Historical Development of Health System in Nepal

Unit I

Kunwar LBPokhara University

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

Brief history of development of health system in Nepal.

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)

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).

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.

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.

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.

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 .

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

• 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)

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.

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.

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.

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.

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.

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.

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

Traditional health care practices.

Health Care Services in Nepal

Traditional Health care Services

With system: Ayurveda,

Homiopathy, Yoga,Neturopath

y, 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

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).

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.

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)

Introduction

Traditional Health Care Practices: With Formal Systems• Ayurveda, • Homiopathy, • Yoga, • Neturopathy, • Unani

Cont…

Traditional Health Care Practices:

Without Formal Systems• Vaidya/Kabiraj, • Jatibutiwal, • Dhami/Jhakri, • Pandit/Lama/Guvaju/Purohit, • Jharpuke, • Jytotisi, • Sudeni, • Amchi etc.

Ayurvedic, Homeopathic and Allopathic medicine in Nepal.

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.

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

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

Difference among Ayurvedic, Homeopathic & Allopathic

Ayurvedic Homeopthic AllopathicOrigin 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.

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.

• 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.

• 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.

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

• Naturopaths aim to prevent illness through stress reduction and changes to diet and lifestyle.

Traces of expansion of curative health centers and preventive and vertical health service programs.

• 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.

• 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.

• 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

Brief introduction to long-term health plans of Nepal

Long term plans of Nepal

1. First Long term Health Plans (1975 – 1990)2. Second Long term Health Plan (1997 – 2017)

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.

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.

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%

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.

SWOT ANALYSIS OF INTEGRATED HEALTH SERVICES

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

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

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

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

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

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

Thank You.