National Health Programs

Dr. Isha Amatya

MBBS (IOM), MD Community Medicine (KMC)
 National Health Policy 2019
Vision:
• Healthy, alert and conscious citizens oriented to happy
life.
Goal:
• To develop and expand a health system for all citizens
in the federal structures based on social justice and
good governance and ensure access to and utilization
of quality health services

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Objectives:
• To create opportunities for all citizens to use their
constitutional rights to health;

• To develop, expand and improve all types of health

systems as per the federal structure;

• To improve the quality of health services delivered by

health institutions of all levels and to ensure easy
access to those services;

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• To strengthen social health protection system by
integrating the most marginalized sections;

• To promote multi-sectoral partnership and

collaboration between governmental, non-
governmental and private sectors and to promote
community involvement; and

• To transform the health sector from profit-orientation

to service-orientation.

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 Universal health coverage (UHC)
• All people and communities can use
the promotive, preventive, curative,
rehabilitative and palliative health
services they need of, sufficient
quality to be effective, while also
ensuring that the use of these
services does not expose the user to
financial hardship.

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 Health Care System In Nepal
• Two tier health care – Government health care with a
Parallel private system

• Government health services coverage - no more than 15-

20% of the population

• Out of pocket model - common

• Health insurance is almost non existent and more than
60% of health cost are met out of pocket by patient.

• Health Service structure: Primary Health Care, Secondary

Health Care, Tertiary Health Care 6
Human Resources &
Financial
Management Division

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 DOHS • National AIDS/ HIV
Control Section
• National Public Health
EPIDEMIOLOGY & Laboratory
FAMILY
CURATIVE
MANAGEMENT
DISEASE CONTROL National HealthNURSING
• WELFARE Training & SOCIAL
DIVISION SERVICE SECURITY DIVISION
DIVISION Center
DIVISION
DIVISION
• Integrated • National Health Education,
• Hospital • NTD & vector borne • Child • Nursing
Health Information &
service disease control health & capacity
Information Communication Center
monitorin section immunizat building
management g& • ion
National TB Control Center
service
• Zoonotic & other section
section strengthen communicable section • Geriatric &
• Environment ing section disease control • Maternal gender based
health & • Basic and section & violence
health care emergency • Disease surveillance newborn management
waste services & research section health section
management managem • Epidemiology & section
section epidemic
• Social health
ent • Family security
• Logistic section management planning &
section section
management • Eye, ENT & reproducti
section oral health • NCD & mental ve health
• Infrastructure section health section section
development • Leprosy control &
disability
• Nutrition
section section
management
section
 Major program
Child Health

Family Health

Disease
Control

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 Nutrition Program
• Control of Protein energy Malnutrition

• Control of Iron deficiency Anemia

– IFA tablet supplementation for pregnant and post-partum mothers

– Iron fortification of wheat flours

• School Health and Nutrition programme

– Biannual distribution of deworming tablets to grade 1 to 10 children

• Control of Iodine deficiency disorders

– Iodization of salt (Iodized Salt Act, 2055)

– Social marketing of certified two child logo iodized salt

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• Control of Vitamin A deficiency

– Biannual supplementation of Vit A capsules to 6-59

months old

– Post partum Vit A supplementation for mothers

• Integrated Management of Acute malnutrition

• Low Birth Weight

• Infectious disease prevention and control

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 INTEGRAGED MANAGEMENT OF NEONATAL AND
CHILDHOOD ILLNESS

Community Based-Integrated Management of Neonatal and

Childhood Illness (CB-IMNCI)

• Child survival intervention began when Control of

Diarrhoeal Disease (CDD) Program was initiated in 1983.

• IMCI program was piloted in Mahottari district

• CB-IMCI included the major childhood killer diseases like

pneumonia, diarrhea, malaria, measles, and
malnutrition
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• CB-NCP (Community Based Newborn Care Program):
Major problems of sick newborn such as birth
asphyxia, bacterial infection, jaundice, hypothermia,
low birth-weight, counseling of breastfeeding.

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 Safe Motherhood and Reproductive Health Rights
Bills, 2075
• The goal of the National Safe Motherhood Programme is
to reduce maternal and neonatal morbidity and mortality
and improve maternal and neonatal health.

• Evidence suggests that three delays are important factors

for maternal and newborn morbidity and mortality in
Nepal (delays in seeking care, reaching care and
receiving care)

• The Safe Motherhood Programme (Aama Suraksha

Programme) promotes antenatal checkups and
institutional delivery 14
National safe motherhood plan (2006 – 2017)
Birth Preparedness Package and community level maternal
and newborn health

• Birth Preparedness Package (jeevan suraksha flipchart

and card) and distributed the matri suraksha chakki
(misoprostol) to prevent postpartum haemorrhage (PPH)
in home deliveries.

• For home deliveries, three misoprostol tablets (600 mcg)

are handed over to pregnant women to take immediately
after delivery and before the placenta is expelled.

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 Nyano Jhola Programme
• The Nyano Jhola Programme was launched in 2069/70 to
protect newborns from hypothermia and infections and
to increase the use of peripheral health facilities (birthing
centers).

• Two sets of clothes (bhoto, daura, napkin and cap) for

newborns and one set of wrapper, mat for baby and gown
for mother are provided for women who give birth at
birthing centers and district hospitals

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 Aama and Newborn Programme
For women delivering their babies in health institutions:

• Transport incentive for institutional delivery: NPR 3,000 in

mountains, NPR 2,000 in hills and NPR 1,000 in Tarai districts

• Incentive for 4 ANC visits: A cash payment of NPR 800* to women

on completion of four ANC visits at 4, 6, 8 and 9 months of
pregnancy

• Free institutional delivery services:

– For a normal delivery health facilities with less than 25 beds receive
NPR 1,000 and health facilities with 25 or more beds receive NPR
1,500.
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– For complicated deliveries health facilities
receive NPR 3,000 and for C-sections (surgery) NPR
7,000.

– Anti-D administration for RH negative is

reimbursed NPR 5,000.

– Laparotomies for perforation due to abortion,

indicated or emergency C-sections, laparotomy for
ectopic pregnancies and ruptured uteruses are
reimbursed NPR 7,000.
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 Safe abortion services in Nepal
• Nepal legalized abortion in September 2002 and the first
ever Comprehensive Abortion Care (CAC) service was
started at the Maternity Hospital, Kathmandu, in March
2004.
• The new law grants women the right to a legal abortion
on the following grounds:
1. Up to 12 weeks of gestation for any woman;
2. Up to 18 weeks of gestation in case of rape or incest.
3. At any time during pregnancy, with the advice of a
medical practitioner or if the physical or mental
health or life of the pregnant woman is at risk or if the
fetus is deformed and incompatible with life.
(National Safe Abortion Service Policy 2060 B.S.) 19
 FCHV Programme

• The government initiated the Female Community Health

Volunteer (FCHV) Programme in 2045/46 (1988/1989)

• FCHVs are selected by health mothers' groups.

• FCHVs are provided with 18 days basic training following

which they receive medicine kit boxes, manuals,
flipcharts, ward registers, IEC materials, and an FCHV bag,
signboard and identity card.

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• Family planning devices (pills and condoms only), iron
tablets, vitamin A capsules, and ORS are supplied to
them through health facilities.

• FCHV Day celebrated on 5th December.

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 Disease Control: Malaria
• Malaria control project in Nepal was first initiated in
1954, with the objective of controlling malaria, mainly in
plain region (Terai belt) of central Nepal.

• Roll Back Malaria (RBM) initiative was launched in 1998

to control malaria transmission in hard‐core forests,
foot‐hills, inner‐terai and hill river valleys, which
accounted for more than 70 % of the total malaria cases
in the country.

National Malaria Strategic Plan (NMSP‐2014‐2025)

Vision: Malaria‐free Nepal in 2025
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 Disease Control: Kala-azar
• Kala-azar: caused by the parasite Leishmania Donovani,
transmitted by the sandfly Phlebotomus Argentipes.

• Disease is characterized by fever for more than two weeks

with spleenomegaly, anaemia, and progressive weight
loss and sometimes darkening of the skin.

• The government committed to the regional strategy to

eliminate kala-azar, with the target of achieving
elimination by 2015.
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• National Strategic Guideline on Kala-Azar Elimination (2010)

– Target: Reduce the incidence of kala-azar to less than 1

case per 10,000 populations at district level.

• The guideline recommended rK39 as a rapid diagnostic test

kit and miltefosine as the first line of treatment in kala-azar in
most situations.

• The further revised national guidelines(2014) recommended

introducing Liposomal Amphotericin B and a combination
regimen for kala-azar and PKDL treatment in Nepal.

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 Diseases Control Program: Lymphatic Filariasis
• Nepal conducted LF mapping in 2001 and 2005 and
remapping in 2012 by using ICT (Immunochromatography
Test card) which revealed 13% average prevalence of LF
infection in the country, ranging from <1% to 39%.

• Wuchereria bancrofti is the only recorded parasite in

Nepal and the mosquito, Culex quinquefasciatus,
an efficient vector of the disease has been recorded in all
the endemic areas of the country.
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• National Plan of Action (2003‐2020 AD) for the
Elimination of Lymphatic Filariasis in Nepal

– Strategy: Interruption of transmission by yearly Mass

Drug Administration using two drug regimens (DEC
and Albendazole) for six years.

– Target: Achieve <1% prevalence (microfilaraemia rate)

in all endemic districts after 6 years of MDA by 2018

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 Diseases Elimination Program: Leprosy

• The establishment of the Khokana Leprosarium in the

nineteenth century was the beginning of organized
leprosy services in Nepal.

• Vision: Leprosy free Nepal

• World Leprosy Day—Celebrated on the last Sunday

in the month of January

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• Prevalence: 0.92 case per 10,000 population
– This rate is below the cut-off point of 1 case per 10,000
population set by WHO to indicate the elimination of
leprosy as a public health problem.

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 Diseases Control Program: Tuberculosis
• Tuberculosis (TB) is a public health problem in Nepal and
is the sixth leading cause of death in the country.

• Nepal adopted the Directly Observed Treatment Short

Course (DOTS) strategy in 1996 and achieved nationwide
coverage in 2001.

• There are 4,344 DOTS treatment centers in Nepal and the

NTP has adopted the Global End TB Strategy as the
country’s TB control
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Vision: Nepal free of tuberculosis

Long term goal: End the tuberculosis epidemic by 2050

problem (threshold of <1 case per million population).

SDG global targets: By 2030, end the epidemics of AIDS,

tuberculosis, malaria and neglected tropical diseases and
combat hepatitis, water-borne diseases and other
communicable diseases.

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 The End TB Strategy
GOAL: End the Global TB Epidemic
MILESTONES FOR 2025:
1. 75% reduction in TB deaths (compared with 2015)
2. 50% reduction in TB incidence rate (less than 55 TB cases per
100,000 population)
3. No affected families facing catastrophic costs due to TB

TARGETS FOR 2035:

1. 95% reduction in TB deaths (compared with 2015)
2. 90% reduction in TB incidence rate (less than 10 TB cases per
100,000 population)
3. No affected families facing catastrophic costs due to TB

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 Diseases Control Program: HIV/AIDS and STI

• With the first case of HIV identification in 1988

• Nepal started its policy response to the epidemic of HIV

through its first National Policy on Acquired Immunity
Deficiency Syndrome (AIDS) and Sexually Transmitted
Diseases (STDs) Control, 1995 (2052 BS).

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• A new National HIV Strategic Plan 2016-2021 is launched
to achieve ambitious global goals of 90-90-90.

– By 2020, 90% of all people living with HIV (PLHIV) will

know their HIV status,

– 90% of all people with diagnosed HIV infection will

receive sustained antiretroviral therapy, and

– By 2020, 90% of all people receiving antiretroviral

therapy will have viral suppression.

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 Prevention of Mother to Child Transmission
• Nepal started its Prevention of Mother to Child
Transmission (PMTCT) program in 2005
• The National Strategy has structured the PMTCT
programme around the following comprehensive and
integrated four-prong approach:
– i. Primary prevention of HIV transmission
– ii. Prevention of unintended pregnancies among
women living with HIV
– iii. Prevention of HIV transmission from women living
with HIV to their Children, and
– iv. Provision of Treatment, Care and Support for
women living with HIV and their children and families.
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 Surveillance and Research
• EDCD’s Disease Surveillance and Research Section was
established in August 2013.

Early Warning and Reporting System (EWARS)

• Disease surveillance is carried out through the EWARS, a

hospital-based sentinel surveillance system that
complements the HMIS (Hospital Management
Information System) by the early reporting of selected
vector-borne, water and food borne diseases with
outbreak potential. 35
• Mainly concerned with the weekly reporting of number of
cases and deaths (including zero reports) of six priority
diseases — malaria, kala-azar, dengue, acute
gastroenteritis (AGE), cholera and severe acute
respiratory infection (SARI).

• Prioritizes the immediate reporting (within 24 hours of

diagnosis) of one or more confirmed cases of cholera,
severe and complicated malaria cases, one
suspected/clinical case of dengue, or five or more cases of
AGE and SARI, from the same geographical locality in a 36
 Primary Health Care
• Alma-Ata Decleration 1978: Alma-Ata, Kazakhistan, Major
milestone of the 20th century in the field of public health

• Goal: Health for All by 2000

• Hallmarks of Primary Health Care: 4 A’s

– Affordability

– Acceptability

– Accessibility

– Availability

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Principle of Primary health care

• Equitable distribution

• Community participation

• Appropriate technology

• Intersectoral coordination (Multi-sectoral approach)

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 Components in Primary Health Care
E – Education for Health and environment health

L – Locally endemic disease control

E – Expanded program for immunization

M – Maternal and Child Health including family planning

E – Essential drugs

N – Nutrition

T – Treatment of common diseases and injuries

S - Safe water and sanitation

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UNICEF-WHO initiative for child survival-GOBI-FFF

• Growth monitoring

• Oral rehydration therapy

• Breast feeding

• Immunization

• Family planning

• Female education

• Food supplementation

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