Healthcare System of Nepal Dr. Tracey Lynn Koehlmoos Lecture 14 HSCI 609

1. Healthcare System of NepalDr. Tracey Lynn KoehlmoosLecture 14 HSCI 609

2. The Roof Top of the World Dr. K’s husband took this shot of Mt. Everest from the air

3. After a decade of political strife…What do we call it? • Kingdom of Nepal—for how much longer? • Gov’t type: constitutional monarchy? Parliamentary democracy? (2006) • Capital: Kathmandu • Divisions: 14 Anchal • Since 1996, more than 13,000 people have died in the Maoist insurgency against the Royal Nepalese government Not one of Dr. K’s sons— at the Monkey Temple

4. Where is Nepal? • One of the poorest countries in the world, Nepal is landlocked between India and China • 8 out of 10 of the world’s tallest peaks including Mt. Everest

5. Challenging Terrain • Nepal is slightly larger than Arkansas (140,800 km) • Cool summers & severe winters in the north • Subtropical summer & mild winters in the south • Three regions: • Himalayas in the north • Central hill region • Terai, flat river plain of the Ganges in the south

6. Population Overview • Population: 28.2 million (2006) estimate • Infant mortality: 65.3 per 1,000 • Life expectancy: 60.43 male/ 59.91 female • Male Life expectancy higher than female • Population >65: 3.7% • Median age: 20.3 years • Healthcare as % of GDP: 5.3 (2003) • Per Capita health expenditures: $64 (Int.)

7. Health System Organization • Ministry of Health & Family Welfare • Director General Health Services • Regional Directorates (5) • Districts (75) • 180 Primary Health Centers • 711 Health Posts • 3179 Sub Health Posts

8. District Headquarters in Baratnapur

9. Health System Organization • A good plan for decentralization and community control (VDC) but lack of infrastructure, financial resources, equipment, supplies, trained staff, electricity, transportation and water supplies as well as insurgent activity continue to hinder the development, expansion, and implementation of basic health services • Still highly centralized for planning and finance

10. Financing Health Care in Nepal • Government Expenditure as % of total: 23.5 % (2000) • Foreign Donor Expenditure as % of total: 62 % • Main foreign donors include: WHO, UNICEF, UNDP, UNFPA, World Bank, GTZ, DFID, USAID, JICA, SDC. • There is a huge gap between the amount of funds committed to Nepal healthcare and the amount of funds that are able to absorbed and actually end up providing healthcare services. • i.e. U.K. donated 5 million dollars a year for 5 years to battle HIV/AIDS

11. Problems with Distribution of Health Related Aid to Nepal • Low absorptive capacity leads to poorly allocated, disbursed and reimbursed funds • There are inconsistencies in the financial rules of the government and donor agencies • There is a general lack of decision making ability and authority at all levels • Poorly managed, difficult and ineffective coordination of finances and efforts • The Ministry of Health organized a Joint MOH/Donor Coordination Mechanism (committee) to help mobilize resources and renew efforts to account for funds and how they are utilized through out the country.

12. Challenges in Nepal • Health indicators are poor in general • Tremendous regional variation • Communicable diseases constitute roughly 70% of the causes of morbidity and mortality • Major contributions to the children health burden are perinatal conditions, acute respiratory illness, diarrhea and measles. • Older age groups suffer disproportionately from tuberculosis (TB) • New in the Terai: Japanese Encephalitis • Problems related to pregnancy, childbirth and burns are major causes of morbidity and mortality among women

13. Children in the Terai

14. More Challenges • Significant barriers to access to health services remain. Only 65 per cent of the population in rural communities are within one hour of a public health centre and only one in ten within an hour of a hospital. Public facilities continue to be the dominant source of care for all income groups. There are major concerns about the quality of services received at such facilities.

15. More Challenges • The system is extremely centralized despite much talk about decentralization • Virtually all management and financial decisions are still made at central levels despite the fact that the Department of Health Services is understaffed and underpaid. • Regional Health Directorates were established in 1993 but their roles have been unclear and they have had little impact to date.

16. Physicians • 0.54 physicians per 10,000 population • Most physicians are located in the cities • Hard to entice providers to serve in remote regions, low renumeration, poor working conditions, no opportunity for advancement • Nepalese MDs train in Kathmandu • Most MDs are foreign graduates from India, Bangladesh, Pakistan, ex-Soviet Union and a few from US & UK

17. Medical Education • Nepal has 10 medical schools • About 500 new doctors graduate each year • Post graduate education is popular in the UK and Pakistan • 70% of faculty from abroad (mostly India) • Problems include inadequate regulation, shortage of faculty, and the high cost of education • Source: American Nepal Medical Foundation • http://www.anmf.net/overview.htm accessed 4 June 2006

18. Nurses in Nepal • 6,216 nurses in 2002 • Underpaid, no autonomy, poor working conditions • Most are hospital based but hospitals are completely understaffed • The MoH has a Division of Nursing and Paramedics—but it is poorly funded, poorly empowered and receives limited donor attention

19. The Work Horses of the Health System • Maternal Child Health Workers (MCHW) • Village Health Worker (VHW) • Auxiliary Nurse Midwives (ANM) • Government trained or through private (donor sponsored) training institutes • Training is through seminars or other short programs (Vitamin A, Polio campaigns) • Scope is limited; practical—not trained to handle serious illness

20. Example of MCHW in Chitwan This volunteer has been trained to give Polio drops and measles vaccinations. The facility is usually used for village meetings.

21. Village Health Workers Volunteers immunize school children in the classroom

22. MCHWs headed out for an immunization day

23. Hospitals • One true “teaching hospital” in Kathmandu • 27 of the districts have a hospital • The German gov’t via GTZ is very active in hospital building • 1.9 hospital beds per 100,000 population (est.) • One children’s hospital, many small TB hospitals, one cancer hospital

24. Hospitals • 5-7 metropolitan cities are well equipped with MDs, in-patient and ambulatory care, diagnostic and emergency services • EVERYWHERE ELSE: • No separate place for out-patient or in-patient care • No emergency services • No electricity and no central water supply • Generators are used for minor-medium surgeries

25. Health and Sub Health Posts • HPs and SHPs do not function as intended and are plagued by several problems • Pharmaceutical supplies are often exhausted during the first few months of the fiscal year • In the Himalayas, HPs are not easy to access for patients (baskets v. stretchers for patients in labor)

26. Example of a Health Post This post has electricity but no working refrigerator or running water.

27. The Price of Ten Years of Insurgency A health post and village headquarters destroyed by the Maoists

28. Everyone comes out for shots!

29. Dr. K during a UN/WHO Survey

30. Campaign Driven Healthcare • A myriad of donors means a myriad of funds and health priorities • Different donors concentrate on different aspects of healthcare: UNAIDS, WHO/PEN, GTZ (infrastructure), KITS (FP) • However, conflict and chaos can exist if a campaign is run without full coordination of local programs (i.e. Filariasis) • A huge area worthy of more research

31. Summary • Despite decades of foreign assistance Nepal still has a lot of room for improvement in the healthcare sector • Lack of institutions, resources, funding • Donor dependent • Lack of adequate national planning • Difficult communications and transportation

32. Conclusion The diverse topography and climate, high levels of illiteracy along with unequal regional development work together to tremendously hinder the provision of and receiving of healthcare services in Nepal More than ten years of insurgency have slowed advancement in all sectors