2. Concept of Health System Development
• Health systems development concerns the
institutional set-up of the health sector and
the way in which the health system’s functions
are organized and performed.
• It includes development and maintenance of
all components of health systems i.e.
provision of health services, health work
force, information system, health financing,
medical products and technology and
stewardship.
3. Cont..
• Provision of health services involves the
design and implementation of health care
delivery models, as well as specific ways in
which services should be organized and
managed to deliver community and clinical
interventions.
4. Principles of Health System development
1. Sustainability: The system must be long-lasting to provide
high quality service and encourage innovation and
continuous improvement.
2. Quality: A quality health system is one that provides the
right care at the right time in the right way by the right
person. Quality should be maintained in all personal and
community health services.
3. Comprehensive: A health system should include all
promotive, preventive, curative and rehabilitative health
services to improve the overall health status of the
populations.
5. Cont..
4. Participatory: It is necessary to involvement of all
stakeholders in planning, implementation and evaluation
of health services.
5. Safety: Health systems should provide better quality
health services without any adverse consequences to the
patients/clients, health care providers as well as whole
community.
6. Cont..
6. Equity: “fairness while providing the health services and
resources” or “justice according to natural law or right;
especially free from bias or favoritism”.
7. Access: All community people should access in reaching
health services or health facilities irrespective to location,
time and social and cultural factors.
7. Cont..
8. Choice: People should have right to select or reject any
course of intervention while providing health services
based on their knowledge, preference and socio-cultural
ethics.
9. Affordable: A sustainable health system should provide
basic health services on an affordable cost to all people
with long-term plan.
10. Efficiency: health system should yield/ generate
maximum output with scarce resources.
8. Different Models of Health Development
• There are about 200 nations on our planet, and each nation
devises its own set of arrangements for meeting the three basic
goals of Health care system:
I. Keeping people healthy
II. Treating the sick
III. Protecting families against financial ruin from medical bills.
1. The Beveridge Model
2. The Bismarck Model
3. The National Health Insurance Model
4. The Out of Pocket Model
9. The Beveridge Model
• This model was developed by William Beveridge, he designed
Britain’s National Health Service.
• In this system, health care is provided and financed by the
government through tax payments.
• Never paid a doctor bill.
• Great Britain, Spain, Newzland are practicing this model.
• Cuba represents the extreme application of the Beveridege
approach; the world’s purest example of total government
control.
10. Bismarck Model
• This model is named after the Prussian Chancellor
Otto von Bismarck, who invented the welfare state as
part of the unification of Germany in the 19th century.
• It uses an Insurance system – the insurance are called
“sickness funds” – usually financed jointly by
employers and employees through payroll deduction.
• The Bismarck model is found in Germany, France,
Belgium, the Netherlands, Japan, Switzerland.
11. The National Health Insurance Model
• This system has elements of both Beveridge and Bismarck
• It uses private sector providers, but payment comes from a
government – run insurance program that every citizen pays
into.
• Since there’s no need for marketing, no financial motive to
deny claims and no profit.
• These Universal insurance programs tend to be cheaper and
much simpler administratively than American – style for profit
insurance.
12. Cont..
• National Health Insurance plans also control costs by
limiting the medical services they will pay for, or by
making patients wait to be treated.
• The classic NHI system is found in Canada but some
newly industrialized countries – Taiwan and South
korea.
13. The Out – of –Pocket Model
• Only the developed industrialized countries, perhaps
40 of world’s 200 countries have established health
care systems.
• Most of the nations on the planet are too poor and too
disorganized to provide any kind of mass medical
care. The basic rule in such countries is that the rich
get medical care; the poor stay sick or die.
14. Cont…
• In rural regions of Africa, India, Nepal, China and South
America, hundreds of millions of people go their whole lives
without ever seeing a doctor.
• For the 15 percent of the population who have no health
insurance, the United States is Cambodia or Burkina Faso or
rural India, with access to a doctor available if you can pay the
bill out-of-pocket at the time of treatment or if you’re sick
enough to be admitted to the emergency ward at the public
hospital.
16. HISTORICAL ERAS OF HSD
Historians have divided Nepalese history into
I. Ancient (first century to 879 AD),
II. Medieval (879 AD to till control of the Kathmandu
by King Prithvi Narayan Shah–1768 AD) and
III. Modern Nepal from 1769 AD onwards.(but the
modern era for health is considered from 1889 AD)
17. DURING ANCIENT ERA
• During Lichchhavi period in the reign of Amshu Verma (605-620
AD) one of the historical document has mentioned about
Aarogyashala.
• There was the practice of separation of baby from mother’s uterus
in case of maternal death during the time of Narendra Dev.
• Lastly, cutting umbilical cord immediately after the baby is born
and not to wait till the placenta is expelled (Amshu Verma).
18. DURING MEDIEVAL ERA
• In the Malla period the King of the Kantipur, Pratap Malla (1641-
1674 AD) established a traditional medicine (Ayurvedic)
dispensary for common people at Royal Palace complex in
Hanumandhoka, Kathmandu.
• It is widely believed that the current Singh Darbar Baidyakhana
is the continuity of the dispensary established earlier by the King
Pratap Malla.
19. ALLOPATHIC MEDICINE BY CHRISTIAN
MISSIONARIES IN MALLA PERIOD
• The first introduction of the modern medicine or allopathic
system of medicine in Nepal was done by the Christian
Missionaries working in Peking, China and Lhasa, Tibet.
• In those days was a trans- Himalayan trade route via Kathmandu
and the Christian Missionaries were used route and have felt
health needs of the Nepal.
20. ALLOPATHIC MEDICINE BY CHRISTIAN MISSIONARIES IN
MALLA PERIOD
• In 1661 AD Jesuit Father Grueber and Dorville and associates
entered Nepal via Lhasa from Christian Mission office in
Peking.
• Pratap Malla allowed missionaries to work in the Kantipur.
• In 1660s missionary team started health service, school
education and Christian religious activities such as education
and preaching.
21. DISCONTINUITY OF MODERN MEDICAL
SERVICES
• After the unification of valley in 1969, the new
administration in Kathmandu considered them as
representatives of overall European policy rather than
the Christian religion.
• The administration decided to close mission offices
including medical clinics and expelled all Christian
Missionaries .
22. DISCONTINUITY OF MODERN MEDICAL SERVICES
• The expulsion of the capuchin monks from the
Kathmandu valley represents the closure of the initial
part of the history of modern medicine in Nepal.
• There is no mention of the use of modern medicine or
establishment of hospitals till another 120 years.
23. Health & Hospital Development in Modern Era
The modern era also can be divided into three phases:
I. First phase medical service from British resident doctors,
II. Second phase the Rana period and
III. The third phase the post democracy period
24. British Residency and the
Medical Service
• British residency got established in Kathmandu in 1802.
• Captain Knox as the resident physician and Dr FB Hamilton as
the resident surgeon appointed for residency office in Nepal.
• The agreement between the British India and the Nepal
government cancelled in 1804 AD and residency staffs returned to
India and war broke again.
• Sugauli agreement signed between Nepal and India in 1815 and
British residency was re-established in 1816.
25. British Residency and the
Medical Service
There is no mention in the history about the appointment of
doctor in the re-established residency.
But Dr. H.A. Oldfield was appointed as the resident doctor in
1850 to 1863 AD in residency.
Dr Oldfield has mentioned in his book about major health
problems of the Nepal such as smallpox, malaria, cholera,
tuberculosis and problems related to childbirth.
26. Rana Periods
• Rana period, which lasted for 104 years; is the important
era of health and hospital development in Nepal.
• In this period several hospitals and dispensaries were
established both in the modern medicine and traditional
medicine as a state initiative.
• Khokna Leprosy Asylum was the first health institution
established by the state in 1857 AD to isolate the leprosy
patients.
27. Rana Periods
Bir Shamsher (1885-1901 AD): Introduction of Hospital
Services
Bir hospital : 1947 BS /1889 AD.
Cholera Hospital in Teku.
Leprosy Hospital in Tripureshwar.
Prithvi-Bir group of hospitals in Birganj, Jaleshwar, Hanuman
Nagar, Taulihawa and Nepalganj.
28. Rana Periods
Chandra Shamsher (1902-1929 AD): National Network of
Hospitals and Dispensaries
Chandra Lok Hospital in Bhaktapur in 1903 AD.
Prithvi-Chandra Hospitals in Palpa, Palhi (Parasi), Doti, and Ilam.
Tribhuvan-Chandra Hospitals established in Dhankuta,
Bhadrapur, Sarlahi, and Rangeli.
In 1925 AD Tri-Chandra Military Hospital in Kathmandu .
Nardevi Ayurvedic Hospital in 1918 AD.
29. Rana Periods
Prime Minister Bhim Shamsher 1929-1932 AD
• He established Tri-Bhim Hospitals in Bhairahawa, Butwal and
Bahadurganj.
• Ramghat dispensary at Pashupati was inaugurated in 1929 AD.
30. Rana Periods
Prime Minister Juddha Shamsher 1932-1945 AD
Tri-Juddha group of hospitals in 1931 AD in Dharan and in 1940
in Bhimphedi, Bardiya, and Kailali.
Tokha Tuberculosis Sanatorium came in operation in 1935 AD .
Leprosy department and treatment center was established at
Pachali in 1937 AD.
31. Rana Periods
Prime Minister Padam Shamsher (1945-1948 AD) and
Mohan Shamsher (1948 –1951 AD)
One health center was established in Sankhu in 1949.
Homeopathic dispensary was opened and a chest clinic
(1951) was started in Bir Hospital.
School health program initiated during this period.
32. Post democracy period (after 2007 BS)
This period is also very important period in the history of
Nepal.
Several new health programs were declared and secondary and
tertiary care health institutions were established in this period.
This period also opened opportunity to nongovernmental
organizations and private sector to provide health care.
This period can also be divided into several phases.
33. Post democracy (after 2007 BS)
New health policies and programs and involvement of NGOs
in healthcare (1951-1963 AD
Health programs for control of malaria (1958), smallpox (1962),
leprosy (1963) and family planning and maternal and child health
(1962) were started.
Kanti Hospitals, Health training institutions.
In 1958 Health Ministry implemented new health policy–one
health center in each 105 electoral constituency.
In the year 1963 there were 32 hospitals and 104 health centers in
the public sector.
34. Contd..
• NGO hospitals funded by missions were established in
Lalitpur (1954), Bhaktapur (1954), Banepa (1957), Kaski
(1957), Gorkha (1957), Okhaldhunga (1963), Nawalparasi
(1962) and Palpa (1954).
• Leprosy mission started Anandban Leprosy Hospital-1963,
Green Pasteur Hospital -1957, Dadeldhura Leprosy Hospital.
• Indra Rajya Laxmi Maternity Hospital (1958) was established
by a national NGO in Thapathali.
35. Post democracy (after 2007 BS)
Regionalization of health services - 1964-1974 AD
With the political division of the country into 75 districts and 14
zones, in 1964 regionalization of health services was started and
new zonal hospitals were established in Biratnagar, Rajbiraj,
Janakpur, Birganj, Butwal, Pokhra and Nepalganj.
Tuberculosis Association opened Tuberculosis Hospital (1970) in
Kalimati, Kathmandu.
Some of the health centers were converted into health posts or
upgraded to district hospitals during this period.
36. • Emergence of single specialty hospitals and implementation of
Primary Health Care system (1975-1992) AD
• Single specialty hospitals were established during this period in
psychiatry and eye.
• Long-term health plan was prepared and primary health care system
was implemented.
• 775 Health posts at community level and district hospitals or bigger
hospitals were established in all districts except Okhaldhunga,
Kavre, Ramecchap, Rolpa, Dolpa, Humla, Syangja, Mugu and
Kalikot.
Post democracy (after 2007 BS)
37. Contd..
• Some hospitals were converted into regional and zonal
hospitals.
• National Tuberculosis Center was established in Sanothimi,
Bhaktapur.
• Traditional medicine dispensaries too were established at
community level.
• High-level health manpower production was started and lower
level health manpower production intensified.
• Smallpox eradication goal was achieved and new program on
expanded immunization was started.
38. Contd..
• Tribhuvan University Teaching Hospital (1986) and Birendra
Police Hospital (1984) were established in Kathmandu .
• NGO sector also actively contributed in health by establishing
Nepal Eye Hospital (1980) in Kathmandu and several eye
hospitals were established.
• Some small hospitals were established in private sector.
• National health policy 1991 was formulated.
39. Contd..
Emergence of tertiary care centers and expansion of PHC
and growth of private health institutions 1993- 2002 AD
Tertiary care services were started in neurosurgery, cardiac
surgery and cancer from public sector.
One hundred eighty health centers at electoral constituency
level and 3107 sub health posts at VDC level were established.
Health program was started to eradicate polio and DOTS
strategy was initiated to control tuberculosis. Leprosy
elimination program was also started.
40. Contd..
• BP Koirala Institute of Health Science (1993) from public
sector and Manipal Medical College (1997), Bharatpur
Medical College (1998), Bhairahawa Medical College (1999),
Nepal Medical College (1997), Kathmandu Medical College
(2000), and Nepalganj Medical College (2002), were
established from private sector providing secondary and
tertiary medical care services and education.
41. Contd..
• Integration of vertical programmes and district hospital and
public health department as DHO.
• Second long term health plan 1997-2017.
• Some mission hospitals were closed, some other were
converted to community hospitals.
• Polio eradication programme was lunched in this period.
42. Contd..
• Introduction of free health care service; provision of
maternity incentives and revitalization of primary health
care (2007 ad to onwards)
• MoHP, recently introduced a policy to provide free essential
curative services to poor populations at district hospitals and
PHCCs.
• Similarly to reduce the high IMR and MMR; the GoN introduced
travel expenditure for women who delivered in health care
institutions having safe delivery facility.
43. Contd..
• Recently; Department of health services has
removed Leprosy Control Division
• In 2009 primary health care revitalization
division is added in division for the
improvement of PHC services
45. Health Care Services in
Nepal
Traditional Health care
Services
With system: Ayurveda,
Homiopathy,
Yoga,Neturopathy, Unani
etc.
Without System: Dhami,
Jhakri, Lama, Jharpuke
etc.
Modern Health Care
Services
Public: SHP/HP/PHC/
Hospitals /DHO/DPHO
Private: Private for
profit and private for
non profit
46. Introduction
• Traditional medicine (TM) refers to the knowledge, skills and
practices based on the theories, beliefs and experiences
indigenous to different cultures, used in the maintenance of
health and in the prevention, diagnosis, improvement or
treatment of physical and mental illness.
• Traditional medicine covers a wide variety of therapies and
practices which vary from country to country and region to
region. In some countries, it is referred to as "alternative" or
"complementary" medicine (CAM).
47. Cont….
• Traditional medicine has been used for thousands of years with
great contributions made by practitioners to human health,
particularly as primary health care providers at the community
level.
• TM/CAM has maintained its popularity worldwide. Since the
1990s its use has surged in many developed and developing
countries.
48. Cont….
• It includes diverse health practices, approaches, knowledge
and belief incorporating plant, animal and/or mineral based
medicines, spiritual therapies, manual techniques and
exercises, applied singularly or in combination to maintain
well-being as well as to treat, diagnose or prevent illness
(WHO)
50. Cont…
Traditional Health Care Practices:
Without Formal Systems
• Vaidya/Kabiraj,
• Jatibutiwal,
• Dhami/Jhakri,
• Pandit/Lama/Guvaju/Purohit,
• Jharpuke,
• Jytotisi,
• Sudeni,
• Amchi etc.
52. Ayruvedic System in Nepal
• Ayruvedic works were started in 935 BS
• Singhadarbar Baidhyakhana was established in Rana regime
• On 31 Ashadh 2038 BS, Aurved was separated from
department of health services and converted into Department
of Ayurveda.
• The ninth five year plan was committed to implement the
policies prescribed by the national Ayurveda policy 1996 AD.
53. Homeopathic System in Nepal
• Pashupati Homeopathic hospital in 2012 BS
• Besides this hospital there are lots of homeopathic
clinics and dispensaries being operated the private
sector.
• Though policies and plans to expand Homeopathic
services from sixth five year plan, it is limited to
Pashupati Homeopathic hospital in the governmental
sector till now
54. Allopathic System In Nepal
• Allopathic System started in mid eighteen century
• Dr. HA Oldfield restarted alloopathic system in Nepal
during Jung Bahadur regime. Prithive Bir hospitals
(now Bir hospital) was established in 1847 AD.
• Nowadays, allopathic system has been a backbone of
the health care system in Nepal
56. Ayurvedic Homeopthic Allopathic
Origin Its origin is traced far
back to the vedic times,
about 5000 BC.
Propounded by
German Doctor
Samuel Hahnemann
(1755 – 1843 AD)
Allopathic System
was been statred
from ancient Greek
and Mesopotamia.
Principle Based on “Tridosh
theory of disease”
“Law of similar and
Law of Minimum
dose”
Theraphy with
remedies that
produce effects
differing from those
of the disease
treated
Diagnosis Based on Patient
examination and disease
examination
Based on history
taking
History taking,
patient examination
and investigations
Treatment Strengthen Internal
Power of the body
Similar substance
should be given as
medicine in low dose
which in healthy
persons produces
symptoms similar to
disease being treated
Symptomatic and
specific treatment
are provided to stop
pathogenesis and
halt recovery.
57. Naturopathy
• Naturopathy, or naturopathic medicine, is a system of
medicine based on the healing power of
nature. Naturopathy is a holistic system, meaning
that naturopathic doctors (N.D.s) or naturopathic medical
doctors (N.M.D.s) strive to find the cause of disease by
understanding the body, mind, and spirit of the person.
58. • Naturopathy or naturopathic medicine is a form
of alternative medicine
• Naturopaths favor a holistic approach with non-invasive
treatment and generally avoid the use of surgery and drugs
• Naturopathic philosophy is based on a belief in vitalism and
self-healing, and practitioners often prefer methods of
treatment that are not compatible with evidence-based
medicine.
59. • The term "naturopathy" was created from "natura" (Latin root
for birth) and "pathos" (the Greek root for suffering) to suggest
"natural healing“.
• Modern naturopathy grew out of the Natural Cure
movement of Europe.
• The term was coined in 1895 by John Scheel and popularized
by Benedict Lust, the "father of U.S. naturopathy“.
• Naturopathic practitioners in the United States can be divided
into three categories: traditional naturopaths; naturopathic
physicians; and other health care providers that provide
naturopathic services.
60. Practice
• Naturopathic practice is based on a belief in the body's ability
to heal itself through a special vital energy or force guiding
bodily processes internally.
• Diagnosis and treatment concern primarily alternative
therapies and "natural" methods that naturopaths claim
promote the body's natural ability to heal.
• Naturopaths focus on a holistic approach, often completely
avoiding the use of surgery and drugs
61. • Naturopaths aim to prevent illness through
stress reduction and changes to diet and
lifestyle.
62. Traces of expansion of curative health centers and
preventive and vertical health service programs.
63. • The Department of Health Services was established in 1953,
under Ministry of Health, which carry out the responsibility of
promotion, regulation and management of hospitals, government
traditional Ayurvedic Dispensaries/School and a unit for
production of Ayurvedic medicines.
• At the beginning in the mid 50s, Nepal started five year
development plans. During that period, the health plans focus on
institutionalization of curative health services.
64. • The preventive health care was begin with establishment of
Vector Borne Disease Control Unit in Dang in 1951 to control
Malaria.
• Promotive health care was institutionalized by establishing the
Health Education Section in 1961 under Department of Health
Services.
• The period of late fifties and sixties was most promising in
prevention and control of infectious diseases like : Malaria,
Tuberculosis, Leprosy and small pox.
65. •For controlling of public health problem following projects were
established
1. Insect borne diseases control project (1951)
2. Inception of Ministry of Health (1956)
3. Malaria Eradication Project in 1958
4. Leprosy Control Project in 1964
5. Tuberculosis Control Project in 1965
6. Smallpox Eradication Project in 1967
7. Family Planning and Maternal Child Health Project in 1968
8. Malaria Control program (1976)
9. EPI 1977
67. Long term plans of Nepal
1. First Long term Health Plans (1975 – 1990)
2. Second Long term Health Plan (1997 – 2017)
68. First Long term plan (1975-1990)
• Was set up in 1975
• More emphasis was given to keep halt the rapidly growing
population and the emphasis was given on family planning
services and maternal and child health.
69. Second long term Health Plan (1997-2017)
• Was set up after the seven years of first long term health plan
(1997)
• The ministry of Health and Population has develpoed a 20 year
second long term health plan (SLTHP) for FY 2054-2074 (
1997-2017).
• The aim of SLTHP is to guide health sector development for
the overall improvement of the health of the population ;
particularly those whose health needs are often not met.
70. The targets of the SLTHP are as follows:
• To reduce the infant mortality rate to 34.4 per thousand live births;
• < 5 mortality rate to 62.5 per thousand live births
• Total fertility rate to 3.05
• Crude birth rate to 26.6 per thousand population
• Crude death rate to 6 per thousand population
• Maternal mortality rate to 250 per hundred thousand live births
• To Increase the contraceptive prevalence rate to 58.2%
• To increase the percentage of deliveries attended by trained
personnel to 95%
• To increasing the percentage of pregnant women attending a
minimum of four Antenatal visits to 80%
71. Cont..
• To reduce the percentage of iron deficiency anaemia among
pregnant women to 15%
• To increasing the percentage of women of child bearing age
(15-44) who receive tetanus toxoid (TT2) to 90%
• To decrease the percentage of newborns weighing less than
2500 grams to 12%
• To have essential healthcare services (EHCS) available to 90%
of the population living within 30 minutes travel time to health
facility.
• To have essential drugs available round the year at 100% of
facilities.
• To equip 100% of facilities with full staff to deliver essential
health care services.
• To Increase total health expenditures to 10% of total
government expenditure.
73. Strengths
• Services are provided in integrated way under single umbrella
• No need of separate infrastructure for each and every
programme
• Maximum utilization of resources
• No need of separate health workforce for each and every
programme
• Time saving while providing services in integrated way
• Easy to carry out supervision as integrated supervision
• Easy management of services
74. Cont..
• Low management and administrative cost
• Increased effectiveness and efficacy
• No duplication of work/services
• Team building
• Integrated Information collection
• No confusion among beneficiaries as they get all services at
one places
• Strengthened organizational capacity
75. Weakness
• Complexity in service delivery
• Difficulty in time managing for each and every services
• May be low quality services due to emphasis in all services
• Difficulty in resource allocation in particular programme and
service
• High workload to health workers
• Complexity in administration and management
• Difficulty in appropriate management of resources
76. Cont..
• Poor supervision to particular service due to its focus
on all services
• Human resource constraints as they may not have
skill and knowledge to manage all services
• Conflicts b/n projects/programs
• Problem in maintaining information as huge
information is collected in integrated way
77. Opportunity
• Favorable government policy: National health policy 1991,
2014
• Involvement of bilateral and multiple partners for integration
process
• Favorable international Environment: Evolution of Primary
Health care concept in Alma Ata Conference in 1978 and
Health for all by the year 2000
• Availability for international funds for integrated services
• Developed mechanism for health information management
78. Threats
• Lack of political commitment
• Political instability, rapid change in government
• Ambitious health workforce wants to work in urban area only
• Geographical difficulties
• Internal resource constraints
• Weak infrastructures for providing integrated services
• Poor road/without road and transportation facility
