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Primary health care

The course offers an opportunity to develop a holistic understanding of Primary Health Care, its functions, and scope. The course attendants will learn the principles of Primary Health Care, the course is expected to help the students to understand and internalize international health and public health transition facilitating the integration of health sector with other sectors.

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Primary health care

  1. 1. Primary Health Care Ashok Pandey 111/19/17
  2. 2. Content Concept of Primary Health Care Conceptualizing Primary Health Care – Hardware – Software Philosophy of Primary Health Care Health for all Strategy by 2000 AD Aspects of Primary Health Care Importance of Primary Care Difference between Primary Health Care vs. Primary Care Linkage of Primary Health Care to a health system 11/19/17 2
  3. 3. Content…….. Declaration of Alma-Ata Conference Ten declarations of Alma-Ata Conference (1978) The twenty-two recommendations of the Alms Ata Conference. The twenty-two recommendations of the Alma Ata Conference by describing the Conference topic with Recommendations Principles and strategies of Primary Health Care •Basic component of Primary Health Care / 8 Essential Component / Elements •Levels of Health Care •Basic Requirements for Sound Primary Health Care •Strategies of Primary Health Care •Principle of Primary Health Care 11/19/17 3
  4. 4. Content…. Critically analyze the Comprehensive and Selective Primary Health Care (PHC) •Various Approaches to Primary Health Care •Models of primary health care •Selective Primary Health Care with advantages and disadvantages •Comprehensive Primary Health Care with advantages and disadvantages Overview of operational aspects of PHC •Operational Aspects of Primary Health Care •Primary health care within the health system Role of the District Public Health Office in meeting Basic Health Needs. •Fundamental health needs •Basic Minimum health needs •Policies of Basic Minimum Needs •Role of District public Health officer •Role of District public officer in meeting basic health needs 11/19/17 4
  5. 5. Content….. Health Care Concepts and Challenges •Concept of health •Concepts of health care •Challenges health care •Challenges health care in Nepali context Challenges and obstacles to PHC: selective PHC, cost recovery of health services, Structural adjustment programs and investing in health care. • Functions of Primary Health Care •Obstacles to the implementation of the Primary Health Care strategy •Major assaults of Primary Health Care •Structural adjustment programmes and user-financed health services, introduced in the 1980s •Criticism of SAP concern in social sector •World Bank 11/19/17 5
  6. 6. Content…… Concept and importance of revitalization of PHC •Background outline of revitalization of PHC •Concept of revitalization of PHC •Importance of revitalization of PHC New challenges of revitalization of PHC in Nepal Approach of health protection, community based health insurance and urban health •Approaches of protection Health •Health Insurance Rules •Models of health insurance •Community based health insurance •Benefits of community-based health insurance •Urban health insurance •Benefits of urban health insurance Free health services and essential health care service in Nepal •Concept of free health services •Essential health care service in Nepal •Essential health care service delivery in urban areas of Nepal 11/19/17 6
  7. 7. The world apart In mid 60s Indicators Developing Developed countries countries IMR 160 19 Life expectancy 45 years 72 years GNP $170 $6,230 Health expenditure 1% 4% 711/19/17
  8. 8. 11/19/17 8
  9. 9. Specific facts Country IMR <5MR per 1,000 live births Mali 233 400 Sierra Leon 219 385 Afghanistan 215 360 India 144 230 Nepal 186 279 Sweden 16 20 Netherlands 18 22 Japan 31 40 911/19/17
  10. 10. What makes difference Child A Diarrhoea Recovers Child B Diarrhoea Dies Suffering from the same disease, why some die while other recover ? 1011/19/17
  11. 11. New commitments In 1977, the 30th World Health Assembly The main social target of governments and WHO should be the attainment by all people of the world at a level of health that will permit to lead a socially and economically productive life by 2000. This is what we called HEALTH FOR ALL BY 2000 1111/19/17
  12. 12. Primary Health Care Historical Background Investment on health Results Global experiences of alternative approaches 1211/19/17
  13. 13. What was admitted? Health status of hundreds of millions of people in the world today is unacceptable, particulaly in developing countries. More than half of the population in the world does not have the benefit of the proper health care From Alma-Ata Declaration. 1978 1311/19/17
  14. 14. A new vision ... Health is Not merely a technology Hospitals Doctors Medicines Health is also a human issue 1411/19/17
  15. 15. At the centre Equity and Justice Tecnology for all to them who need it 1511/19/17
  16. 16. Conceptualizing Primary Health Care Primary Health Care Hardware Services Elements Structure Persons Equipment, etc. Software Philosophy Principles 1611/19/17
  17. 17. Philosophy and Principles Right to live and Social justice Relation between state and citizen responsibility of the government responsibility of the citizen individually and collectively 1711/19/17
  18. 18. Paradigm shift Liberated Health from imprisonment of technology Technical Societal paradigm paradigm 1811/19/17
  19. 19. At the end of the Century How equitable is the globe? Countries IMR Life expectancy USA 7.2 72 years UK 5.7 74 years Nepal ? ? 1911/19/17
  20. 20. Equitable planet ... ... Countries Health Hospital beds expenditure per 100,000 pop. USA $ 6,000 UK $ 2,500 413 EU average $ 2,500 630 Nepal ? ? 2011/19/17
  21. 21. Discrepancies ... ... Exist even within a poor country Life expctancy IMR Kathmandu 71 years 40 Mugu 34 years 110 ... ... ... 2111/19/17
  22. 22. Dreams ... ... Came true or shattered What happened with the Primary Health Care Was PHC a wrong path? Was PHC treated wrongly ? 2211/19/17
  23. 23. Fate of PHC McDonaldization of health care Medicalization of health problem 2311/19/17
  24. 24. Setbacks ... Selective primary health care Cost sharing, cost recovery Investing in health 2411/19/17
  25. 25. PHC beyond the national boundaries Key players World Bank International Monetary Fund Multinational Corporates 2511/19/17
  26. 26. Beyond the national boundaries Structural Adjustment Programme World Trade Organization 2611/19/17
  27. 27. Equation SAP WTO Creates gap Creates market 2711/19/17
  28. 28. Ultimately ... Role of the state Role of the people What Next ? 2811/19/17
  29. 29. but PHC is now more than ever 2911/19/17
  30. 30. Primary Health Care
  31. 31. Health Care • Health is fundamental human right. • It is the responsibility of the government. • Current criticism – predominantly urban oriented - mostly curative - accessible mainly to small part of the population
  32. 32. Levels of Health Care primary Secondary Tertiary
  33. 33. Primary Health Care • Primary – first level of contact….essential health care PHC, HP, SHP • Secondary – complex problems are dealt… district hospitals, Zonal Hospital • Tertiary – specialized level ….medical colleges, specialized hospitals
  34. 34. District hospital Primary health centre Health Post Sub Health Post
  35. 35. Primary Health Care • In the year 1946 Sir Joseph Bhore recommended in his report • A PHC for every 30,000 pop & 20.000 pop in hilly areas
  36. 36. Concept of Primary Health Care • PHC is for all specially the needy • Regardless of social and economic status every individual in the nation must have access to good health care • The services should be acceptable to the community and there must be active involvement of the community • The health services must be effective, preventive, promotive and curative • The services should form an integral part of the country’s health system • The programme must be efficient, multi- sectorial because health does not exit in isolation 11/19/17 36
  37. 37. ALMA ATA DECLARATION ‘The main goal of Governments and World Health Organization in the coming decades should be the attainment by all people of the world by the year 2000, a level of health that would permit them to lead a socially and economically productive life’ 51ST WHA in 1998 reaffirmed the declaration for the 21st century
  38. 38. Themes Leading to Alma Ata 1. Changing theories of health & development: shift away from GNP as measure of development towards recognition of the need of social development 2. Concerns about poverty & population control 3. Increasing reliance upon alternative approaches to medical care model 4. Success of CHWs & associated emphasis on community participation 5. Revival of interest in public health; tackling causes of ill health rather than symptoms
  39. 39. Primary Health Care • Definition: In 1978 the alma-Ata conference( USSR) “Is the essential health care made universally accessible to individuals and acceptable to them , through their full participation and at a cost the community and country can afford.”
  40. 40. PRIMARY HEALTH CARE Definition: PHC 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 the country can afford… It forms an integral part of the country's health system, of which it is the central function and the main focus, and of the overall social and economic development of the community
  41. 41. 10 Declaration of Alma-Ata Conference 11/19/17 41
  42. 42. I • Health • fundamental human right • joint action 11/19/17 42
  43. 43. II • Existing gross inequality in the health status of the people particularly between developed and developing countries 11/19/17 43
  44. 44. III • The economic and social development • “Health for all” objective, 11/19/17 44
  45. 45. IV • People have the right and the duty to contribute, both individually and collectively, to the process of planning and implementing health-care practices. 11/19/17 45
  46. 46. V • Governments are responsible for the health-state of their populations 11/19/17 46
  47. 47. VI Primary health care is considered essential medical care ,being based on acceptable scientific and social methods and technologies, accessibile to individuals and families belonging to all communities, 11/19/17 47
  48. 48. VII • Primary health care: 11/19/17 48
  49. 49. VIII • All governments should establish national policies, strategies and action plans in order to organize and support primary health care practices. 11/19/17 49
  50. 50. IX • Cooperate as partners, • WHO/UNICEF 11/19/17 50
  51. 51. X • Better and more complete use of global resources, • Alma-Ata also set 22 recommendations, 11/19/17 51
  52. 52. The twenty-two recommendations of the Alms Ata Conference. 11/19/17 52
  53. 53. Basic Components of Primary Health Care (WIMEN & CHD) 1. Water & Sanitation, 2. Immunizations, 3. Mother & Child Care (&FP), 4. Essential Drugs, 5. Nutrition & Food 6. Curative Care, 7. Health Education, 8. Disease Control 11/19/17 53
  54. 54. COMPONENTS OF PHC 1. Education concerning prevailing health problems & the methods of preventing & controlling them 2. Promotion of food supply and proper nutrition 3. An adequate supply of safe water and basic sanitation 4. MCH including FP 5. Immunization against major infectious diseases 6. Prevention and control of locally endemic diseases 7. Appropriate treatment of common diseases and injuries
  55. 55. Principles and strategies of Primary Health Care 11/19/17 55
  56. 56. Principles of primary health care. • Equitable distribution- urban & rural areas • Community participation – trained SBA • Intersectoral co-ordination- education , nutrition..etc • Appropriate technology – ORS, growth monitoring • Focus on prevention activities- Polio, Malaria
  57. 57. 1. Equitable distribution • The first key principle in primary health care strategy is equity or equitable distribution of health services • Countries should find means to ensure every person’s access to services. • Something for all and most for those who need the most • 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 • health services are mainly in towns Inaccessibility to majority of population • Social injustice • Availability -Insurance 11/19/17 57
  58. 58. 2. Community participation • There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, besides maximum reliance on local resources such as manpower, money and materials • Community involvement: the involvement of individuals in promoting their own health is essential for the future well-being of the community. 11/19/17 58
  59. 59. 3. Intersectoral coordination • "primary health care 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, communication and others sectors". • To achieve cooperation planning at country level is required to involve all sectors11/19/17 59
  60. 60. 4. 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" • Should be acceptable, cost-efficient, cheap and available at the local level 11/19/17 60
  61. 61. 5. Focus on the prevention activity Acquiring knowledge, through education for health and/or the mobilization of communities for immunization; the role of communities in making decisions related to the provision of resources for medical priorities. As prevention is essential for solving the long-term problems of the community, though it is not always the solution to individual problems, preventive services should exist alongside curative services. 11/19/17 61
  62. 62. 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. 11/19/17 62
  63. 63. 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. 11/19/17 63
  64. 64. Models of primary health care 11/19/17 64
  65. 65. Critically analyze the Comprehensive and Selective Primary Health Care (PHC) 11/19/17 65
  66. 66. SELECTIVE PRIMARY HEALTH CARE PHC implies that if one cannot afford to offer universal coverage for even the most basic of health care, one could would offer treatment & preventive strategies for the few diseases identified as having the greatest threat to mortality, & which are amenable to prevention / cure at low cost.
  67. 67. • Selective PHC was evolved from the broader concept of PHC. It is a more cost focused approach than the traditional PHC and tries to improve the health of a wide range of people • An important part of selective PHC was the creation of political will for funding opportunities. • Selective PHC: “old wine in new bottles” • These are the original diseases on which SPHC should focus: • Diarrhoea • Measles • Malaria • Whooping cough • Neonatal tetanus. • By 1988, acute respiratory infections gained weight (Warren 1988: 900). 11/19/17 67
  68. 68. Selective PHC ADVANTAGES 1.Donor friendly 2.Elimination of selected disease 3.Easy to plan & implement 4.Is focused & have more impact 5.Easy to manage & measure output 6.Require limited resources 7.Improve quality of services DISADVANTAGES 1. Disease rather than health oriented 2. Doesn’t ensure equity 3. Top down decision making 4. Neglect other problems 5. Leads to outbreak 6. Resources (tight) might not be available for urgent needs (emergencies) 7. Less community involvement– donor priority
  69. 69. Comprehensive PHC • Acknowledges other factors that contribute to poor health including: • social influences which look at the – impacts of the key determinants of health which leads to the social determinants of health • Social justice and equity • Community control • Social change • Manages factors that generate ill health • Involves an approach to health care over a continuum from health promotion to illness treatment 11/19/17 69
  70. 70. Comprehensive PHC ADVANTAGES 1.Looks at total health care 2.Involvement of community 3.Covers all elements of PHC 4.Ensures equitable distribution of resources 5.Facilitates effective referral system 6.Government goal DISADVANTAGES 1. More costly to implement 2. Takes long time to see impact 3. Long time to process 4. Lack of specialized treatment 5. Expensive 6. Inefficient referral system ???-- misuse
  71. 71. Overview of operational aspects of PHC 1. Primary health care within the health system 2. Planning 3. Planning and organization of PHC in a community 4. Coverage and accessibility 5. Appropriate health technology 6. Human resource 7. Community health workers 8. Traditional medical practitioners 9. Family members 10.Referral system 11/19/17 71
  72. 72. 11. Logistics of supply 12. Physical facilities 13. National managerial process 14. Budgeting 15. Decentralization 16. Control 17. Evaluation 18. Information 19. Research 20. Financing 11/19/17 72
  73. 73. Role of District public officer in meeting basic health needs • Need: Circumstances without which something is lacking and missing • Basic Minimum health needs: requirements needs to improve the health status of people • On the 16th Dec 1985, His majesty the king Birendra declared the “Basic Minimum needs” to provide basic Nepalese people. • Policies of Basic Minimum Needs: Food grain, Clothing, Fuel wood, Drinking water, Primary and skill oriented education, Minimum rural transportation facilities • Basic Minimum health needs: Child spacing, Oral rehydration, MCH, Immunization, Nutritional services, ARTI 11/19/17 73
  74. 74. Role of District public Health officer • FP/MCH Services and Systems. • NGO/CBO Partners • Supervision • VDC Capacity Building • Decentralization • Coordination and Communication • Policy Dialogue • Information System • Co-ordination and supervision of all governments, non-government and primary health services within the districts • Preparation of periodic and annual plan • Organisation and running of the district hospital services • Management of all Govt. PHC services • Organize in service training • Conduct operational research11/19/17 74
  75. 75. Health care concept and challenges Health care concept • Not only Medical care • Render comprehensive healthcare services. • -Preventive, Promotive and curative services. • -Should be as close to the beneficiaries as possible. • -Irrespective of their ability to pay.11/19/17 75
  76. 76. The Challenges of changing World • Unequal growth, unequal outcomes • Adapting to new health challenges • Trends that undermine the health systems’ response • Changing values and rising expectations • PHC reforms: driven by demand 11/19/17 76
  77. 77. Challenges and obstacles to PHC: Selective PHC, Cost recovery of health services, Structural adjustment programs and Investing in health care 11/19/17 77
  78. 78. Obstacles to the implementation of the PHC strategy • Misinterpretation of the PHC concept • Misconception that PHC is a 2nd rate health care for the poor. • Selective PHC strategies • Lack of political will • Centralized planning and management 11/19/17 78
  79. 79. Selective PHC at the end of 1970s • Focus on GOBI • Goal: Improved survival rates fir high risk groups (Children) • Strategy: Technological interventions that leave in place the inequities of the globalization economic order • Disease in Underdeveloped and developed countries 11/19/17 79
  80. 80. Structural adjustment programmes and user- financed health services, introduced in the 1980s • Cutbacks in public spending • Privatization of government enterprises • Freezing of wages and freeing of prices • Increase export of production rather than local consumption • Reducing tariffs and regulations while creating incentives to attract foreign capital and trade • Reducing government deficits by charging user-fees for social services including health • Structural Adjustment is a term used to describe the policy changes implemented by International monitory Fund and World Bank 11/19/17 80
  81. 81. • Conditions loans.. • Goal obtaining low interest loans reducing country balance of payment , promote economic of country and to pay off debt which the countries have accumulated • SAPS are economic policies for developing countries • Promoted by World bank and International Monitoring fund (IMF) • Provision of loans conditional for their adoption of such Policies 11/19/17 81
  82. 82. SAP policies include • Currency devaluation , • manage balance of payment , • reduction of inflation, • wage suppression, Privatization, • Lower tariffs on import and tighter monitory policy increase free trade, • Cuts in social spending , and business Deregulations • Government also interested or reduce their role in the economy by Privatizing state- owned industries, including the health sector and opening up their economy to foreign competitions 11/19/17 82
  83. 83. World Bank • “INVESTING IN HEALTH”, but more accurate title would be ‘TURNING HEALTH INTO AN INVESTMENT” • A masterpiece in disinformation to restructure health policy to conform to the market friendly macro-economic paradigm promoted by the world bank. • Health care is no longer a basic human right • Privatization 11/19/17 83
  84. 84. Functions of PHC • Medical care. • MCH including family planning • Safe water and basic sanitation • Prevention & control of locally endemic diseases. • Collection & reporting of vital statistics. • Education about health. • National health programmes • Referral services • Training of health guides, health workers, local dais & health assistants
  85. 85. Thank you
  86. 86. Revitalization of PHC 11/19/17 86
  87. 87. 11/19/17 87
  88. 88. 11/19/17 88
  89. 89. • The Revitalization of PHC has been done in 30th anniversary year of Alma Ata Declaration in 2008. The central theme of Revitalization of PHC is “Health System Strengthening” using PHC approach that can also accommodate the needs of vertical programmes. The position and combined advocacy of WHO's global leadership is an extraordinary moment in WHO's history. • To improve the health status of people and to ensure sustainability, revitalization of the tenets of Alma Ata’s PHC was felt by WHO. 11/19/17 89
  90. 90. Revitalizing PHC is outlined • (1) Reaffirm high political commitment toward PHC. • (2) Improve health equity through specific actions in the health sector as well as other sectors • (3) Foster more effective multisectoral collaboration • 4) Strengthen health workforce including Community-Based Health Workers (CBHW) and Community Health Volunteers (CHV). • (5) Implement equitable health-care financing such as tax- based and social health insurance and various community- based health financing. • 6) Strengthen partnership with civil society that includes the community, the private sector and NGOs. • (7) Promote better transparency and accountability of the health systems through improved leadership and governance (stewardship). • (8) Utilize to its fullest various global health initiatives (e.g. Global Fund for HIV/AIDS, Tuberculosis in Malaria). 11/19/17 90
  91. 91. New challenges of revitalization of PHC in Nepal • Countries and donors can do to save lives and avoid disability. • Three ills of life in the 21st century: • The globalization of unhealthy lifestyles, • Rapid unplanned urbanization, and • The ageing of populations. 11/19/17 91
  92. 92. Approach of health protection 1. A systems-wide approach 2. A health system that is progressively financed, inclusive and equitable 3. A comprehensive approach 4. A community empowerment approach 5. A health system based on the ‘Right to Health’ 6. The appropriate use of technology 11/19/17 92
  93. 93. Community based health insurance and urban health 11/19/17 93
  94. 94. Health Insurance :(Definition) Health insurance term is generally used to describe a form of insurance that pays for medical expenses Health insurance is a type of insurance whereby the insurer pays the medical costs of the insured, if the insured becomes sick due to covered causes, or due to accidents
  95. 95. INRODUCTION WORLD: • About 13.7 Millions of people around the world →Without the coverage of insurance • More than150 million people in 44 million households every year face financial ruin as a result of large medical bills • People becoming bankrupt/ indebt ness because of high medical bill -15 crores/year • About 33% of the Americans are without the coverage of insurance • Lack of health insurance affects the health system as a whole, not only against those who are insured
  96. 96. Advantages of health insurance: • People pay when they are healthy and able • Patients do not have to meet their entire health care costs, they contribute small amount • There is minimal expenses at the time of illness Disadvantages of health insurance: • It is administratively more complex • Conceptually, difficult to explain to the people • One needs large numbers for it to be successful
  97. 97. CLASSIFICATION OF HEALTH INSURANCE: There are broadly three types of health insurance:  Social health insurance  Private health insurance  Community health insurance
  98. 98. Community health insurance/Micro Health Insurance • Definition: A not- for-profit health insurance, that is organized mainly for the informal sector and is managed by the community. Introduction:  In India first Community health insurance was organized in 1955  Most of them are organized by NGOs  Today, there are more than 40 such schemes, covering 4 million people objectives: • To improve the access to the health care • To subsidize the cost of medical care at primary, secondary and tertiary levels • To reduce exploitation from money lenders  To protect households from high medical expenditure • To encourage peoples participation in health services • To make medical facilities available at grassroot level
  99. 99. Specific “organized” organized communities have been targeted. Eg Farmers cooperatives in Yashasvini, students in students health home etc Patterns of Community Health Insurance: • Type 1 provider model • Type 2 Insurer model • Type 3 linked model:
  100. 100. TYPES OF COMMUNITY HEALTH INSURANCE: 1) Type 1 provider model: NGO HOSPITAL COMMUNITY premiu m Health care Eg KLE Hospital
  101. 101. In the Provider model: • Here the hospital organizes the health insurance and is also provider of care • Advantages Cost of treatment is usually low • Disadvantage: Quality of care is low Hospitals do not have much link with the community
  102. 102. • Type 2 Insurer model: NGO HOSPITAL COMMUNITY HOSPITAL Re-imbursement Reimbursementpremium Health care
  103. 103. In the Insurer model: • Here NGO acts as a Insurer & organizes the insurance • It collects premium from the community & then contacts specific hospitals to provide care Advantage: Scheme is tailor made to meet the requirements of the community Disadvantage : Insurance fund is in danger of becoming bankrupt
  104. 104. • Type 3 linked model: INSURANCE COMPANY NGO COMMUNITY HOSPITAL Group premium Re-imbursement Re-imbursement premium Health care
  105. 105. Advantages of community health Insurance:  Creating awareness by the community  A community can afford to pay the premium  Management of funds & maintenance by NGO  The capacity within organization to manage the programme  Reason for instituting CHI: eg high medical costs, financial barriers to health care etc
  106. 106. Disadvantages of CHI:  People pay less premium  Cost & quality not standardized  No financial stability  Most Schemes during membership time
  107. 107. Urban Health 11/19/17 107
  108. 108. • Around 21 % of the total urban population lives in and many of slum populations comprise of -squatter populations, -migrant colonies, -pavement dwellers, -families on construction sites, -street children, etc.
  109. 109. Concentrate on Urban slums
  110. 110. Health Status of Urban Poor • Health status and access of reproductive and child health services of slum dwellers is poor and comparable to the rural population. • Slum dwellers in cities suffer from adverse health conditions owing to insufficient services, low awareness, and poor environment • Public sector health delivery system in urban, especially for poor, has so far been sporadic, far from adequate and limited in its reach.
  111. 111. Contd.. • Factors contributing to inadequate reach of services are - illegality - social exclusion of slums -hidden slum pockets - weak social fabric - lacking coordination among various stakeholders and neglected political consciousness.
  112. 112. Free health services and essential health care service in Nepal Free health care service is the health service provided by the government of Nepal free of cost. This programme has been launched since December 2006. 11/19/17 112
  113. 113. At first free health care services were provided to poor and vulnerable people seeking services from PHCC and hospital up to 25 beds capacity. Since January 2009, Under the "New Nepal, Healthy Nepal" initiative of the Government, all citizens are able to access District Hospitals (DH) and Primary Health Care Centers (PHCC) without having to pay for registration: they are eligible for free outpatient, emergency and in-patient services, as well as drugs. 11/19/17 113
  114. 114. In Sub-Health Posts (SHP), Health Posts (HP), Primary Healthcare Centers (PHC) and District Hospitals (DH), consultations are free of charge for everybody, as well as a selection of basic medicine. The list of free basic medicine is comprised of 22 items in SHP, 32 in HP, 42 items in PHC and 52 items in DH 11/19/17 114
  115. 115. The 6 categories of people entitled to free care are: 1.poor, 2.ultra poor (those whose income is insufficient to buy food for their families for up to 6 months), 3.disabled, 4.senior citizens, 5.underserved (ethnic minorities, Dalit people), 6.Female Community Health Volunteers (FCHV). 11/19/17 115
  116. 116. Essential Health Care Services Essential health care services are priority public health measures and essential curative services that will be available to the total population. Currently there are 20 elements and out of them 11 are prioritized elements.
  117. 117. Elements of Essential Health Care … contd. • Implemented by the public sector* • Jointly implemented by the MOHP & Nepal Eyesight Association & alliance** • Implemented by the ministry of housing and transport+ • Jointly implemented by the public sector and NGOs
  118. 118. Elements of Essential Health Care Services 1. Reproductive health services* 2. Immunization* 3. Control of AIDS & STD* 4. Leprosy control* 5. Tuberculosis control* 6. Integrated management of childhood illness* 7. Appropriate treatment of common diseases*
  119. 119. Elements of Essential Health Care … contd. 8. Nutrition supplementation, enrichment, education and rehabilitation* 9. Prevention and control of blindness** 10. Environmental sanitation and hygiene+ 11. School health services 12. Vector borne disease* 13. Oral health services++ 14. Prevention of deafness++
  120. 120. Elements of Essential Health Care … contd. 15. Substance abuse including tobacco and alcohol control++ 16. Mental health services++ 17. Accident prevention and rehabilitation 18. Community based rehabilitation++ 19. Occupational health++ 20. Emergency preparedness & management*