Concept of Health for all

and Primary health care

Dr. Alok Acharya

Assistant Professor
Department of Community Medicine
NOMCTH
Biratnagar
"health for all by the year 2000".
 What does "health for all"
mean?
• It means simply the realization of WHO's objective of "the
attainment by all peoples of the highest possible level of
health"; and that as a minimum all people in all countries
should have at least such a level of health that they are
capable of working productively and of participating actively
in the social life of the community in which they live.
• To attain such a level of health every individual should have
access to primary health care and through it to all levels of a
comprehensive health system.
• In 1978 an International Conference on Primary Health Care
was held in Alma-Ata, USSR. This Conference, which
declared that primary health care is the key to attaining
health for all.
 PRIMARY HEALTH CARE –
HEALTH FOR ALL
• All WHO members adopted Primary
health care after the Alma Ata
declaration in 1978.
• Reasonably good progress in health
status BUT gaps exist among & with in
developing & developed countries .
• Fundamental principles of Health For All
- Equity , Social Justice & Solidarity
• FOR ALL Means EQUITY
 PRIMARY HEALTH CARE
• Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology
made universally accessible to individuals 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.
 PRIMARY HEALTH CARE
Definition
• Essential Comprehensive Health Care
• Universally Accessible and Available
• Socially & Culturally Acceptable
• Affordable by community & country
• Active community participation
• Practical & Scientifically sound
 PRIMARY HEALTH CARE -
PRINCIPLES
• Equitable distribution
• Inter-sectoral coordination
• Appropriate technology
• Community participation
• Political will
• Decentralization
• Referral services
 Appropriate technology
• Technology that is scientifically sound, adaptable to local
needs and acceptable to those who apply it and those for
whom it is used and that can be maintained by the people
themselves in keeping with the principle of self-reliance
with the resources the community and country can afford’
This means methods, procedures, techniques and
equipment that are:
– Scientifically valid
– Adapted to local needs
– Acceptable to users and recipients
– Maintainable with local resources
 Appropriate technology
• Appropriate technology is any technology
that makes the most economical use of a
country's natural resources and its relative
proportion, of capital, labour and skills-and
that contributes to national and social
goals. Where machinery and/or equipment
are involved, it should be simple to run
and repair. It should be locally produced
as far as possible.
 Appropriate technology
• Examples of Appropriate Technology:
• ORS instead of expensive intravenous
replacement of fluids in mild and moderate
dehydration
• Growth charts: these can be maintained
by health workers
• Chlorine tablet for water disinfection
 PRIMARY HEALTH CARE –
COMPONENTS
• Education on health & diseases
• Prevention of locally endemic diseases
• Immunization
• Mother & Child Health services
• Provision of essential drugs
• Nutrition & growth monitoring
• Treatment of the common illnesses
• Ensure safe water & basic sanitation
 FACTORS AFFECTING THE
PRIMARY HEALTH CARE
• Geographical area
• Level of health care
• Responsiveness
• Felt needs of the community
• Political commitment
• Social accountability
 PRIMARY HEALTH CARE-
SHORTCOMMING
• Limited Political Will
• Inadequate , improper Human resource
development and staff deployment.
• Lack of Supportive supervision at all level.
• Lack of proper referral services.
• Inadequate application of PHC
 EQUITY
• “Minimizing avoidable disparities in health
and its determinants “

• Equity in health status

• Equity in health care ( services / resource
allocation)
EQUITY
• According to the WHO, equity is
"the absence of avoidable or
remediable differences among
groups of people, whether those
groups are defined socially,
economically, demographically or
geographically." Therefore, as the
WHO notes, health inequities
involve more than lack of equal
access to needed resources to
maintain or improve health
outcomes. They also refer to
difficulty when it comes to
"inequalities that infringe on
fairness and human rights norms."
 EQUITABLE ACCESS
MEASURES
MEASURES EXAMPLES

According to felt Gen. Health Conditions /

need Symptoms
According to Race/Ethnicity, Occupation,
Social Education
Advantage
According to Income/ health insurance
personal coverage
Resources
 FACTORS AFFECTING THE
EQUITY
• Availability of health facilities
• Ability & willing to pay for the services
• Quality of the care
• Globalization of health
• Privatization of health
 BARRIERS IN PRIMARY
HEALTH CARE
• Poverty , Population growth
• Environmental degradation
• Political. Social & Economical instability
• Societal indiscrimination, Gender bias etc.
• Health system deficiency , Bureaucracy
• Managerial inadequacy
• Lack of effective partnership
• Privatization
• lack of Professionalism
 PRINCIPLES TO ACHIEVE
PHC IN RURAL AREAS.
• Accessibility & Equity
• Community participation & empowerment
• Poverty alleviation programs
• Elementary education to all
• Commitment to HFA & PHC
• Development of Scientific norms &
standards for rural primary health care.
• Development of appropriate human
resource.
• Inter and Intra- sectoral coordination
In-patient Top Ten Morbidity

N= 287,616

Source: Annual Report 2015

DALY(burden of disease)

Source: Population and Housing Census, 2011

History of Health System Post Democracy
1975-92 Emergence of
Single Speciality Home
1951-1963 New Health 1964-74 Regionalisation
and Implementation of
Policy of Health Services
Primary Health Care
System

1993-2002 Emergence of
Tertiary Care Centres and
1997-2017 Second Long Expansion of Primary 1991: National Health
Term Health Plan Health Care Centres and Policy was formulated
Growth of Private Health
Institutions

2007: Introduction of Free 2009: Primary Health

Health Care Service; Care Revitalization 2014 New Health Policy
Provision of maternity Division was added for
initiatives and the improvement of PHC
revitalization of PHC Services
 National Health Policy
Adopted in 2014
Objective:
• To make available free the basic health services that existed
as citizen’s fundamental right.
• To establish an effective and accountable health system with
required medicines, equipments, technologies and qualified
health professional for easy access to acquire quality health
services by each citizen.
• To promote people’s participation in extending health
services. For this, promote ownership of the private and
cooperative sector by augmenting and managing their
involvement.

Source: Annual Report 2015

 National Health Care System
• Health care system of Nepal is managed
by Ministry of Health( MoH)
• MoH is responsible for making necessary
arrangements and formulation of policies
for effective delivery of
– Curative Services
– Disease Prevention
– Health Promotion
– Establishment of Primary Health Care System

Source: Annual Report 2015

• Department of Health Services (DoHS) has five Divisions
and Three Sections.
• Divisions of DoHS are:
– Management Division
– Family Welfare Division
– Curative Service Division
– Nursing and Social Security Division
– Epidemiology and Diseases Control Division
• Similarly, three sections of DoHS are:
– Leprosy Control Program/section
– Personnel Administration Section
– Finance Administration Section
 Provincial health directorate
• Province No. 1
• Province No. 2
• Province No. 3
• Gandaki Pradesh
• Province No. 5
• Karnali Pradesh
• Province No. 7
Health care delivery: Provincial level
• The seven-provincial health directorates provide technical
backstopping and programme monitoring to district health
systems and come directly under Ministry of Social
Development of Province.
• The regional, sub-regional, zonal hospitals and district
hospitals are planned to be categorized into three level of
hospitals; Primary, Secondary and Tertiary.
• There are also training centres, laboratories, TB centres (in
some regions) and medical stores at the provincial level.
Health care delivery: Provincial health
directorate
Health care delivery: Provincial level
• Plans to establish one health office in 77 districts which
are under provincial health directorate.
• All Primary Health Care Centres (PHCC) are planned to
be upgrade into primary level hospital which will be
under local authority.
• On the need basis, community health units and urban
health clinics are being run by local bodies.
Health care delivery: Provincial level
• Health posts
– They are the first institutional contact point for basic health
services.
– Health Posts (HP) are present at ward level in the changed
context.
– These lowest level health facilities monitor the activities of
Female Community Health Volunteers (FCHVs) and the
communitybased activities of Primary Health Care Outreach
Clinics (PHC-ORCs) and Expanded Programme on
Immunization (EPI) clinics.
– In addition, they are the referral centres of FCHVs as well as
venues for community based activities such as PHC-ORC and
EPI clinics.
Health care delivery: Provincial level
• Each level above the health post level is a
referral point in a network from PHCCs on to
primary and secondary level hospitals, and
finally to tertiary level hospitals.
• This hierarchy is designed to ensure that most of
the population can receive public health and
minor treatment in accessible places. Inversely,
the system works as a supporting mechanism
for lower levels by providing logistical, financial,
monitory supervisory and technical support from
the centre to the periphery.
 Neglected tropical diseases (NTDs)–

• Neglected tropical diseases (NTDs)– a diverse

group of communicable diseases that prevail in
tropical and subtropical conditions in 149
countries – affect more than one billion people
and cost developing economies billions of
dollars every year. Populations living in poverty,
without adequate sanitation and in close contact
with infectious vectors and domestic animals
and livestock are those worst affected.
 List of NTD
• Buruli ulcer
• Chagas disease
• Dengue and Chikungunya
• Dracunculiasis (guinea-worm disease)
• Echinococcosis
• Foodborne trematodiases
• Human African trypanosomiasis (sleeping sickness)
• Leishmaniasis
• Leprosy (Hansen's disease)
• Lymphatic filariasis
• Mycetoma, chromoblastomycosis and other deep mycoses
• Onchocerciasis (river blindness)
• Rabies
• Scabies and other ectoparasites
• Schistosomiasis
• Soil-transmitted helminthiases
• Snakebite envenoming
• Taeniasis/Cysticercosis
• Trachoma
• Yaws (Endemic treponematoses)
Human Resource Development
• MD/MBBS: National Academy of Medical Science,
Tribhuwan University, Kathmandu University, BP
Koirala Institute of Health Sciences and 20 affiliate
colleges (MBBS only).
• 4 University (Tribhuwan University, Kathmandu
University, Pokhara University and Pubanchal
University) and BPKIHS produce paramedics
(Bachelors and Masters).
• Council for Technical Education and Vocational
Training (CTEVT) produces general medical
practitioners (Certificate Level).
 National Health System
• The Alma-ata and other charters focus on
– That the local administration and other
sectors than the health sector alone carry the
responsibility for the health of the people in
village, district or region
 National Health System Continue

• Hence the health system is now widened

to inclusion of private sector such as;
– Non-governmental (NGO) care, care provided
by missionaries, red cross, local NGOs
– Medical practices by private doctors, nurses
– The licensed pharmaceutical seller
– The large non-biomedical professionalized
healing systems (Ayurvedic, Unani,
homeopathic etc)
 National Health System Continue
• PHC approach has added not only the
medical care providers suffice the health
care to the people
• It has taken the people and community at
the centre.
 Referral and Feedback Mechanism
Level
System
Central Hospital

National/Central

Regional
/Zonal Hospital
Regional

Hospital District

PHC/HP
Referral Line Catchment
area and
Feedback Line Community
AHW/ANM
Source: mohp.gov.np
 Health Management Information System

• Integrated Health Management Information System

(HMIS) was designed and implemented under DoHS,
MoHP in entire country since 1994.

• The current HMIS manages information on all health

services mostly delivered through government’s health
facilities, and partially from non‐government health
facilities.

• MIS Section in Management Division, DoHS generates

statistical tables with raw and analyzed data in every
three months and produces performance review report
every year.
Source; dohs.gov.np
Data Collection/Information Flow Reporting Feedback Latest
Reporting
Mode of
Frequency Frequency Information
Chart Time Flow

NPC
By end of By
Trimesterly 1st month Person/
National/
MOH of each Intranet
Central
Trimester
By end of
DoHS 1st month By
Centers Divisions Trimesterly Person/
MD/HMIS Trimesterly/ of each
Trimester Intranet
Periodic
By AIR
7th day /Express
of Next Delivery / Post
RHD Central/Regional
Regiona Monthly Trimesterly Month / Person
l /Zonal Hospital
By AIR
12th day /Express
District DHO Hospital Monthly Monthly of Next Delivery / Post
Month / Person

Catchment PHC/HP • 7th day of

area and next month
Monthly Monthly • 3rd day of By
Community
SHP next month Person
Reporting Line
• 1st day of
next month
Feedback Line
VHW/MCHW
 Nepal’s Free Health Care Policy
• 2008: Nepal launched a program for free
essential healthcare for primary health services
and access to a number of essential drugs for
all citizens seeking care at health post.

• 2009: the services were extended to primary

health care centres and at district hospitals, all
outpatient, inpatient and emergency services,
as well as essential medicines, are free of
charge to all the citizens of Nepal.
Source: Annual Report 2015
Nepal’s Free Health Care Policy Continue
• February 2009 institutional deliveries are free
of charge to all women nationwide.

• 70 kinds of Essential Drugs are provided free

of costs.

• Upto NRS 100000 is provided to

underprivileged family by government for
treatment of chronic diseases.
Source: Annual Report 2015
Nepal’s Free Health Care Policy Continue

• NRS 400 is provided to all the pregnant

women who have ANC Visit in health facility
as per protocol.

• Transportation Cost provided to pregnant

mother who have institutional delivery.
– NRS 500 for Terai Region
– NRS 1000 for Hilly Region
– NRS 1500 for Mountainous Region
Source: Annual Report 2015
 Nepal’s Free Health Care Policy Continue
• Iron Tablet Free distribution (225 tablet) for
pregnant women with Albendazole.

• Vitamin A supplementation to delivered

mothers

• Treatment of Heart, Kidney and Liver disease;

and Cancer is free for the citizens at
government hospitals.

• Dialysis facility free until Kidney transplant.

Source: Annual Report 2015
 Nepal’s Free Health Care Policy Continue

• Nyano Jhola (or warm bag) is the set of

dress provided to mother and the child
immediately after delivery.

Source: Annual Report 2015

Nepal Free Health Care Policy continue

• Family Planning Services as provided free of

cost by the government Health Facilities.
Condoms, Depo-provera, Pills, Implant, IUCD,
Minilap and Vasectomy.
• TB and Leprosy Screening is done and medicine
is provided accordingly free of cost under direct
superision of the health worker.
• Cotrimoxazole, Zinc tablet and ORS is given
free of cost for children suffering from diarrhoeal
disease.
Source: Annual Report 2015
Programs Under Department of Health Services

• Child Health Program

–Expanded Program on immunization
–Nutrition Program
–Control of Diarrheal diseases
–Control of Acute Respiratory infection
–Integrated management of Childhood illnesses

• Family Health Program

– Family Planning
–Safe motherhood
–Female Community Health Volunteer
–Primary Health Care outreach clinics
–Demography and Reproductive health research
Source: mohp.gov.np
 Programs Continue

• Disease control program

– Malaria control
– Kala-azar control
– Japanese Encephalitis control
– Lymphatic Filariasis
– Tuberculosis control
– Leprosy control
– AIDS and STD control
• Curative Services
– Out/In patient care Source: mohp.gov.np
 Programs Continue
• Supporting programs
– Health Training
– Health education information and
communication
– Logistic management
– Community drug program
– Laboratory services
– Administrative management
– Financial management
– Management
• FCHV Program
Source: mohp.gov.np
 National Health Insurance

• Budget for the fiscal year 2016/17 says that it

will implement 'National Health Insurance
Scheme' in a phase-wise manner.

• The scheme targets to provide health

insurance facility to every Nepali citizen within
three years.

• The scheme will be expanded in the 25

districts in the upcoming fiscal year 2016/17.
Source: mof.gov.np
National Health Insurance Continue

Source: myrepublica.com
 Choice of Practitioners
• 69 percent of people with an acute illness
reported to have consulted with some kind
of medical practitioner
– 28 percent consulted paramedic,
– followed by doctor (25 percent), pharmacists
(16 percent), and traditional and others (2
percent)

Source: Nepal Living Standard Survey 2010-11

 Choice Continue
• 43 percent of people of urban area consult
with doctors
• The consultation with a paramedics is higher
in rural areas, particularly in the mid and far
western hills, where as many as 46 percent
of acutely ill people visit these paramedics.
• Urban areas have expensive consultations
relative to their rural counterparts (Rs. 2069
versus Rs. 1040) in government facility

Source: Nepal Living Standard Survey 2010-11

Challenges of Health System of Nepal

• Resource Gap

• Geographical Constraints

• Traditional Beliefs

• Privatization of health services: increase quality

in urban areas but challenging for remote and
far people.
Pictures of Traditional Beliefs
 Challenges Continue
• Epidemiological transition: Still facing huge burden of
communicable disease (Diarrhea, ARI) with newly emerging
Non-communicable disease along with some new concentrated
epidemic (HIV/AIDS)

• Human Resource for health: Urban centered highly skilled

manpower

• Globalization:
– Commercialization (Safe Delivery kit, ORS, FP devices)
– Privatization (Quality increase but accessibility and
affordability)
– Introduction of user’s fee in public health facilities:
Affordability for poor people
 Female Community Health Volunteer

• Program Initiated in 1988/89.

• 5th December is celebrated as FCHV Day
to show respect to FCHVs.
• In 19th November 2009, FCHV Program in
Nepal received GAVI awards for the
highest average annual rate of reduction
of child mortality among all of the 72 GAVI
countries since 1990.

Source: www.mohp.gov.np/index.php/publication-1/guideline
 Female Community Health
Volunteer

Nepal
75 Districts
MID- MID-WESTERN
WESTERN REGION
REGION

WESTERN
REGION

CENTRAL
REGION

EASTERN
REGION
Female Community Health Volunteer

Village Development
Committees
3,157
Female Community Health Volunteer

2
1
3
4

5 7
6

8
9

Wards
48523
Female Community Health Volunteer

Ward

FCHVs
51416
 Female Community Health
Volunteer
• The innermost circle shows that the action starts
at community or ward level by individual FCHV,
(as community is the centre of health activities)
• Second circle shows the action is spread in the
entire VDC
• Third circle depicts whole district will be covered
by FCHV’s actions
• The outermost circle shows that the action of
FCHV will cover the whole nation

Source: www.mohp.gov.np/index.php/publication-1/guideline
 Female Community Health Volunteer
• The main role of FCHV will be concentrated on the health
promotional activities of mothers and children in their
working area.

• Help in promoting utilization of available health services and

raise awareness on health through MGH.

• FCHV will help in various health programs such as family

planning, safe motherhood, newborn care, immunization,
nutrition, communicable and epidemic diseases, acute
respiratory diseases and diarrheal diseases control,
environmental sanitation, health education and other
national programs.
Source: www.mohp.gov.np/index.php/publication-1/guideline
 Female Community Health Volunteer
• FCHV will also provide recommended
services like drug distribution and diseases
management as directed by Nepal
government based on community based
approach.
• FCHV has to submit an annual report to local
health institution and her MGH.
• FCHV has to submit a monthly report of her
activities to local health worker or supervisor
every month).
Source: www.mohp.gov.np/index.php/publication-1/guideline
Female Community Health Volunteers

Backbone of our health system

National Immunization Program

Healthy Children: Healthy Community

National Immunization Program
• A high priority program (P1) program of
Government of Nepal.
• One of the most cost effective health intervention.
• Helped in reducing the burden of Vaccine
Preventable Diseases (VPDs) and child mortality.
• Contributed in achieving the Millennium
Development Goal on child mortality reduction
(MDG 4).

Source: dohs.gov.np Nepal cYMP 2012-2016

National Immunization Program Continue

• Goal
To reduce child mortality, morbidity, and
disability associated with vaccine
preventable diseases.

Source: dohs.gov.np Nepal cYMP 2012-2016

National Immunization Program Continue

• Objectives
– Achieve and maintain at least 90%
vaccination coverage for all antigens at
national and district level by 2016.
– Ensure access to vaccines of assured quality
and with appropriate waste management.
– Achieve and maintain polio free status.
– Maintain maternal and neonatal tetanus
elimination status

Source: dohs.gov.np Nepal cYMP 2012-2016

National Immunization Program Continue

• Objective Continue
– Achieve measles elimination status by
2016
– Accelerate control of vaccine-preventable
diseases through introduction of new and
underused vaccines
– Strengthen and expand VPD surveillance
– Continue to expand immunization beyond
infancy
Source: dohs.gov.np Nepal cYMP 2012-2016
Vaccination Schedule

Source: dohs.gov.np Nepal cYMP 2012-2016

 Accomplishment
S.N. Objective Status of Achievement
1 Achieve and sustain > 90% of coverage since 1990
90% coverage of all
vaccine of routine
immunization

2 Maintain Polio Free No indigenous wild poliovirus

Status cases reported since August
2010. Nepal was declared
Polio Free Country on 27th
March 2014.

Source: dohs.gov.np Nepal cYMP 2012-2016

 Accomplishment Continue
3 Sustain MNT Status Sustained. No cases
detected since 2005.

4 Initiate Measles Elimination Plan to eliminate

measles by 2016

5 Expand VPDs Surveillance Integrated surveillance

for AFP, measles, JE,
NT and pneumonia for
ARI
6 Accelerate Control of VPDs Hib, JE and PCV
through introduction of new vaccine introduced in
vaccines regular immunization
Source: dohs.gov.np Nepal cYMP 2012-2016
 Accomplishment Continue
7 Expand Immunization TT immunization
Series beyond Infancy continues in 12
districts

“ Every Child Counts”: Till now 16 districts,

around 1500 VDCs and 40 Municipalities
has been declared All Child Fully
Immunized (ACFI) with plan to declare the
country ACFI within 2017.

Source: dohs.gov.np Nepal cYMP 2012-2016

Problems/ Constraints/ Action to be Taken
Problems/ Action to be Taken Responsibility
Constraints
Inadequate HRH • Provision for alternative MoHP/DoHS/
and ill defined JD of vaccinators for the vacant posts DHO
AHW& ANM • Incorporate responsibility of
delivering immunization service
in Job Description of all HA,
SAHW, AHW/ANM to conduct
immunization sessions
Poor quality • Supportive supervision of HF/DHO/RHD/
immunization data: Immunization as per HMIS. CHD/HMIS
Under and over •Strengthen supportive
Reporting supervision at all levels
• Quarterly review of
performance of data at
HF/DHO level as ‐HMIS31,
HMIS 5.
 Problems/ Constraints/ Action to be Taken
Continue
Poor •Update inventory of cold chain RMS/
Inventory equipment with their cold chain District
keeping and capacity and vaccine, syringes, Cold
distribution diluents etc. and use of stock control Store
system register.
•Maintain maximum and minimum
stock level.
•Always make vaccine requisition by
deducting the stock at hand from
maximum stock level of
vaccine/syringes/diluents
In effective Utilize immunization month as an District
immunizatio opportunity to intensify routine s
n immunization activities especially all
month
celebration
Logo of Immunization Clinic