Issues and Challenges of public Health Practice Prof. Dr. M.R. Chhetri Chitwan Medical College

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Nepal has made progress in raising the health status and living standards of the population .

The country continues to be suffered by the double burden: persistent problems of infectious diseases along with emerging epidemics and increasing trends of lifestyle-related non-communicable diseases.

The free essential care policy has become one of the popular programme, however, it has undermined demand for community based health insurance.

The free essential care policy itself has focused largely on provision of drugs and has not addressed the extra demands placed on human resources and facility running costs resulting from additional utilisation.

Additionally, policies do not always deliver what they promise Additionally, policies do not always deliver what they promise. Very little efforts have been made to support research and knowledge development and their applications for improving public health.

Likewise, financial, social, political and governance factors have been critical barriers to implementing an effective public health system in Nepal

Critical Appraisal

National Health System of Nepal Organized as Central, regional & district health system and primary health care District health system integrated with preventive, promotive and curative services.

Types of Health Care Systems Allopathic system or modern medicine Oriental or traditional medicine e.g.- Ayurveda, Homeopathy/Unani/Naturopathy

Health Care System at District Level DHO/DPHO Hospital Primary health care center Health post Outreach clinics FCHVs

Barriers to Health Service Delivery Socio-cultural barriers Financial barrier ( 31% below poverty line Gender barrier (health professionals/low status of women) Geographical/topographical barrier Communication & Language Program & service barriers

Health Disparities in Rural Area High morbidity and mortality rate Low nutritional status (specially in women & children) Poor clinical and inadequate public health services Low affordability and accessibility

Budget for Health Care

Barriers of Health System Equity and equality – equal access for equal need Human resource for health distribution. Poverty and health Coordination and collaboration Resource distribution Accessibility and affordability

Barrier to HR utilization Poor incentive Poor monitoring and performance appraisal system Poor supervision and supportive supervision Lack of necessary instrument/ equipment/ infrastructure Security problem

Mechanism of retention

Govt. policy Provides study opportunity to people who work in rural areas (ANM, CMA, MD, MPH etc) Skill enhance policy Short and long term training (SBA, epidemic management, public health training, Bio medical engineering) National and international seminar

Efforts for retention of health work force Nepal Government CTEVT Scholarship for MBBS study. Mandatory services in rural area Rural service mandatory for promotion

Nick Simons Institute MDGP program Anaesthiologist Anesthesia assistant SBA training MLP

Patan Academy of Health Science Admission priority to: Rural area /remote area Commitment and willing to work in rural area Experiences of rural area services 50 percent scholarship to 24 students Full scholarship by Academy and DDC

Pokhara University 20 percent scholarship in all subjects Mandatory to work in rural area as recommended by University Scholarship in affiliated colleges

International and national organizations

To ensure the availability and accessibility of public health services for the entire population and in particular for the most vulnerable and under-privileged groups, some major issues and challenges have to be addressed urgently.

Human resource management (e.g. shortage, mismatching and brain drain)

Proper man in proper place

Communicable and non communicable diseases including mental illness and geriatric problems should be addressed.

Careful watch about towards emerging and re emerging diseases.

Coverage and distribution of services

Accessibility and affordability of clinical and public health service

Social and political issues.

To address these issues and overcome the challenges evidenced based research and application of findings will be more useful.

Thank you