National Health System Profile

1. TRENDS IN POLICY DEVELOPMENT

The national health policy was adopted in 1991 (FY 2048 BS) to bring about mprovement in the health conditions of the people of Nepal with emphasis on (i) preventive health services (ii) promotive health services (iii) curative health services (iv) basic primary health services with one health post each in the entire 205 electoral constituencies to be converted into primary health care centre (v) ayurvedic and other traditional health services (vi) community participation (vii) human resources for health development (viii) resource mobilisation (ix) decentralisation and regionalisation (x) drug supply, and (xi) health research.

The second long term health plan (SLTHP) 1997-2017 (FY 2054-2074) aims at guiding
health sector development for improving the health of the inhabitants, particularly those whose health needs are not often met. The main objectives of SLTHP are: To improve the health status of the most vulnerable groups, particularly those whose health needs often are not met - women and children, the rural population, the poor, the underprivileged, and the marginalized population To extend to all districts cost-effective public health measures and essential curative services for the appropriate treatment of common diseases and injuries To provide technically competent and socially responsible health personnel in appropriate numbers for quality health care throughout the country, particularly in under-served areas To improve the management and organization of the public health sector and to increase the efficiency and effectiveness of the health care system To develop appropriate roles for NGOs, and the public and private sectors in providing health services; and To improve inter-and intra-sectoral coordination and to provide the necessary support for effective decentralization of health care services with full community participation To increase total health expenditure to 10 percent of total government expenditure (Ministry of Health, Annual Report 2002/2003).

The national health policy aims at improvement in the health conditions of the people of Nepal through extension of primary health care system to the rural population with a view to provide the benefits of modern medical facilities through trained health care providers; active involvement of private sector and NGOs in health services; and adequate training and community participation.

The strategic analysis of health sector in 1999 resulted in the development of the medium five-year health plan (2002-07). This included essential, term strategic plan for the 10affordable and accessible health care services, promote a public-private NGO partnership, decentralize the health system and execute particular approaches at all levels, and to improve quality of health care through the public/private/NGO partnership by total quality management of human, financial and physical resources.

Considering the Local Self Governance Act (LSGA) of 1999 and the decentralized health management of the Health Sector Reform Strategy (HSRS), it is anticipated that more resources will be mobilized at the local level to ensure financial sustainability (Ministry of Health, Annual Report 2002/2003).

The Nepal government is committed to bring about tangible changes in the health-sector development process. It aims at providing an equitable, high quality health care system for all the Nepalese during tenth five-year plan (2002-07). The proportion of the government budget allocated to health will increase from the present 5 percent to 6.5 percent in 2006 and 7 percent in 2009 (Nepal health sector programme implementation plan, 2004-09).

2. TRENDS IN SOCIO-ECONOMIC DEVELOPMENT

2.1 Economic trends

In more than a decade, the GNP increased only by US $ 16. It was reported to be US $ 250 in 2000 but it declined to US $ 249 in 2002 due to socio-political instability and insecurity in the country. It has again gone up to US$300 in 2004/05 (as per Nepal Millennium Development Goals: Progress Report 2005) The GDP per capita has increased from US $ 227 in 1998/99 to US $ 237 in 2002/03. The average annual growth during 1990-2000 was 2.4 percent (Statistical Yearbook, 2003).

Nepal is a less indebted country, as the present value of debt is 193 percent of export of goods, services and income (The World Bank, World Development Indicators, 2005). In Nepal, the foreign aid increased from Rs. 16,188 million in 1998-99 to Rs. 16,974 million in 2002-03. The share of annual health expenditure as percentage of the national budget was 5.1 in 2001-03. Nepal’s rank in terms of the UNDP human development index (HDI) is 138 among 177 countries. The index increased from 0.291 in 1975 to 0.527 in 2004 (Nepal Annual Report DOHS, 2002-03, Human Development Report, 2006).

Nepal’s labour force increased from 8.8 million in 1990 to 11.7 million in 2003. The average annual growth rate for the period is 2.2 percent. The unemployed population aged 10+ is reported to be 5.1 percent while unemployment rate is 3.8 percent (Statistical

Yearbook, 2003 and Nepal Living Standard Survey 2003/04). However, the proportion of females in labour force has not increased much. It was 38.5 percent in 1990 and 39.5 percent in 2003 (World Development Indicators, 2005). In Nepal, 24.1 percent of the population earn less than an American dollar per day and 31 percent of the population is living below poverty line (Nepal Millennium Development Goals: Progress Report 2005).

2.2 Demographic trends

The population of the country increased from 11.6 million people in 1971 to 25.8 million
in 2006. However, the annual growth rate during the period did not decline; rather it increased from 2.1 percent in 1971 to 2.6 percent in 1981, and again decreased to 2.1 in 1991, but again increased to 2.25 in 2001. The CBR decreased from 35.4 per 1,000 population in 1996-97 to 33.5 population in 2001 to 28.4 per 1,000 population in 2006 (Nepal Demographic and Health Survey, 2006) while CDR decreased from 11.5 per 1,000 population in 1996-97 to 9.96 per 1,000 population in 2001. The average fertility estimate for 2006 is 3.1 (Nepal Demographic and Health Survey, 2006) and 2001 was 4.1 as against 5.1 during 1984-86. There is significant difference in TFR for urban and rural areas i.e. 2.1 and 3.3 , respectively (Nepal Demographic and Health Survey, 2006).

As per the census 2001, 39.3 percent of population was below 15 years and 6.5 percent was 60 years and above. About 54.2 percent of population was between 15-59 years (Computed from Population Census 2001, National Report).

The life expectancy at birth increased from 42.0 years for males and 40.0 years for females in 1971 to 55.0 years and 53.5 years for males and females, respectively, in 1991. However, it has shown slight increase in female life expectancy over the males since then. It was 61 years for females and 60 years for males as per 2001 report (Demographic and Health Survey, 2001).

Trends in infant mortality rate (IMR) show that it declined from 140 per 1,000 live births in 1976 to 103 in 1986, to 64 in 2001 (Demographic and Health Survey, 2001) and is estimated to be 61 in 2005 (Nepal Millennium Development Goals: Progress Report 2005) and according to NDHS survey tis 51 per 1,000 live births (Nepal Demographic and Health Survey, 2006)

The percentage of the urban population in 2001 was 14.2 and it was expected to increase 5.15 percent annually during the period (2000-03) (Statistical Yearbook, 2003).

Social trends

The literacy rate is showing a steep upward trend. It was 54 percent in 2001. The Ministry of Education pegs the latest rate at 57 percent. Enrolment ratio in the primary and secondary schools are 0.79 and 0.69, respectively. Gender inequality in the rate of literacy is, however, glaring. It was 42 percent for females and 65 percent for males (National Population Census, 2001). The Net Enrolment Rate in primary education in 2005 is 84 (Nepal Millennium Development Goals: Progress Report 2005)

2.4 Food supply and nutritional status

The proportion of newborns weighing less than 2,500 grams at birth was 23 percent in 1996/97 and 14.3 percent in 2006. The government has set a target to reduce it to 12 percent by 2017 (Health Information Bulletin 2001).

The demographic and health survey of 2001 reported that about 50.5 and Nepal Demographic and Health Survey, 2006 reported that about 49.3 percent children below 5 years were affected by stunting (short of their age), which can be a sign for early chromic under nutrition. The survey also found that 48.3 percent in 2001 and 38.6 in 2006 of the children were under weight. Also, in the year 2000, 55 percent of children below 5 years were stunted (Nepal Millennium Development Goals: Progress Report 2005), an indicator of acute malnutrition.

The Nepal Micronutrient Status Survey (NMSS) report 1998 revealed that the median urinary iodine level among women was 114.0 mg/I and among school-aged children it was 143.8 mg/I. According to the ‘between census household information monitoring evaluation survey 2000’, only 63 percent households were adequately covered with iodized salt. These reports show that the median urinary iodine level is higher than the WHO cut-off point but household coverage of adequately iodised salt is still lower than the WHO cut-off point. Therefore, IDD is still a public health problem in Nepal.

Iron deficiency anaemia is the most common nutritional problem in Nepal affecting approximately three-quarters of women. Anaemia is one of the underlying risk factors in pregnancy. Anaemia reduces work capacity of adults by 10-30 percent. Among women, there is distinct variation in the prevalence of anaemia according to the ecological zone with highest levels in the Terai followed by the mountainous regions. The most common cause of anaemia in Nepal is considered to be inadequate intake of iron from food followed by parasitic infection, as 71 percent pregnant women are not consuming adequate amount of iron from their daily diets. This is despite fact that antenatal iron supplementation is in place in Nepal since more than two decades. However, the coverage and compliance of antenatal iron supplementation is beyond satisfaction. There is a big gap between supply and demand of iron tablets.

A baseline study was carried out in the districts where Intensified Antenatal Iron Supplementation Programme (IAISP) was implemented. The findings in the programme areas revealed that 27 percent and 47 percent of pregnant women took iron tables in the second and third trimester, respectively. Similarly, drop-out rate was 19 percent during the second trimester and 25 percent in the third trimester. Lack of knowledge about the importance of iron tablets is stated to be the main reason for not taking iron supplementation. However, due to continuous effort by health workers to improve the coverage of iron tablets during pregnancy and postpartum, the coverage of iron tablets reached to 68 percent in the fiscal year 2002-03.

Breastfeeding is nearly universal in Nepal and the median duration of breastfeeding is long (34 months). Nearly one in three children is breastfed within one hour of birth, while two out of three babies are breastfed within one day of birth. This is an improvement over the last five years. However, contrary to the WHO recommendation, only two-thirds of children less than six months of age are exclusively breastfed. Only 53 percent of children under six months of age are exclusively breastfed. Bottle-feeding is not common in Nepal (Nepal Demographic and Health Survey, 2006)

It also reported that 40.9 percent of newborn receive pre-lacteal feed which needs to be reduced (Demographic and Health Survey, 2001).

2.5 Lifestyle and Risk Factors

Smoking is associated with increased risk of lung and heart diseases and is also closely related to other behaviours risky to health, such as alcohol and drug use.

Nearly three-fourths of men smoke cigarettes, bidis or other tobacco, two-thirds consume alcohol; more than one in two both smoke and consume alcohol. Smoking and alcohol consumption is much less common among men in the age group of 15-19. Smoking and alcohol consumption is also less common among divorced, separated, or widowed men and women living in the Terai ecological zone, western development region, and central Terai sub-region than in other regions. heart disease, diabetes and cancer are on the increase. That is why the government has taken several steps to create awareness among the public about the harmful effects of tobacco, alcohol and narcotic drugs. Besides, other measures such as increase in excise duty on tobacco and alcohol products, health tax on tobacco products, compulsory health warning on every cigarette package, ban on smoking in public places, ban on advertising and promotion of tobacco products, and import and export tax on tobacco products have been enforced to discourage use of tobacco and alcohol. The Smoking (Prohibition and Control Act, 2058) is awaiting the parliamentary approval. Under the national anti-tobacco programme, anti-tobacco communication campaign, a five-year action plan (2004-08) has been prepared by the health ministry (Update on the National Health System Profile Nepal, 2004).

3. HEALTH AND ENVIRONMENT

3.1 General protection of the environment

Air water pollution and deforestation are assuming alarming proportion. Water pollution is due to inadequate sewerage and sanitation, industrial wastes and pesticides from agricultural sources. On the other hand, vehicular and industrial emissions, combustion of fossil fuels and biomass are the main causes of air pollution. To address these problems, the Nepal environment policy and action plan was formulated in 1993 and in the same year the environment protection council was also established. The Ministry of Population and Environment was created in 1995. A ban on diesel driven three-wheelers in Kathmandu, regular check up of vehicle emission by the government and other designated agencies, a policy decision to keep the vehicles more than 20 years old off the road, are some of the important steps taken in recent years.

Lack of resources and trained human resources, inadequate infrastructure, weak coordination and lack of awareness on environmental issues, are some of the main problems in the implementation of environmental programme.


3.2 Water supply and sanitation

The piped water is considered as a safe source of water. According to the living standards survey report 2003/04, 14 percent households had access to piped water supply within their houses and 30 percent outside of their houses. The remaining 56 percent households depended on covered well (37 percent), open well (5 percent) and others (14 percent), including rivers, streams, ponds etc.

Urban areas have better access to safe drinking water (68 percent) as compared to rural areas (39 percent).The piped water facilities were available to 33 percent households in 1995/96 as compared to 44 percent in 2003/04.

The proportion of households with proper toilet facilities in their dwelling units was 39 percent in 2003/04 as compared to 22 percent in 1995/96. About 12 percent of households have access to sanitary (sewerage) system, but it is concentrated in urban areas (54 percent). Only eight percent households have disposal facilities for solid waste by public and private collector (Nepal Living Standard Survey 2003/04).

In Nepal 25 percent of the population have access to excreta disposal facility with coverage of 21 percent rural population and 53 percent of the urban population.

According to a joint study by the government, National Planning Commission (NPC) and UNICEF in 1996, the major reasons for not having a latrine among the households were: no perceived need (66 percent), resource constraint (31 percent), smell and privacy (three percent).

The Nepal Water Supply Corporation, a government agency, serves the major municipalities while the department of drinking water and sewerage serves rest of the country.

The government strategy is to integrate sanitation with water supply, promotion and utilisation of local knowledge, skills, resources and low-cost technology. Local bodies, user groups, NGOs are involved in the operation, repair and maintenance jobs. Small-scale drinking water projects are handed over to local communities and user groups. But the major constraints facing its better implementation are lack of resources, weak cost recovery, etc. Hence private investment is lacking. There is poor coordination among the stakeholders at local levels. Besides, rapid urbanisation, pollution of surface water, diminishing spring water sources and high leakage rate (38 percent) are some of the other problems. High content of arsenic in tube well water in the Terai region is posing a new problem.

4. HEALTH RESOURCES

4.1 Human resources for health

Human resource development has been an area of priority of health services delivery programme in Nepal. The integrated and community health programmes of 1974 introduced systematic training process with the aim to develop all health personnel on integrated health care, who were brought in to mainstream of the integrated public health services from vertical health projects. The revision of the health services structure in 1993 brought the institutional leadership in the area of health manpower training. The number of personnel trained at central and district level training centres during the 2000-01 and 2002-03, is given below:

Training performance over the three-year period
Sr. Training
Numbers of persons trained
No. 2000-01 2001-02 2002-03
1. Central level 4,961 7,745 2,440
2. District level 83,937 93,191 102,425
3. Training achievements 84 % 87 % 87 %
Source: Ministry of Health, Annual Report 2002/2003.

The above table shows that the training achievements increased from 84 percent in 2000-01 to 87 percent in 2002-03.

It may be seen from the table that health manpower has not increased, except for categories of doctors, FCHV/TBAs. The post of village health worker is a new creation According to the Central Bureau of Statistics, Nepal, 2003, there was one physician per 5,886 people.

4.2 Financial resources for health

A public expenditure review of the health sector was carried out during early 2003. The review brought out many important findings, some of which are given below.

i. Public funding in health care increased from US$ 3.5 to US$ 5.1 during 1999-2002.
ii. The contribution of external development partners (EDPs) in health sector through the ministry of finance was reduced to almost one-third during this period
iii. The share of recurrent budget is being spent more on wages
iv. The funding in health care to rural areas is decreasing. Health services are comparatively less utilised by the female population.

Resources available for health care during fiscal year 2003-04 (in rupees) are as follows:

A. Total outlay in health care
Fund from government 1,410 million (49.3percent)
Fund from external sources 1,450 million (50.7percent)

B. Breakdown of the fund
Physical infrastructure 300 million (10.5percent)
Salary and services 2,560 million (89.5percent)

C. Percentage outlay in health Percentage of national budget in helath 6.2
Percentage of the current five-year plan allocation in health: 6.0

About 10 percent of the expenditure on health care comes from the state-owned enterprises. Local bodies have been contributing more for the health sector in recent days. In absolute terms, the budget allocation for the whole nation and for the health sector has gradually been increasing over the last 30 years, but in percentage terms there has been no actual enhancement in the allocation for health. For example, in 1983-84 it was 4.6 percent, in 1993-94 it was 4.0 percent and in 2002-03 it was 4.9 percent. Unfortunately even the allocated budget for the health sector was hardly expended to the fullest. It is on an average 68 percent of the total allocation.

Financial resources in the health sector have been coming down noticeably during the last few years due to mounting concern for maintaining internal security. External donors have also reduced their contributions to the health sector. Funding from the external donors is increasingly going to the international and national NGOs.

Although the policy of the government, as per the 10th five- year plan, is to stress on giving priority to primary health care and to the poor in remote areas, in practice, distribution of funds is mainly urban-centric and more funds are being allocated for areas that already have better infrastructure, e.g., with better transportation and communication facilities.

Government Expenditure in Health Care by Level

Level of Care Fiscal year 1999/2000 2000-01 2001-02
Primary (percent) 62.8 55.1 59.5
Secondary (percent) 5.1 7.2 6.9
Tertiary (percent) 22.7 26.9 24.4

In Nepal, total health expenditure as percentage of GDP has been fluctuating since 1998. It was 5.1 percent in 1998 and 5.2 percent in 2002. Share of public expenditure in total health expenditure declined from 67.2 percent in 1998 to 65.6 percent in 2002, whereas the share of private expenditure increased from 32.8 percent in 1998 to 34.4 percent in 2002. On the other hand, the share of public expenditure increased nominally as it was 7 percent in 1998 and 7.5 percent in 2002 (World Health Report, 2005).

The per capita total expenditure on health has been increasing gradually as it was US $ 10 in 1998 and US $ 12 in 2002, whereas the per capita public expenditure on health stagnated since 1998 as it was constant at US $ 3 during 1998-2002 (World Health Report, 2005).

Main sources of funding are the royal government and external resources. In March 2004, the International Labour Organisation launched a national campaign on social security and coverage for the benefit of all Nepalese. It aims at providing access to health insurance and other benefits. It was initiated for the first time in Asia, particularly Nepal, where 95 percent of the people are not included in any form of social security.

4.3 Physical infrastructure for health

The lowest level of formal health care starts from Sub-Health Posts (SHPs) at the Village Development Committee (VDC) level to Health Posts (HPs), Primary Health Centres (PHCs) and hospitals at the district, zonal, sub-regional, regional and central levels. Basically all PHC services provided at various levels in the public sector are by the Department of Health Services (DHS) and the Department of Ayurvedic Medicine (DAM). The SLTHP, periodic plans and the general policy of the government emphasises in providing PHCs to people, particularly living in remote, rural and unserved areas and focusing on pregnant women and children.

Topography-wise the Distribution of the Health Care Facilities

Type of institution Total Mountain Hill Terai
Hospital 85 16 45 24
PHCC/HC 193 20 94 79
Health Post 701 152 379 170
Sub-Health Post 3,129 387 1,606 1,136
Ayurvedic Hospital 2 - 1 1
Dist. Ayurvedic HC 50 8 27 15
Ayurvedic Dispensary 211 28 125 58
Zonal Ayurvedic Dispensary 14 1 8 5
Homeopathic Dispensary 1 - 1 -
Unani Dispensary 1 - 1 -
Source: DHS Annual Report 2001-2002

Source: Ministry of Health 2001-2002*
* As per an exercise organised by the government, a total of 3,210 beds will be required for the district level alone by 2017.

In addition to the above-mentioned allopathic hospitals/health care facilities, there are two ayurvedic hospitals (one of which is a 100-bed hospital and the other one a regional hospital) and one regional ayurvedic dispensary. There are 14 zonal, 55 district and 216 general ayurvedic dispensaries throughout the country. Nepal also has a six-bedded homeopathic hospital and one Unani dispensary. All of these are run by the public sector.

Concern on equity, particularly in a country like Nepal, is louder than ever. The concern for the poor, marginalised and the unserved people has been the priority of the government in providing health services, education and employment in general and to the Dalits in particular. Similar provisions have also been made in the community drug programme. On the whole, the ministry spends about 51 percent of its funds in rural areas, 18 percent in semi-urban and 31 percent in urban areas. Each hospital allocates five percent of the contribution received from the government and five percent of their own income for the services of the poor.

The policy of Nepal Government as set out in the SLTH plan, health ministry has given low priority to the hospital based services. In practice, however, this policy could seldom be translated into reality. The policy, as set in the present five- year plan and in the medium-term expenditure framework (2002/03-2004/05), suggests that the private sector will be more involved in catering to hospital based services.

Due to the thinly scattered population profile in the hilly and mountainous regions, the accessibility to health facilities is still a problem in this Himalayan country.

4.4 Essential drugs and other supplies

The policy on medicine, which came into force in 1995, emphasises on establishment of coordination among the government, NGOs and private organisations involved in production, import, export, storage, supply, sale, distribution, quality assessment, regulation, rational use and information flow of medicines in the country.

The department of drug administration (DDA) was established in 1979 following the promulgation of the Drug Act the previous year. Since then, it has been implementing the following: Development of constitution and regulation for the drug consultative council and drug advisory committee Registration of medicine Maintaining of medicine standards Inspection of compliance of the regulations Promulgation and implementation of the codes for production of medicine Promulgation and implementation of the codes for sale and distribution of medicine Promulgation and implementation of the codes on advertisement of medicine.

It has developed and distributed books on the rational use of drugs, Standard Treatment Schedules (STS) for health posts and sub-health posts to encourage and enforce rational use of drugs. The drug administration has also developed and published training manuals for HPs and SHPs on drug quantification, prescribing and dispensing practice to be used for training health workers.

The drug administration also took 317 administrative actions and 33 legal actions during 2002-2003 for non-compliance of the Drug Act and other regulations. Similarly, 14 roducts from eight domestic and nine from four foreign companies were recalled from the market and import license of seven foreign companies was cancelled during the same period.

The Nepal Drug Research Laboratory is another principal body for testing and analysis of medicines. It works as the national drug control laboratory. Procurement and supply of drugs, equipment, insecticide, vaccine and medical consumables are organised for all the divisions of DHS by the Logistics Management Division (LMD) and a supply section in the department of ayurvedic medicines for ayurvedic medicines. Quality of medicine is overseen by the drug authority. .

While half of the procurements are still in the hand of the central office at the national level, half of the procurement is now done at five regional health service directorates for the peripheral units. Essential drug procurement is gradually being shifted to SHPs. This has however, raised questions on the quality of the medicine procured.

Since the establishment of the drug authority, Nepal has been producing medicines and meeting 65 percent of the domestic needs (39 percent allopathic and 26 percent Formatted: English (U.S.)traditional).

4.5 International partnership for health

The external development partners are generally involved in strengthening and expanding the health facilities and services in different parts of the country supporting preventive, promotional and curative services. In recent times, a health sector reform committee was formed under the chairmanship of the health minister and a core group was formed consisting of EDPs, international NGOs, national NGOs and private sector to plan and coordinate the use of resources available for health sector programmes from all stakeholders. The group is expected to mobilise bigger resources and also increase the fund absorption capacity of the government. Currently, Nepal is partnering with 21 international NGOs, four multi-lateral and six bi-lateral development partners.

The GFATM has provided US$7 million for the HIV/AIDS control programme and US$4 million for the malaria control programme.
DEVELOPMENT OF THE HEALTH SYSTEM

5.1 Health policies and strategies

After the world nations agreed to attain the goal of ‘Health For All’ (HFA) by the year 2000AD through primary health care approach, Nepal also stepped ahead to extend and strengthen the integrated approach to meet the national goals.

The ninth five-year plan (1997) had set a target to improve public health status by strengthening of the existing infrastructure for preventive, promotive, curative and rehabilitation services.

The second long-term health plan (1997-2017) aims at improving health status of the people, particularly those whose health needs are often not met; the most vulnerable groups, women and children, the rural population, the poor, the under-privileged and the marginalized. It emphasises on assuring equitable access by extending quality essential health care services with full community participation and gender sensitivity by technically competent and socially responsible health personnel throughout the country. In addition to essential health care, specialist services are also to be extended gradually on a cost-effective basis. The targets to be achieved by the second long- term health plan (SLTHP) by the end of the plan period of 1997-2017, are as follows:

i. IMR will be reduced to 34.4 per thousand live births from its present level ;
ii. Under- five mortality rate to be reduced to 62.5 per thousand live births from the its present level;
iii. TFR to be reduced to 3.05 from its present level;
iv. Increase life expectancy to 68.7 from its present level;
v. To reduce CBR to 26.6 per thousand population from the its present level;
vi. To reduce CDR to 6 per thousand population from its present level;
vii. To reduce maternal mortality ratio to 250 per 100,000 births from the its present level;
viii. To increase CPR to 58.2 percent of its present level;
ix. To reduce percentage of new born < 2,500 gm to 12, and
x. To provide essential health care services at district level to 90 percent of the
population living within 30 minutes of travel time

Millennium Development Goals (MDGs)The progress made towards achievement of health related MDGs is given at Annex-2.

5.2 Organisation of the health system

The overall purpose of the Department of Health Services is to deliver preventive, promotive and curative health services throughout the country. The Department of Health Services (DoHS) is one of three departments under the Ministry of Health. As seen in Figure 1, the organisational structure of the ministry MoH outlines how different levels of the health care system relate to each other in the form of a health care network under the DoHS.

According to the institutional framework of DoHS and MoH, the Sub-Health Posts (SHPs), from an institutional perspective, is the first contact point for basic health services. However, in reality, the SHPs are the referral centres of the volunteer cadres like TBAs and Female Community Health Volunteers (FCHVs) as well as a venue for community-based activities such as PHC outreach clinics and EPI clinics. Each level above the SHP is a referral point in a network from SHPs to HPs to PHCs, and to district, zonal and regional hospitals, and finally to the speciality tertiary care centres in Kathmandu. This referral hierarchy has been designed to ensure that the majority of population receives public health care facilities and minor treatment in places accessible to them and at a price they can afford. Inversely, the system works as a supporting mechanism for lower levels by providing logistical, financial, supervisory and technical support from the centre to the periphery.