Nepal. It conducts different health program nationwide and some programs in region
wide.
Goal
The main goal of UNICEF is to contribute the national goal of reducing IMR, U5MR, morbidity
in children associated with preventable childhood illness, to facilitate reduction of MMR. Protein
Energy malnutrition in children under five years and to develop the sustainable drug program
throughout the national and internationally.
Activities of UNICEF
a. Support to increased immunization coverage.
b. Support to successful coverage of over 90% for measles during campaign in October 2004 /
2005.
c. Support to successful introduction of Hepatitis 'B' vaccine.
d. Support to complete coverage of Maternal and Neonatal Tetanus Elimination (MNTE)
nationwide.
e. Support to health and nutrition program planning and management.
f. Support to delivery of basic services to children and women through PHC activities.
g. Support to enhance Female Community Health Volunteers' Capacity to deliver services at the
community level.
h. Support to integrated approach to the prevention and treatment of childhood illness.
WORLD BANK
The World Bank provides assistance in various sectors aiming at reducing poverty and uplifting
the overall Socio-economic development of people of Nepal. It worked as assistant in
implementation of population and Family Health Project.
Goal
To ensure a package of affordable, sustainable and prioritized interventions based on diseases,
equity and quality of care.
Activities of the World Bank
1. Prioritized allocation of resources and effects to ensuring access to Essential Heath care
services.
2. Decentralization of management of health care services delivery to the local bodies.
3. Promoting Public private partnership to increase service access and quality.
4. Conduction of MCH / FP program.
5. Improving Function of the grass root health facilities.

United Nations Population Fund (UNFPA)
United Nations Population Fund (UNFPA) extends assistance to developing countries. UNFPA's
collaboration in Nepal was started since 1974 but it was established in 1969 AD in other
countries.
Goal of UNFPA
To assist the developing countries, countries in economic transmission and other countries at
their request to help them address Reproductive Health and Population Issues.
Activities of UNFPA
i) Strengthening Reproductive Health service management capacity
ii) Strengthening Human Resource Capacity
- Basic training to health worker.
- In service training for upgrading knowledge.
- Training on community mobilization.
- Strengthening Infrastructure.
iii) Strengthening IEC for the promotion of Reproductive Health and Family Planning.
UNDP (United Nation Development Programme)

UNDP is the UN's global development network, an organization advocating for change and
connecting countries to knowledge, experience and resources to help people build a better life.
We are on the ground in 177 countries and territories, working with them on their own solutions
to global and national development challenges. As they develop local capacity, they draw on the
people of UNDP and our wide range of partners. UNDP was formed in 1965. And Headquarter is
located in New York City.
Objective:
The basic objectives of the UNDP is to help poorer nations develop their human & natural
resources more fully.
Area of operation:
 Agriculture
 Industry
 education & science
 Health
 Social welfare etc.
Functions:
UNDP’s offices and staff are on the ground in 177 countries, working with governments and
local communities to help them find solutions to global and national development challenges.
 Democratic Governance:
UNDP supports national democratic transitions by providing policy advice and technical support,
improving institutional and individual capacity within countries, educating populations and

advocating for democratic reforms, promoting negotiation and dialogue, and sharing successful
experiences from other countries and locations.
 Poverty Reduction:
UNDP helps countries develop strategies to combat poverty by expanding access to economic
opportunities and resources, linking poverty programs with countries’ larger goals and policies,
and ensuring a greater voice for the poor.
 Environment and Energy:
UNDP seeks to address environmental issues in order to improve developing countries’ abilities
to develop sustainably, increase human development and reduce poverty.
 HIV/AIDS:
UNDP works to help countries, prevent further spreading and reducing its impact, convening The
Global commission on HIV.
Other functions:
 To accomplish the MDGs and encourage global development. It focuses on poverty reduction,
HIV/AIDS, Democratic governance, energy and environment, social development and Crisis
prevention and recovery. It also encourages the protection of human rights and the
empowerment of women in all of its programmes.
 The UNDP Human Development Report office also publishes an annual Human Development
Report (since 1990) to measure and analyse developmental progress. In addition to a global
Report, UNDP publishes regional, national, and local Human Development Reports.
Asian Development Bank (ADB)
The Asian Development Bank (ADB) is a regional development bank established on 19
December
1966, which is headquartered in the Ortigas Center located in Mandaluyong, Metro
Manila, Philippines. The company also maintains 31 field offices around the world to promote
social and economic development in Asia.
Aim
The ADB defines itself as a social development organization that is dedicated to reducing
poverty in Asia and the Pacific through inclusive economic growth, environmentally sustainable
growth, and regional integration. This is carried out through investments – in the form of loans,
grants and information sharing – in infrastructure, health care services, financial and public
administration systems, helping nations prepare for the impact of climate change or better
manage their natural resources, as well as other areas.
Focus areas
Eighty percent of ADB’s lending is concentrated public sector lending in five operational areas.
[18]

• Education - Most developing countries in Asia and the Pacific have earned high marks for a
dramatic rise in primary education enrollment rates in the last three decades, but daunting
challenges remain, threatening economic and social growth.
• Environment, Climate Change, and Disaster Risk Management - Environmental
sustainability is a prerequisite for economic growth and poverty reduction in Asia and the
Pacific.
• Finance Sector Development - The financial system is the lifeline of a country’s economy.
It creates prosperity that can be shared throughout society and benefit the poorest and most
vulnerable people. Financial sector and capital market development, including microfinance,
small and medium-sized enterprises, and regulatory reforms, is vital to decreasing poverty in
Asia and the Pacific.
• Infrastructure, including transport and communications, energy, water supply and
sanitation, and urban development.
• Regional Cooperation and Integration - Regional cooperation and integration (RCI) was
introduced by President Kuroda when he joined the ADB in 2004. It was seen as a long-
standing priority of the Japanese government as a process by which national economies
become more regionally connected. It plays a critical role in accelerating economic growth,
reducing poverty and economic disparity, raising productivity and employment, and
strengthening institutions.
• Private Sector Lending - This priority was introduced into the ADB's activities at the
insistence of the Reagan Administration. However, that effort was never a true priority until
the administration of President Tadeo Chino who in turn brought in a seasoned American
banker - Robert Bestani. From then on, the Private Sector Operations Department (PSOD)
grew at a very rapid pace, growing from the smallest financing unit of the ADB to the largest
in terms of financing volume. As noted earlier, this culminated in the Long Term Strategic
Framework (LTSF) which was adopted by the Board in March 2008.
South Asian Association for Regional Cooperation (SAARC)
The South Asian Association for Regional Cooperation (SAARC) is the regional
intergovernmental organization and geopolitical union of nations in South Asia. Its member
states include Afghanistan, Bangladesh, Bhutan, India, Nepal, the Maldives, Pakistan and Sri
Lanka. SAARC comprises 3% of the world's area, 21% of the world's population and 9.12% of
the global economy, as of 2015.
SAARC was founded in Dhaka on 8th December, 1985. Its secretariat is based in Kathmandu,
Nepal. The organization promotes development of economic and regional integration. It
launched the South Asian Free Trade Area in 2006. SAARC maintains permanent diplomatic
relations at the United Nations as an observer and has developed links with multilateral entities,
including the European Union.
The guiding principles of SAARC are:
1. Respect the principles of sovereign equality, territorial integrity, political independence,
noninterference in internal affairs of other States and mutual benefit.
2. It is no substitute for bilateral and multilateral cooperation but complements them.
3. Its obligation shall not be inconsistent with bilateral and multilateral obligation; the charter
excluded bilateral and contentious issues from its deliberations.

Its Goals and Objectives:
1. It promotes quality of life and economic growt5h in the region.
2. It strengthens collective self-reliance.
3. It encourages active collaboration in economic, technical and scientific fields.
4. It aims at increasing people to people contact and sharing of information among the SAARC
members.
Bilateral Partners
United States Agency for International Development (USAID)
The United States Agency for International Development (USAID) is the United States
Government agency which is primarily responsible for administering civilian foreign aid.
President John F. Kennedy created USAID from its predecessor agencies in 1961 by executive
order. USAID's programs are authorized by the Congress in the Foreign Assistance Act, which
the Congress supplements through directions in annual funding appropriation acts and other
legislation. Although it is technically an independent agency, USAID operates subject to the
foreign policy guidance of the President, Secretary of State, and the National Security Council.[5]
USAID operates in Africa, Asia, Latin America, the Middle East, and Eastern Europe.
Goals:
• Disaster relief
• Poverty relief
• Technical cooperation on global issues, including the environment
• U.S. bilateral interests
• Socioeconomic development
Mode of Assistance:
 Technical assistance
 Financial assistance
GIZ
GIZ has been active in Nepal since 1975 on behalf of the German Federal Ministry for Economic
Cooperation and Development (BMZ) and opened its own office in the capital, Kathmandu, in
1979.
Nevertheless, it is expected that the country, with the help of the international community and the
efforts of its own government, will be able to achieve almost all the
 Millennium Development Goals.
 School enrolment rates, for instance, are very encouraging. Today, nine children out of ten
are able to go to school.
Goal of GIZ
The goals of our work there are to
 reduce poverty,
 to ensure inclusive development

 Improve the country’s economic and political framework.
Area under work
The priority areas of Nepalese-German cooperation are:
 sustainable economic development and trade
 renewable energies and energy efficiency
 Health.
Projects and Programme
 Sustainable infrastructure
 Security, reconstruction and peace
 Social development
 Environment and climate change
 Economic development and employment
Department for International Development's (DFID)
The Department for International Development's (DFIC) is the bilateral agency working in
Nepal.
Goal of DFID
Elimination of poverty in poor countries through progress towards the following targets.
 To reduce by 2/3 the rate of infant and child mortality by 2015.
 To reduce of three quarters the rate of maternal mortality by 2015.
 To attain universal access to RH, before 2015.
 To reduce by one quarter HIV infection rates in 15-24 years by 2010.
Activities of DFID
1. Support to Nepal Safe Motherhood Program
2. Support to National Health Sector Program (2000-2009)
3. Support to National HIV I AIDS Program (2004 -2000)
4. Support to Reproductive Health Care Program (1997-
2006)
5. Support National Tuberculosis Program (2001 - 2007)
6. DFID spent a total of £.5,357,951 (NRS 670 million) during the FY 2061/ 62 (2004 /
065)
Swiss Agency for Development and Cooperation (SDC)
The origin of the Swiss assistance in Nepal dates back half a century to when SDC implemented
its first project and pioneered many approaches.
Objectives:
The overall objective of the Swiss Cooperation Strategy for Nepal 2005-2008 is to contribute to
conflict transformation and peace building through three main components.

Components:
Harmonized bi- and multilateral framework: Switzerland aims to foster and to deepen a
coherent approach and dialogue between bilateral and multilateral development partners,
including the UN system, the international development banks, as well as agencies providing
humanitarian assistance.
Livelihood and Inclusion: SDC aims to maintain and improve the living standard in the villages
with a strong focus on access and inclusion of disadvantaged people through management of
natural resources, building of rural infrastructure, providing health services and promoting local
democracy.
Meaningful Dialogues and conflict transformation: Switzerland is committed to contribute to
the creation, from the grassroots right up to the track-one level, of a favorable environment for
reconciliation and peace building that addresses and transforms the political and social conflicts
in the country.
2.2: CURRENT GLOBAL HEALTH ISSUES
Human Development Index (HDI)
The Human Development Index (HDI) is a composite statistic of life expectancy, education, and
per capita income indicators, which are used to rank countries into four tiers of human
development. A country scores higher HDI when the lifespan is higher, the education level is
higher, the GDP per capita is higher, the fertility rate is lower, and the inflation rate is lower.
The HDI was developed by the Pakistani economist Mahbub ul Haq working alongside Indian
economist Amartya Sen, often framed in terms of whether people are able to "be" and "do"
desirable things in their life, and was published by the United Nations Development Programme.
Dimensions and calculation
New method (2010 Report onwards
Published on 4 November 2010 (and updated on 10 June 2011), the 2010 Human Development
Report (HDI) combines three dimensions:
• A long and healthy life: Life expectancy at birth

• Education index: Mean years of schooling and Expected years of schooling
• A decent standard of living: GNI per capita (PPP US$)
In its 2010 Human Development Report, the UNDP began using a new method of calculating the
HDI. The following three indices are used:
1. Life Expectancy Index (LEI) = LE-20/85-20
LEI is 1 when Life expectancy at birth is 85 and 0 when Life expectancy at birth is 20.
2. Education Index (EI) = MYSI+ EYSI/2
2.1 Mean Years of Schooling Index (MYSI) = MYS/15

Fifteen is the projected maximum of this indicator for 2025.

2.2 Expected Years of Schooling Index (EYSI) = EYS/18
Eighteen is equivalent to achieving a master's degree in most countries.
3. Income Index (II) = In(GNIpc)-In(100)/In(7500)-In(100)

II is 1 when GNI per capita is $75,000 and 0 when GNI per capita is $100.
Finally, the HDI is the geometric mean of the previous three normalized indices:
LE: Life expectancy at birth

MYS: Mean years of schooling (i.e. years that a person aged 25 or older has spent in formal
education)
EYS: Expected years of schooling (i.e. total expected years of schooling for children under 18
years of age)
GNIpc: Gross national income at purchasing power parity per capita
World scenario
Very high HDI country:
Norway
HDI=0.944
LIFE EXPECTANCY AT BIRTH=81.6
EXPECTED YEARS OF SCHOOLING=17.5
MEAN YEAR OF SCHOOLING=12.6

GROSS NATIONAL INCOME $PPP=64,992
Australia
HDI=0.935
MEAN YEAR OF SCHOOLING=13
GROSS NATIONAL INCOME $PPP=42,261
Very low HDI country
Central African Republic
HDI=0.350
GROSS NATIONAL INCOME $PPP=581
Niger
HDI=0.348
South-east Asia
High HDI (Singapore)
HDI= 0.912
GROSS NATIONAL INCOME $PPP= 52613
Low HDI (Afghanistan)
HDI=0.465

Category of HDI by region:
Human Life Expected Mean
Developme expectancy years of years of
nt at birth schooling schooling
Index
Regions (HDI)
Arab States 0.686 70.6 12.0 6.4
East Asia and the Pacific 0.710 74.0 12.7 7.5
Europe and Central Asia 0.748 72.3 13.6 10.0
Latin America and the
0.748 75.0 14.0 8.2
Caribbean
South Asia 0.607 68.4 11.2 5.5
Sub-Saharan Africa 0.518 58.5 9.6 5.2
Category of HDI
Human Life Expected Mean
Human development
Development expectancy years of years of
groups
Index (HDI) at birth schooling schooling
Very high human
0.896 80.5 16.4 11.8
development
High human development 0.744 75.1 13.6 8.2
Medium human
0.630 68.6 11.8 6.2
development
Low human development 0.505 60.6 9.0 4.5
International Health Regulation (IHR) Policy

The International Health Regulations (IHR) are an international legal instrument that is binding
on 196 countries across the globe, including all the Member States of WHO. Their aim is to help
the international community prevent and respond to acute public health risks that have the
potential to cross borders and threaten people worldwide.
The IHR, which entered into force on 15 June 2007, require countries to report certain disease
outbreaks and public health events to WHO. Building on the unique experience of WHO in global
disease surveillance, alert and response, the IHR define the rights and obligations of countries to
report public health events, and establish a number of procedures that WHO must follow in its
work to uphold global public health security.
International Health Regulations (2005)
A (very) short history

 1969 IHR covered 3 diseases: YF, cholera, plague
 Revision started 1995 –adopted by all States in 2005
 IHR in force, and implemented, globally since 2007
Legally binding on 194 States Parties
 Concerns during revision included –
 e.g. Ebola/VHFs, BSE, Nipah, SARS, avian influenza,
future serious potentially unknown international risks
 Global legal framework against international spread of serious disease
– Apply to government as a whole, not just particular ministry, department or agencies
– Broad / open disease scope for early warning/response & to catch emerging risks
– Overall framework: surveillance, response, support ,information sharing, capacities
– Does not replace existing regulatory regimes – Does mandate collaboration
Major innovations
 From control at borders to containment at source and development of core public health
capacities in all countries
 From disease list to broad range of serious int'l public health risks
 From preset health measures to generalized rules and risk assessment in particular context
Purpose and Scope of IHR
 "To prevent, protect against, control and respond to the international spread of disease…
 "in ways that are commensurate with and restricted to public health risks
 "and which avoid unnecessary interference with international traffic and trade"
Broad scope and coverage of IHR (2005)
 “Disease“an Illness or medical condition, irrespective of origin or source, that presents or

could present significant harm to humans”
 “Event”: “a manifestation of disease or an occurrence that creates the potential for disease”
 "Public health risk": "the likelihood of an event that may adversely affect the health of human
populations,"
 Events/risks may be:

– Biological/infectious, chemical, radio nuclear
– Known or unknown, emerging or re-emerging
– Transmissible by persons, transport conveyances, cargo/goods food/animals/products),
vectors, environment, etc.
Government areas and functions affected by International Health Regulations
 Public health

 Environment
 Radio-nuclear and chemical activities / safety
 Customs
 Food safety
 Borders / immigration
 Agriculture (and animal health)
 International ports, airports, ground crossings
 Transportation (including dangerous goods)
 Collection, use and disclosure of public health information
 Activities of authorities at national, state/provincial/district, local levels.
National IHR Core Public Health Capacities: Monitoring and reporting
 8 Core capacities
- Legislation and Policy
- Coordination
- Surveillance
- Response
- Preparedness
- Risk Communications
- Human Resources
- Laboratory
 levels
- National
- Intermediate
- Peripheral/Community
 Potential Hazards
- Biological
o Infectious
o Zoonosis
o Food safety – Chemical
- Radio nuclear
 Events at Points of Entry
Cross border disease
HIV AIDS
AIDS, the acquired immunodeficiency syndrome (sometime called “slim diseases”) is a fatal
illness caused by a retro virus known as the HIV stands for “Human immunodeficiency virus”
which breaks down the body’s immune system.
Route of transmission
1 During sexual contact
• Unprotected sex
• Vaginal
• Anal
• Oral
2 Through infected blood/blood products

• HIV infected blood or blood products.
• Transfusion sharing of needles and syringes.
3 From mother to child
• During pregnancy
• During child birth
• Through breast feeding.
HIV spread by:

• Infected blood
• Mother to child
• Unsterilized infected needles
• Unsafe sex
• Sharing the needles.
Agent
Virus classification
• Family: Retroviridae
• Genus: lentivirus
• Species: HIV-1,HIV-2
• Destroys T4 lymphocytes
• Inactivated by ether, acetone, ethanol.
Incubation
While the natural history of HIV infection is not yet fully known, current data suggest that the
incubation period is uncertain, (from few months to ten years or even more) from HIV infection
to the development of AIDS. The virus can lie silent in the body for many years.
History
It is widely believed that HIV originated in Kinshasa, in the Congo around 1920 when HIV
crossed species from Chimpanzees to humans. The first case of HIV infection in a human was
identified in 1959. The infected individual lived in the Democratic Republic of Congo. He didn’t
know (and research could not identify) how he was infected. The first case of HIV in the United
States date back to 1981.Homosexual man began to die from mysterious, Pneumonia like
infections. By 1980, HIV may have already spread to 5 continents (North America, South
America, Europe, Africa and Australia). In this period, between 1to3lakh people could have
already been affected. In June 1981, the U.S centers for disease control and prevention first
described the symptoms of this unknown diseases in one of their publication.
Sign and symptoms
The clinical features of HIV infection have been classified into 4 broad categories.
1 Initial infection
2 Asymptomatic carrier state
3 AIDS- related complex (ARC)
4 AIDS
1. Initial infection

 Fever
 Severe fatigue
 Swollen glands
 Muscles Aches
 Sore throat
 Night sweats
 Ulcer in mouth
2. Asymptomatic carrier state
Infected people have antibodies, but no overt sign of diseases. It is not clear how long the
asymptomatic carrier state lasts.
3. AIDS- related complex
 A person with ARC has illness caused by damage to the immune system, but without the
opportunistic infection and cancer associated with AIDS, some clinical signs are
 Unexplained Diarrhoea lasting longer than a month
 Fatigue
 Loss of more than 10% body weight.
 Fever
 Night sweats
 Enlargement of spleen
4. AIDS
AIDS is the end stage of HIV infection. A number of opportunistic infection commonly
occur in this stage. Death is due to uncontrolled or untreatable infection.
BURDEN
World Scenario:
Global summary of the AIDS epidemic 2014
Number of people
Total: 36.9million
Living with HIV in 2014
Adults: 34.3million
Women: 17.4million
Children (<15 years): 2.6million
People newly infected
Total: 2.0million
With HIV in 2014
Adults: 1.8million
Children (<15years): 220,000
AIDS deaths 2014
Total: 1.2million

Children (<15years) 150,000
Nepal Scenario:
• In 2012: 48600 adults and children are infected with the HIV virus.
• In 2013: 22994 cases of HIV had been reported. Out of which 4027(8.3%) are children of
014 years age group and 44620(91.78%) are adults 15 yrs. and above.
• In 2014: 39249 cases of HIV had been reported. And Total death cases –567
Total new cases - 1493
Programs of HIV-AIDS in Nepal
 1988:- Launched the first National AIDS prevention and control
program.
 1990-1992:- First medium term plan.
 1993-1997:- Second medium term plan.
 1993:- National policy on blood safety.
 1995:- National policy on HIV-AIDS.
 1997-2001:- Strategic plan for HIV-AIDS prevention.
 2000:- Situation analysis of HIV-AIDS.
 2002-2006:- National HIV-AIDS strategic plan.
 2003-2007:- National HIV-AIDS operational plan.
 2006-2008:- National HIV-AIDS action plan.
 2006-2011:- New national HIV-AIDS strategic plan.
 2008-2011:- National HIV-AIDS Action plan.
 2007:- National HIV-AIDS and STI control board established.
 2008:- National HIV-AIDS action plan.
 2011:- New national policy on HIV-AIDS and STI.
 2011-2016:- New national HIV-AIDS strategic plan
Preventive Measures:
1. Parenteral:
 Routine screening of blood/blood products for HIV.
 Needle exchange program for intravenous drug user.
2. Sexual:
 Public awareness campaign for HIV-AIDS.
 Safe sex practices- Use of condoms.
 Controll of different STDs.
3. Perinatal:
 Routing HIV testing in antenatal clinics.
 Avoidance of pregnancy if HIV- Sero positive.
 Antiretriviral therapy during pregnancy.
 Avoidance of breast feeding.
4. Antiretriviral drugs- not a cure, limited access by all.
Control:
1. Prevention

2. Anti-retroviral treatment.
3. Specific prophylaxis against
 P.carinni pneumonia
 M. tuberculosis
 Candidiasis
4. Primary health care
Malaria
Malaria is a protozoal disease caused by parasitic plasmodium and transmitted to man by certain
species of infected female Anopheles mosquito.
Agent:
Malaria in man is caused by four distinct species of the malaria parasites. These are:-
1. Plasmodium vivax
2. Plasmodium falciparum
3. Plasmodium malariae
4. Plasmodium ovale.
Mode of transmission:
 Malaria is transmitted from one infected person to another by the bite of Female Anopheles
Mosquito.
 Direct transmission. Eg:- Blood transfusion.
Incubation period
P.Falciparum P.Vivax P.Malariae P.Ovale
IP (9-14)days (8-17)days (18-40)days (16-18)days
Sign and symptoms
 Fever
 Headache

 Dizziness
 Anaemia
 Jaundice
 Dry cough
 Nausea and vomiting
 Diarrhoea
 Abdominal pain
 Enlargement of spleen and liver.
 Fatigue
Complication:
 Cerebral malaria
 Liver damage
 Renal failure
 Pulmonary oedema
 Dehydration
 Nephrotic syndrome
 Hypotension
 Severe Anaemia
 Shock
Burden:
World scenario in 2011:-
• 107 countries of the world have reported malaria.
• 2.5 billion People at risk.
• 40% of the world population live at the risk of malaria.
• More than 500 million people are infected by malaria every year.
• 90% death reported from the African region.
In Asia in 2011:-
• 84% of total population are at risk of malaria.
• Malaria is endemic in all the countries except maldives.
• There is the estimate over 1lakh deaths per year.
• 38% of world’s clinical cases of malaria occur in Asia.
Nepal scenario in 2013/14:-
• Approximately 13.02 million population live in malaria endemic areas. Out of which
1million lives in high risk.
• High risk district:- Morang, Jhapa, illam, Sinduli, dhanusa, mahottari, kavre, nawalparasi,
banke, bardiya, kailali and kanchanpur.
• A total population of 14.13million people is estimated to live in VDCs where there is no
malaria transmission.
Malaria control program:-
 Malaria control program was started in nepal in 1954.
 It is the first public health program in nepal.

 Malaria eradication program was started in nepal in 1958 which was unsuccessful. Due to
various reason, it was changed into malaria control program in 1978.
 In 1998 Roll back malaria program was launched to find out the problem of malaria in
nepal.
 Distributing SUPANET to risk areas.
 Vision:-malaria free nepal by 2026.
Preventive Measures:
 Use of mosquito net during sleep.
 Screening of blood donar before donation of blood.
 Use of mosquito repellent cream to exposed skin.
 Use screens over doors and windows.
 Proper sanitation and spraying around human habitat.
 Proper disposal of wastage materials.
 Available of health care services for early diagnosis and prompt treatment.
 Conduct awareness programs.
POLIOMYELITIS
It is an acute viral infection caused by an RNA virus.It is primarily an infection of the human
alimentary tract but the virus may infect the central nervous system in a very small percentage
(about 1%) of cases resulting in varying degrees of paralysis and possibly death.
History
• First described by Michael underwood in 1789.
• First outbreak described in us in 1843.
• 21,000 paralytic cases reported in the USA in 1952.
• In pre-vaccination era, it was found in all countries.
• The extensive use of polio vaccine since 1954 has eliminated polio in developed countries.
Causative agent:
It is due to a filter passer polio virus, which is found in nasopharyngeal secretion, faeces, urine of
patient & carriers. The virus is of three types:
• Viz.brnuhilde
• Lansing
• Leon
Mode of transmission
• faeco-oral route:
This is the main route of spread in developing countries.The infection may spread directly
through contamined fingers where hygiene is poor,or indirectly through contaminated
water,milk,foods,flies and articles of daily use.
• Droplet infection:
This may occur in the acute phase of disease when the virus occurs in the throat.close personal
contact with an infected person facilitate droplet spread.
Incubation period

Usually 7-14 days (sometimes 3-30 days)
Clinical feature:
When an individual susceptible to polio is exposed to infection, one of the following responses
may occur.
• Subclinical Infection:This occurs aproximately in 91-96% of poliovirus infection.There are
no presenting symtoms.Recognition only by virus isolation or rising antibody titres.
• Minor Illness:occurs in approx.1% of all infections.It causes only a mild illness due to
viraemia.The patient recovers quickly.Recognition only by virus isolation or rising antibody
titres.
• Non-Paralytic Polio: Occurs in approx.1% of all infections.The presenting features are
stiffness & pain in the neck & back.Recovery is rapid.
• paralytic polio: Occurs in less than 1% of infection.The virus invades CNS & causes varying
degrees of paralysis.Fever at the time of onset of paralysis is suggestive of polio.The others
associated symptoms are anorexia,nausea, vomitting,headache,sore throat,constipation &
abdominal pain.
Burden
• Since 1988, implementation of the eradication strategies has reduce the number of polio
endemic countries from more than 125 in 1988 to 3 in 2012.
• In 21st august 2012, 123 cases of wild polio virus were reported globally, out of which 72
cases were reported from Nigeria, 17 from Afghanistan and 29 from Pakistan.
Burden in Nepal
• From 2000 -2004, Nepal did not detect any wild poliovirus cases, but from 2005 we have
cases until 2008.
• While in 2008,426 AFP (acute flaccid paralysis) cases were reported and 6 of them were
confirmed to be polio.
• In 2009, 444 AFP cases were reported and all of them were discarded as non-polio AFP.
Program in Nepal
• Nepal introduce expanded program on immunization in 1975 with 3 antigens in 3 district. By
the year 1988-1989, the program expanded district included all 6 globally recommended
antigens (BCG, DPT, measles, and polio).
• In 1996, Nepal initiated polio eradication efforts by holding the first national immunization
days in all 75 districts.
• The polio eradication strategy in Nepal includes Increase and sustain the coverage of OPV3
to 95% at the ward level.
• Conduct national immunization days aiming to have universal coverage.
• Surveillance of acute flaccid paralysis case.
• Mop-up activities in places reporting to have polio cases and high risk area.
• Female community health volunteers are the key vaccinators for polio in the campaign,
campaign are run for 2 days and 2 round each time.
• In 2009 there was only 1 national campaign on polio.
Prevention

• Immunization is the sole effective means of preventing poliomyelitis. Both killed & live
attenuated vaccines are available & both are safe & effective when used correctly. It is
essential to immunize all infants by 6 months of age to protect them against polio.
• Two types of vaccine are used throughout the world-inactivated polio vaccines and oral
polio vaccines.
TUBERCULOSIS
Tuberculosis is a specific infectious disease caused by M. tuberculosis. The disease primarily
affects lungs and causes pulmonary tuberculosis. It can also affect intestine, meninges, bones and
joints, lymph glands, skin and other tissues of the body. The disease is usually chronic varying
clinical manifestations. The disease also affects animals like cattle, this is known as “bovine
tuberculosis", which may sometimes be communicated to man. Pulmonary tuberculosis is the
most important form of tuberculosis which affects man.
History:
• TB is caused by Mycobacterium tuberculosis known since 1000 B.C.
• World TB day is held every year on 24 th March, the anniversary of the discovery of the TB
bacillus in 1882 by the German microbiologist Robert Koch.
Types
There are mainly 2 types of TB
1. Pulmonary TB
2. Extra pulmonary TB
Mode of Transmission
Pulmonary tuberculosis is transmitted by air borne route.
• Patients with the disease ( bacilli) expel droplets into the air by:
o coughing o sneezing o shouting o or any other way that will expel
bacilli into the air.
• People with prolonged, frequent, or close contact with people with TB are at particularly high
risk of becoming infected.
• If not treated, each person with active TB infects on average 10 to 15 people every year.
Incubation Period: Incubation period: 3-6 weeks
Clinical Features:
Symptoms can vary depending upon the part of the body infected- the lungs, heart, brain, spine,
stomach, kidneys etc.
Some general sign and symptoms are:
1. Chronic cough
2. chest pain
3. weight loss
4. loss of appetite

5. low grade fever
6. night sweats
7. fatigue
Prevention and control
• Environmental factors: (nutrition, better housing, hygiene)
• Changed social attitudes towards TB
• Improved diagnostic techniques, recognition and awareness
• Improved notification procedures
Strategies of prevention and control :
• Bacillus Calmette-Guerin (BCG) vaccination.
• Case finding.
• Effective chemotherapy.
• Health education.
Burden of disease
WORLD
• billion people ,equal to a third of the world’s total populations are infected with the TB
bacilli
• 1 in 10 people infected with the TB bacilli will become sick with active TB.
• TB is curable but kills 5000 people, every day.
• 98% of TB deaths are in developing world affecting mostly young adults in their most
productive years.
• TB is a leading killer among HIV-infected people with weakened immune system, about
200 000 people living with HIV/AIDS die from TB every year, most of them being in
Africa.
• There were 8.8 million new TB cases in 2005 and 80% of them in 22 countries.
• If left unchecked, within 20 years TB will kill a further 35 million people.
• Global TB incidence is still growing at 1% a year due to the rapid increase in Africa;
intense control efforts are helping incidence fall or stabilize in other region.
ASIA
• TB is a disease of poverty; affecting mostly young adults; the vast majority of TB deaths
are in the developing world, with more than half of all deaths occurring in Asia.
• million prevalent and about 3.5 million incident cases of tuberculosis in 2010, carries
about 40% of the global burden of the disease.
• Five of the eleven Member States of the Region are among the 22 TB high-burden
countries in the world, with India alone accounting for more than 25% of the world’s
incident cases.
NEPAL
Tuberculosis (TB) is a major public health problem in Nepal. About 45 percent of the total
population is infected with TB, of which 60 percent are adult. Every year, 45, 000 people
develop active TB, out of them 20,580 have infectious pulmonary disease. These 20,000 are able
to spread the disease to others. Treatment by Directly Observed Treatment Short course (DOTS)

has reduced the number of deaths; however 5,000-7,000 people are still dying per year by TB.
Expansion of this cost effective and highly successful treatment strategy has proven its efficacy
in reducing the mortality and morbidity in Nepal.
DoHS, Annual Report 2069/70 (2012/2013)
Programs in Nepal
Major Activities
Key activities of NTP are as follows:
• Provide effective chemotherapy to all patients in accordance with national treatment policies.
• Promote early diagnosis of people with infectious pulmonary TB by sputum smear
examination.
• Establish a network of microscopy centers and a system of quality control of sputum smear
examination.
• Establish treatment centers for every 100,000 population within the existing primary health
care system.
• Provide continuous drugs supply to all treatment centers. This includes systems for
procurement, storage, distribution, monitoring and quality control of drugs.
• Maintain a standard system for recording and reporting.
• Monitor the result of treatment and evaluate progress of the program, by analyzing periodic
treatment outcome in cohorts of patients.
• Provide continuous training and supervision for all staff involved in the NTP, at each level.
• Pilot and expend health communication project to improve communication between health
workers and TB patients and to promote community awareness about TB.
• Expansion of income generation and skill development training activities to needy DRTB
patients in all over the country.
• Strengthen cooperation between non – government organizations (NGOs), bilateral aid
agencies and donors involved in the NTP. Coordinate NTP activities with other primary
health care activities, especially leprosy and AIDS/STD programs.
• Carry out research programs to improve the NTP performance.
DOTS (Directly observed Treatment Short Course) and Centre Expansion:
Nepal has adopted microscopy diagnosis and DOTS treatment policy in order to control TB.
Thus full coverage of microscopy center for diagnosis and DOTS for treatment of TB patients is
must to enhance the program. Starting with 4 DOTS center and microscopy center in 1996, the
TB control program initiated a momentum toward its goal. Till today the expansion of DOTS
center and microscopy center is almost complete throughout the country. Even the number of
DOTS center and microscopy center is slightly increasing over every year in the country to make
more accessible for the people who are unreached. In this regard, non-state actors including
private sectors have important contribution by technical and logistic support.

SWINE FLU
 A Contagious respiratory disease of pig caused by type A influenza virus that regularly
causes outbreaks in pigs.
 Also called Pig influenza, Swine influenza, Pig flu & hog flu.
 An infection caused by any one of several types of swine influenza viruses. I.e. Influenza A
– H1N1, H1N2, H2N1, H3N1, H3N2 & H2N3.
 Swine influenza virus is common throughout pig populations worldwide.
 The most common version is H1N1. The current strain is a new variation of an H1N1 virus,
which is a mix of human and animal versions.
Virus
• RNA, enveloped
• Viral family: Orthomyxoviridae
• Size:
- 80-200nm or 0.8-0.12μm (micron) in diameter
• Three types
- A, B, C
• Surface antigens
- H (haemaglutinin)
- N (neuraminidase)
Swine Influenza A (H1N1) History
• Swine influenza was first proposed to be a disease related to human flu during 1918,flu
pandemic, when pigs became ill at the same time as humans.
• However, direct transmission from pigs to human is rare, with only 12 recordedcases in
US since 2005.(called as zoonotic disease).
• A swine flu outbreak in (Fort Dix, New Jersey, USA) occurred in 1976 that caused more
than 200 cases with serious illness in several people and one death.
• In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was
hospitalized for pneumonia after being infected with swine flu and died 8 days later.
• From December 2005 through February 2009, a total of 12 human infections with swine
influenza were reported from 10 states in the United States.
Recent Pandemics
World Scenario:
• 1889-1890 - first recorded pandemic
• 1918 - “Spanish” flu- 20-40 million deaths
• 1957 - “Asian” flu- 1 million deaths
• 1968 - “Hong Kong” flu- 1 million deaths
• 1976 - Outbreak in US (unreported deaths)
• 2007 – outbreak in Philippine
• 2009 – Again Pandemic
• 2015 – Outbreak in Iran and Northen Ireland
In India:
In 2015: 10,000 cases reported & 660 deaths occurred.

The highest no. of cases & deaths were found in Rajasthan,Gujraat,Madhya Pradesh,Delhi.
In Nepal:
On June 11, 2009, World Health Organization (WHO) had declared swine flu pandemic.
The Normal Burden of Disease
Seasonal Influenza
 Globally: 250,000 to 500,000 deaths per year
 In the US (per year) o ~35,000 deaths o >200,000
Hospitalizations o >$10 billion in productivity lost
Pandemic Influenza
An ever present threat
Swine Influenza A (H1N1) Transmission to Humans
• Through contact with infected pigs or environments contaminated with swine flu viruses.
• Through contact with a persons infected with swine flu.
• Human-to-human spread of swine flu has been documented also and is thought to occur in
the same way as seasonal flu, through coughing or sneezing of infected people.
Just like seasonal flu, H1N1 swine flu spreads as:
• Through droplets produced when a contagious person coughs, sneezes, or talks.
• A person can be infected by breathing in these wet drops or by touching something that was
recently contaminated and then touching their mouth, nose, or eyes.
• H1N1 virus Can survive on hard and smooth surfaces for 24 –48 hours and on porous
surfaces (e.g. tissues, clothes) for up to 12 hours.
• Can survive for 5 min. after it gets on the hands.
• That Is easily killed by heat and household cleaners.
Influenza vs Cold Symptoms
Signs & Symptoms Influenza Cold
Onset(beginning) Sudden Gradual
Fever high grade(over 101F) lasting 3 to 4 days Rare

Cough can became severe Hacking
Headache Prominent Rare
Myalgia ( pain in muscle) Usual; often severe Slight
Fatigue; weakness Can last up to 2-3 weeks Very mild
Extreme exhaustion Early and prominent Never
Chest discomfort Common Mild to moderate

Stuffy nose Sometimes Common
Sneezing Sometimes Usual

Sore throat
(inflamation of pharynx) Sometimes Common
Risk factors for complications:

• especially age less than 4 and ages > 65 years.
• At pregnancy
• Residence of nursing homes and other chronic care facilities
• Chronic cardiac or pulmonary disorders like asthma
• Chronic conditions such as diabetes etc.
Swine Influenza A(H1N1) Guidelines for General Population (Preventive Measures)
 Covering nose and mouth with a tissue when coughing or sneezing  Dispose the tissue
in the trash after use.
 Handwashing with soap and water
 Especially after coughing or sneezing.
 Cleaning hands with alcohol-based hand cleaners .
 Avoiding close contact with sick people.
 Avoiding touching eyes, nose or mouth with unwashed hands.
 If sick with influenza, staying home from work or school and limit contact with others to
keep from infecting them.
 Wear masks at the groups and while going to the infected area.
 Eat properly cooked meat.
Programs in Nepal:
 On 29th April, 2015 , the government of Nepal issued an alert to over 40 Rapid Response
Teams and stationed a team of health professionals at Tribhuvan International Airport.
 The government has also deployed surveillance teams across the country and strengthened
hospitals, mainly Tribhuvan University, Teaching Hospital and Sukraraj Tropical and
Infectious Disease Hospital to provide special treatment.
 The department has stockpiled drugs, namely Tamiflu & masks and now has in place a
system capable of attending to 40,000 patients
 It has also stepped up vigilance for symptoms of the flu at border points.
 Seasonal flu shots(vaccine) can prevent H1N1 flu viruses which are presently available in
Advanced Polyclinic in Kathmandu and Pokhara.
BIRD FLU
Bird flu is also called avian influenza or avian flu and sometimes H5N1.
 Birdflu viruses infect birds,including chicken,poultry and wild birds such as ducks. On rare
occasions,these bird viruses can infect other species,including pigs and humans.
 This could lead to pandemic ,or a worldwide outbreak of illness.

History
 The H5N1 strain first infected human in Hongkong in 1997,causing 18 cases , including six
death.
 Then the highly pathogenic avian influenza form that has spread across Asia,into western
Europe and africa.
 Since mid-2003 , this virus has caused the largest and most severe outbreaks in poultry on
record.
 The wide spread of birdflu makes it a serious threat to human.
In Nepal
The 1st outbreak of birdflu in nepal is on jan. 16.2009 when chickens died suddenly on
mechinagar municipality-10 jhapa ,eastern nepal.
Agent
• It is caused by an RNA genome group of virus.
• It has three recognized types A,B,C.
• From the epidemological point of view , there are two antigens involved in infection-one
hemagglutinin(H) antigen and the other neuraminidase(N) antigen.
• Their sub types are from H1 to H12 and N1 to N9 antigen recognized so far.
Route of transmission
In managing environment risk we need to understand the routes of virus transmission that is how
it moves through the environment and eventually reaches a site of infection .for human influenza
virus transmission occur primarily by inhalation of infectious droplets or airborne droplet nuclei
and direct or possibly indirect (fomite),contact follow by transfer to the upper respiratory tract
via the nose, mouth or eyes .e.g ingestion of contaminated water,although there is, as yet no
evidence of this reported.
Clinical features:
At present most cases of human H5N1 infections were characterised by a severe influenza
syndrome,clinically indistinguishable from severe human influanza,with symptoms of
• Fever
• Cough
• Shortness of breathe
• Radiological evidence of pneumonia
• Radiological evidence of pulmonary damage could still be obsorved in surviving patient
several months after the illness
• Gastrointestinal symptoms such as vomitting & abdominal pain, in some cases diarrhoea.
World scenario
• Since december 2003 over 478 human cases have been laboratory confirmed in 15 countries
& about 286 people have died.Most cases have occurred in previously healthy children &
young adults.
• During 2011,62 human cases of birdflu were reported from
cambodia,egypt,indonesia,bangladesh and china of which 34 were fatal.

Burden in Nepal
• Fortunately it is found only in one place of nepal on jan 16,2009(kakadvitta,jhapa).
• Second outbreak on 20th feb 2009 at sharnamati V.D.C jhapa eastern nepal.
• The government conducted birdflu assessment in major cities including kakadvitta, pokhara,
surkhet, rupendehai, biratnagar, sindhuli, where there are large poultry market but found no
evidence of virus after examing more then 100 sample according to AICP(avian influenza
control project).
Program in nepal
• Interaction program on birdflu on 6th Aug 2013 was held with the aim to discuss on current
situation.
• The main issues raised and discuss among the stakeholder were birdflu status of nepal,reason
behind the spread of birdflu,impacts of birdflu outbreak,vaccination & insurance & the
activities carried out by government and other bodies to address the situation.
• The government destroys chickens ,ducks,and parrots,eggs and sacs of feed and bury them
away from the residential area according to ministry of health.
• The effective means of communication such as Radio,T.V, Newspaper provide information
to people in a large scale.
Preventive measures
• Avoid sources of exposure
• Avoid contact with sick or dead infected poultry
• People who work with poultry are advised to follow recommended bio-security & infection
control practices including hand hygiene with soap and water or an alcohol-based hand
sanitizer, and to cover mouth and nose, eye protection, gloves.
• Meat should be cooked properly before eating.
• Public awareness about preventive measures.
Global Health Issues
Bioterrorism
Bioterrorism is terrorism involving the intentional release or dissemination of biological agents.
These agents are bacteria, viruses, or toxins, and may be in a naturally occurring or a
humanmodified form. For the use of this method in warfare, see biological warfare.
According to the U.S. Centers for Disease Control and Prevention a bioterrorism attack is the
deliberate release of viruses, bacteria, toxins or other harmful agents used to cause illness or
death in people, animals, or plants. These agents are typically found in nature, but it is possible
that they could be mutated or altered to increase their ability to cause disease, make them
resistant to current medicines, or to increase their ability to be spread into the environment.
Biological agents can be spread through the air, water, or in food. Terrorists tend to use
biological agents because they are extremely difficult to detect and do not cause illness for
several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread
from person to person and some, like anthrax, cannot.[1]
Bioterrorism is an attractive weapon because biological agents are relatively easy and
inexpensive to obtain, can be easily disseminated, and can cause widespread fear and panic
beyond the actual physical damage.[2] Military leaders, however, have learned that, as a military
asset, bioterrorism has some important limitations; it is difficult to employ a bioweapon in a way

that only the enemy is affected and not friendly forces. A biological weapon is useful to terrorists
mainly as a method of creating mass panic and disruption to a state or a country. However,
technologists such as Bill Joy have warned of the potential power which genetic engineering
might place in the hands of future bio-terrorists.[3]
The use of agents that do not cause harm to humans but disrupt the economy have been
discussed.[citation needed] A highly relevant pathogen in this context is the foot-and-mouth disease
(FMD) virus, which is capable of causing widespread economic damage and public concern (as
witnessed in the 2001 and 2007 FMD outbreaks in the UK), whilst having almost no capacity to
infect humans
Bioterrorism Agent Categories
Bioterrorism agents can be separated into three categories, depending on how easily they can be
spread and the severity of illness or death they cause. Category A agents are considered the
highest risk and Category C agents are those that are considered emerging threats for disease.
Category A
These high-priority agents include organisms or toxins that pose the highest risk to the public and
national security because:
 They can be easily spread or transmitted from person to person

 They result in high death rates and have the potential for major public health impact
 They might cause public panic and social disruption
 They require special action for public health preparedness.
Category B
These agents are the second highest priority because:
 They are moderately easy to spread

 They result in moderate illness rates and low death rates
 They require specific enhancements of CDC's laboratory capacity and enhanced disease
monitoring.
Category C
These third highest priority agents include emerging pathogens that could be engineered for mass
spread in the future because:
 They are easily available

 They are easily produced and spread
 They have potential for high morbidity and mortality rates and major health impact.
World Bank
The World Bank is an internationally supported bank that provides financial and technical
assistance to developing countries for development programs, (E.g. Bridges, roads, schools) with
the stated goal of reducing poverty
President: - Robert B. Zoellick
Membership: - 185 countries

Headquarters: - Washington DC and more than 100 country
Established: - July 1, 1944
History
The World Bank is one of the two Bretton Woods institutions which were created in 1944 to
rebuild a Western Europe after World War 2
Operations
 Fund generation
 Loans
 Grants
 Analytic and advisory services
 Capacity building
Fund generation
To provides free loans and grant assistance to the poorest countries.
Loans
 Investment loans
 Development policy loan
 World bank treasury
Grants
 Relieve the debt burden of heavily indebted poor countries.

 Improve sanitation and water supplies
 Support vaccination and immunization programs to reduce the incidence of
communicable diseases like malaria
 Combat the HIV/AIDS pandemic
 Support civil society organizations
 Create initiatives to cut the emission of greenhouse effect
Analytic and advisory services
 Poverty assessments
 Public expenditure reviews
 Topics in development
Capacity building
 Advisory services
 Global development learning network

 World bank institutes global and regional programs
Area of operation
 Agriculture and rural development

 Economic policy
 Education
 Energy
 Environment
 Financial sector
 Health nutrition and population industry
 Law and justice
 Social protection
 Trade
 Water supply and sanitation etc
Criticism
 It was started to reduce poverty but it support United States business interests  The
president of the bank is always a citizen of the United States.
 Lack transparency to external publics
 It is an instrument for the promotion of US or western interests
 The decision making structure is undemocratic
Priorities of World Bank
 World bank provides the largest external funds for education

 It is a big support in reducing poverty
 It provides fund for biodiversity projects  It helps to bring clean water, electricity.
 It helps in controlling emerging conflicts
International Monitory Fund (IMF)

The IMF is an international organization of 185 member countries. It was established to promote
international monetary cooperation, exchange stability, and orderly exchange arrangements; to
foster economic growth and high levels of employment; and to provide temporary financial
assistance to countries to help ease balance of payments adjustments.
Why was it created?
The IMF was conceived in July 1944, when representatives of 45 governments meeting in the
town of Bretton Woods, New Hampshire, in the northeastern United States, agreed on a
framework for international economic cooperation.
What does it do?
• Surveillance

• Lending
• Technical assistance
Surveillance
It is an assessment of economic and financial developments, which provides a framework that

facilitates the exchange of goods, services, and capital among countries and sustains sound
economic growth. It consists in:
Focusing on assessing whether countries' policies promote external stability
It is to be remembered that surveillance is a collaborative, candid, and evenhanded process

between the Fund and its members
Lending
- IMF lending enables countries to rebuild their international reserves; stabilize their currencies;
continue paying for imports; and restore conditions for strong economic growth.
- IMF does not lend for specific projects.
- It eases the adjustment policies and reforms that a country must make to correct its balance of
payments problem and restore conditions for strong economic growth.
Technical assistance
• It supports the development of the productive resources of member countries by helping

them to effectively manage their economic policy and financial affairs.
• About 90 percent of IMF technical assistance goes to low and lower-middle income
countries, particularly in sub-Saharan Africa and Asia.
Trade Related Intellectual Property Rights (TRIP'S)
The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is an

international agreement administered by the World Trade Organization (WTO) that sets down
minimum standards for many forms of intellectual property (IP) regulation as applied to
nationals of other WTO Members.[3] It was negotiated at the end of the Uruguay Round of the
General Agreement on Tariffs and Trade (GATT) in 1994.
TRIPs came into effect in 1995. It imposes minimum standards in seven areas of intellectual
property i.e. patents, copyright, trademarks, geographical indication, industrial design, and
undisclosed information (trade secrets) and covers diverse areas as computer programming and
circuit design, pharmaceuticals and transgenic crops.
Negative Impact
Differences in economic and technological capabilities between the North and the South,
‘technological protectionism’ aimed at consolidating an international division of labour where
the North generates the innovations and the South will be the market for the resulting products
and services.

Privatising Knowledge
In the area of medicine and health, stronger and wider IPR protection will affect the practice of
medicine and the spread of medical knowledge. Protectionism of medical knowledge and
medical practice commodifies medicine further and threatens well being and public health.
EXAMPLE.
 A doctor owns the rights to a basic suturing technique

 A doctor own the rights to the technique of making a slit in a skin graft in
order to expand it
Trade Marks
TRIPs protection of ‘well known’ trademarks even if they are known on the basis of publicity
and not of effective use in a country.
Price Increase on Medicines
TRIPs will have the greatest impact on the pharmaceutical industry and the Third World’s access
to medicines. Third World countries are going to suffer from substantial price increases and
other costs.
Lack of Access to Essential Medicines
Except for China, no Third World country is self-sufficient in essential drugs. Some 2.5 billion
people have little or no access to essential drugs (UNDP 1991). WHO estimates that some
countries pay 150-250 percent more than the world market prices for essential drugs while others
are faced with unreliable suppliers and poor quality drugs?
Health Threats from Biotechnology
Patenting of life forms and biological materials through genetic engineering, also raises adverse
health and environmental concerns. Genetically modified food can cause allergies, toxicity and
antibiotic resistant organisms.

Primary Health Care

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Primary Health Care

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UNIT 1: PRIMARY HEALTH CARE (PHC)

1.1: Alma – Ata Conference on Primary Health Care

 Control of major infectious disease

 Eradication of small pox (1977)

 Malaria eradication and malnutrition

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Easy to remember: Elements

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15. Female Community Health Volunteer Program

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Specifically, in health sector SAP means

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Rational behind Revitalization of PHC in Nepal

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 Free health care service

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UNIT 2: INTERNATIONAL HEALTH 2.1: Introduction of international Health

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Why international health stands for?

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UNDP (United Nation Development Programme)

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New method (2010 Report onwards

• A long and healthy life: Life expectancy at birth

2. Education Index (EI) = MYSI+ EYSI/2

2.1 Mean Years of Schooling Index (MYSI) = MYS/15

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3. Income Index (II) = In(GNIpc)-In(100)/In(7500)-In(100)

LE: Life expectancy at birth

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High human development 0.744 75.1 13.6 8.2

International Health Regulation (IHR) Policy

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 “Disease“an Illness or medical condition, irrespective of origin or source, that presents or

 Events/risks may be:

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HIV spread by:

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