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Basic Health Services for GII officer Training at NASC Mahendra Prasad Shrestha Director National Basic Health Services for GII officer Training at NASC Mahendra Prasad Shrestha Director National Health training Centre

Content covered • • • Concept of health and public health Basic health services Content covered • • • Concept of health and public health Basic health services Health indicators HDI in relation to health Access to health services Issues and improvement areas

Definition of health • WHO 1948 “Health is a state of complete physical, mental Definition of health • WHO 1948 “Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease of infirmity”

Philosophy of health • Health is not mainly an issue of doctors, social services Philosophy of health • Health is not mainly an issue of doctors, social services and hospitals. It is an issue of social justice; • Health is a Fundamental human right • Health is the Essence of productive life • Health is inter-sectoral • Health is central to the concept of quality of life • Health is an integral part of development • Health and its maintenance is a major social investment, and world wide social goal • Health involves individual, state and international responsibility.

Public Health • C. E. A. Winslow 1920 : “the science and art of Public Health • C. E. A. Winslow 1920 : “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts…”

Basic health services • The current Interim Constitution of Nepal, for the first time Basic health services • The current Interim Constitution of Nepal, for the first time in Nepal’s history, guarantees health as a fundamental right of every citizen. • NHP-2071 sets out a forward looking agenda for improving the health and well-being of all citizens of Nepal, including the old, disabled, single women, poor, marginalized and at risk communities.

Changing concept • • • Basic health services Essential health care services Health for Changing concept • • • Basic health services Essential health care services Health for All Primary health care services Health promotion

Basic health services • UNICEF/ WHO 1965: “A basic health service is understood to Basic health services • UNICEF/ WHO 1965: “A basic health service is understood to be a network of coordinated, peripheral and intermediate health units capable of performing effectively a selected group of functions essential to the health of an area and assuring the availability of competent professional and auxiliary personnel to perform these functions. ”

Essential Health Care Services • 2 nd long term health plan 1997 -2017 identified Essential Health Care Services • 2 nd long term health plan 1997 -2017 identified the 20 essential health services: • Appropriate treatment of common diseases and injuries • RH, EPI, IMCI, Condom distribution and promotion, TB, Leprosy, Nutrition, prevention and control of blindness, environmental sanitation, school health, vector born control, oral health, deafness, substance abuse, occupational health, • Accident prevention and rehabilitation, community based rehabilitation, Emergency preparedness and management

Health for ALL • In May 1997, World Health Assembly decided that the main Health for ALL • In May 1997, World Health Assembly decided that the main social goal of government and WHO in coming years should be the “ attainment by all the people of the world by the year 2000 AD of al level of health that will permit them to lead a socially and economically productive life”

Primary Health Care Alma Ata Conference 1978 • “Essential health care based on practical, Primary Health Care Alma Ata Conference 1978 • “Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individually and families in the communities through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of selfdetermination. ”

Primary Health Care ELEMENTS I. Education about health and diseases. II. Promotion of food Primary Health Care ELEMENTS I. Education about health and diseases. II. Promotion of food supply and proper nutrition III. Safe water and basic sanitation IV. FP/ MCH V. Immunization against infectious diseases VI. Prevention and control of endemic diseases VII. Treatment of common diseases and injuries VIII. Provision of essential drugs

Principles of PHC 1. 2. 3. 4. Equitable distribution Community participation Intersectoral coordination Appropriate Principles of PHC 1. 2. 3. 4. Equitable distribution Community participation Intersectoral coordination Appropriate technology

The Jakarta Declaration on Health Promotion (July 1997) The determinants of health; new challenges The Jakarta Declaration on Health Promotion (July 1997) The determinants of health; new challenges in the 21 st century; and the fundamental conditions and resources for health are: • Peace, Shelter, education, social security, social relations, food, income, the empowerment of women, a stable ecosystem, sustainable resource use, social justice, respect for human right and equity. • Above all, Poverty is the greatest threat to health.

Basic need indicator By ILO • • Calorie consumption Access to water Life expectancy Basic need indicator By ILO • • Calorie consumption Access to water Life expectancy Death due to disease Literacy Doctor and nurses per population Rooms person GNP per capita

Indicators of Health 1. Health Policy Indicators 2. Social and economic indicators related to Indicators of Health 1. Health Policy Indicators 2. Social and economic indicators related to health 3. Indicators for the provision of health care 4. Health status indicators

1. Health policy Indicators • Political commitment • Resource allocation • The degree of 1. Health policy Indicators • Political commitment • Resource allocation • The degree of equity of distribution of healtth services • Community involvement • Organizational framework and managerial process

2. Social and economic indicators related to health • • Rate of population increase 2. Social and economic indicators related to health • • Rate of population increase GNP and GDP Income distribution Work conditions Adult literacy rate Housing Food availability

3. Indicators for the provision of health care • • Availability Accessibility Utilization Quality 3. Indicators for the provision of health care • • Availability Accessibility Utilization Quality of care

4. Health status indicator • Low birth weight (percentage) • Nutritional status and psychosocial 4. Health status indicator • Low birth weight (percentage) • Nutritional status and psychosocial development of the children • Infant Mortality rate • Child Mortality rate • Life expectancy at birth • Maternal mortality rate • Disease specific mortality • Morbidity- Incidence and prevalence • Disability prevalence

Selected health and socio-economic indicators (WHO/UNICEF 2012) SN Indicator LDC ODC HDC 1 Life Selected health and socio-economic indicators (WHO/UNICEF 2012) SN Indicator LDC ODC HDC 1 Life expectancy at birth (2010) 59 68 80 2 IMR (per 1000 live births) 2010 71 44 5 3 Under 5 mortality (per 1000 live births) 2010 110 63 6 4 MMR 2009 (per 100, 000 live birhs) 410 53 14 5 Doctor population ration per 10, 000 (2009) 4 24 28 6 Nurse population ration per 10, 000 (2009) 10 40 81 7 GN I per capita Us $ (2009) 669 3, 304 40, 845 8 Per capita public expenditure on health USD (2009) 25 326 4, 692 9 Adult literacy rate (2005 -2010) 58 80 99 10 Access to safe water % population (2010) 65 93 100 11 Access to adequate sanitation % population (2010) 37 73 100

Under-five, Infant, Neonatal and Postnatal Deaths Under-five, Infant, Neonatal and Postnatal Deaths

We have Made Impressive Progress in Reducing MMR We have Made Impressive Progress in Reducing MMR

Quality of Care: Need Our Focus Quality of care at the point of service Quality of Care: Need Our Focus Quality of care at the point of service delivery Availability and readiness of quality services • • • Commodities, drugs & equipment Working environment Provider satisfaction Infrastructure Human resource • Quality of care Client satisfaction • • • Maternal deaths in health facility increased from 21% in 1998 to 41% in 2009 82% institutional maternal deaths were emergency admissions (MMMS 2009) 22% of health workers’ post is vacant/not fulfilled Lower level facilities are ‘underutilized’ and referral hospitals are ‘overcrowded’ 32% of public hospitals; 91% of PHCCs; and 16% of HPs meet infrastructure standard (HIIS 2013/14) Procurement and supply of commodities, drugs, equipment and services are generally ‘delayed’ for some reasons Quality at point of production vs. point of service delivery

Suicide: A preventable killer: Alarming facts Suicide cases: Data from other sources Per 100, Suicide: A preventable killer: Alarming facts Suicide cases: Data from other sources Per 100, 00 population 25 WHO estimate 2014 Per 100, 000 WRA 22 MMMS 1997/98 Per 100, 000 WRA 28 MMMS 2008/09 % of WRA deaths 10 MMS 1997/98 % of WRA deaths 16 MMMS 2008/09

Road Traffic Accidents 4500 8 4000 7. 5 3500 3000 7 2500 6. 5 Road Traffic Accidents 4500 8 4000 7. 5 3500 3000 7 2500 6. 5 2000 1500 6 1000 5. 5 500 0 2007 -08 Fatalities 2008 -09 Serious Injuries 2010 -11 Injury Fatal Ratio 2009 -10 2011 -12 Reference : Status Paper on Road Safety in Nepal 2013 http: //data. opennepal. net/content/road-traffic-accident-records-2013 2012 -13 5

Human Development Index (HDI) • Human Development Index (HDI) is defined as “a composite Human Development Index (HDI) • Human Development Index (HDI) is defined as “a composite index combining indicators representing three dimensions- longevity (life expectancy at birth); Knowledge (mean years of schooling and expected years of schooling) and income( GNI per capita in purchasing power parity in USD). ”

Human Development Index Dimension Indicator Dimension Index Knowledge Standard of living Life expectancy Schooling Human Development Index Dimension Indicator Dimension Index Knowledge Standard of living Life expectancy Schooling Mean and expected GNI per capita Life exp index Education Index GNI Index Long life Human Development Index (HDI)

Dimension Index Actual value-minimum value = Maximum value-minimum value Dimension Index Actual value-minimum value = Maximum value-minimum value

Nepal’s development priorities post 2015, including graduation of Nepal from LDC to DC by Nepal’s development priorities post 2015, including graduation of Nepal from LDC to DC by 2022 • Second half of 13 th Development Plan (mid July 2013 – mid July 2016) coincides with Post-2015 SD agenda • The current plan has the long term vision of graduating Nepal from it current status of “least developed country” to “developing or middle income country” by 2022 • The main objective of the current plan is to improve the living standard of the people of Nepal by reducing poverty. . .

Development priorities • Development of hydro power and other sources of energy • Increase Development priorities • Development of hydro power and other sources of energy • Increase in agricultural productivity through diversification and commercialization of agriculture • Development of tourism, industry and trade • Development of basic sectors such as education, health, drinking water and sanitation • Promotion of good governance • Development of roads and other physical infrastructure • Protection of natural resources and environment

Graduation of Nepal from LDC to DC by 2022 • • Graduating from the Graduation of Nepal from LDC to DC by 2022 • • Graduating from the LDC category requires progress on three indicators: (i) per capita GNI higher than $1, 190); • (ii) progress in Human Assets Index (HAI), which comprises – (a) nutrition (percentage of population undernourished), (b) health (mortality rate of children aged five years or under), and (c) education (gross secondary school enrolment ratio and adult literacy rate); and – (iii) progress on Economic Vulnerability Index (EVI), which comprises • (a) population size, (b) remoteness, (c) merchandise export concentration, (d) share of agriculture, forestry and fisheries in gross domestic product (GDP), (e) share of population living in low elevated coastal zones, (f) instability of exports of goods and services, (g) victims of natural disasters, and (h) instability of agricultural production. • The latest thresholds for graduation from the LDC category are (i) per capita GNI of $1, 190 or more, (ii) HAI of 66 or more, and (iii) EVI of 32 or less. At least two of the three criteria must be met to qualify for graduation.

Current status and challenges • Gross national income (GNI) per capita US$730 (WB: 2013). Current status and challenges • Gross national income (GNI) per capita US$730 (WB: 2013). • GNI average annual growth rate about 4% to 5%. • Nepal need to achieve GNI per capita of US$1, 190 or more by 2022. • WB study (June 2014) shows with an average GNI growth rate of 7% from FY 2014 onwards & a constant annual pop growth rate of 1. 2% , Nepal would achieve Middle Income status as defined by GNI per capita • However, if the current growth rate of about 4. 2% maintained, it would yield this outcome only by 2025.

Current status and challenges • Human Assets Index: Social indicators such as nutrition, child Current status and challenges • Human Assets Index: Social indicators such as nutrition, child mortality, secondary school enrolment and adult literacy must be at least 20% above threshold set (current 59. 8). • 3. The Economic Vulnerability Index: the economic structure of a country and its ability to cope with potential ‘economic shocks', such as natural disasters (current 37).

SDG in Health • SDG 3: Ensure healthy lives and promote wellbeing for all SDG in Health • SDG 3: Ensure healthy lives and promote wellbeing for all at all ages – Continue reducing MMR to achieve MMR 70 by 2030 – Pay increasing attention to NCDs – Increase access to health services -universal health coverage – Emphasize quality of care – Invest more on health – Build both human and physical capacities

SDG in Health • Adhere to PPP – Involve EDPs, NGOs, CSOs and the SDG in Health • Adhere to PPP – Involve EDPs, NGOs, CSOs and the private sector – Secure resources from donors and use them effectively • Ensure good governance – Ensure timely implementation of activities planned • Strengthen monitoring • Conduct independent periodic evaluation – Ensure inclusive policies in health -areas, socioeconomic classess and gender – Make services client-friendly

Issue and challenges • • Equity and equality Globalization and expectation Commercialization Access to Issue and challenges • • Equity and equality Globalization and expectation Commercialization Access to care Demographic transition Climate change and health NCDs and RTA New and emerging diseases

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