Unit 1: Introduction to Public Health

 Concept, definition, philosophy and scope of public health

Public health

The term “public health” came into general use around 1840. It arose from the need to protect
“the public” from the spread of communicable diseases. Later, it appeared in 1848 in the name of
a law, The Public Health Act in England to crystallize the efforts organized by society to protect,
promote, and restore the people’s health. Now days, it has become wider. It has broad concept. It
embraces the non communicable diseases, social factors, and etiological factors of disease,
health law, consumer’s right, act justice and equality.

John M. Last’s Dictionary of Public Health (2001) gives the following:

• Public Health is one of the efforts organized by society to protect, promote, and restore
the peoples’ health.  
• Public health is the combination of sciences, skills, and beliefs that is directed to the
maintenance and improvement of the health of all the people through collective or social
actions.
• The programs, services, and institutions involved emphasize the prevention of disease
and the health needs of the population as a whole.
• Public health activities change with changing technology and social values, but the goals
remain the same: to reduce the amount of disease, premature death, and disease produced
discomfort and disability in the population.
• Public health is thus a social institution, a discipline, and a practice.
• The Acheson Report (1988) defines Public health more succinctly as: The science and
art of preventing disease, prolonging life, and promoting health through organized efforts
of society.

C.E.A. Winslow in 1923 defined Public Health as the science and art of preventing disease,
prolonging life, and promoting physical health and efficiency through organized community
efforts for the sanitation of the environment, the control of community infections, the education
of the individual in principles of personal hygiene, the organization of medical and nursing
services for the early diagnosis and preventive treatment disease, and the development of the
social machinery which will ensure to every individual in the community a standard of living
adequate for the maintenance of health.

An operational definition o public health is as follows:- “Public health is the planning, carrying
out and evaluation of health measures and system services that both maintain and improve the
health of a population group by preventing and controlling diseases within population groups.
Public health in its present form is a combination different discipline of sciences (e.g.
epidemiology, medical science, health education, social science etc.).

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In 2003, Detels defined the goal of public health as: The biologic, physical, and mental well-
being of all members of society regardless of gender, wealth, ethnicity, sexual orientation,
country, or political views.

This definition or goal emphasizes equity and the range of public health interests as
encompassing not just the physical and biologic, but also the mental well-being of society. Both
the World Health Organization (WHO) and Detels’ goals or definitions depict public health as
being concerned with more than merely the elimination of disease.

To achieve the WHO goal of ‘health for all’, it is essential to bring to bear many diverse
disciplines to the attainment of optimal health, including the physical, biologic, and social
sciences. The field of public health has adapted and applied these disciplines for the elimination
and control of disease, and the promotion of health.

Scope of public Health

The scope of public health can be described under the following four categories:

1. Field, which needs Community-based public health services and activities:

– The supervision of food, water and milk available to the community
– Insect and rodent control (Entomology)
– Prevention of atmospheric and stream pollution
2. Field, which deals with preventable illness, disability and premature death:
– Communicable diseases including infestation
– Dietary deficiency
– Effects of addictive drug and narcotics
– Allergic manifestation and their community effect
– Certain mental, personality and behavioral disorder
– Occupation health
– Cancer
– Cardio-vascular and metabolic disorders
– Certain risk of maternity, child growth or development
– Certain heredity condition
– Home, community and industrial accident
– Rehabilitation of victims of accident and disorder
– Dental caries
3. Field, which needs organized official leadership:
– Facilitation of the postgraduate and pre graduate education
– Promotes equitable distribution of resources and facilities
– Assistance of development and controllers of quality and quantity of community
resources and facilities
4. Research:
Scientific investigation and education, which are obtained through research, are essential for
health development to remain progressive and effective.

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Other scope of public health

– Health policy
– Infrastructure
– Service delivery (accessible, adequate and affordable)
– Geographical boundaries
– Coverage of the country population
– Social justice/equity
– Health system
Functions of public health
To accomplish its task of ensuring the well-being of the population, public health must perform a
wide range of functions, which are listed below. The primary functions are to prevent disease
and injuries and to promote healthy lifestyles and good health habits; but in order to succeed in
these two objectives; public health must perform additional functions. Public health identifies,
measures, and monitors community health needs through surveillance of disease and risk factors
(e.g. smoking) trends. Analysis of these trends and the existence of a functioning health
information system provide the essential information for predicting or anticipating future
community health needs.

In order to ensure the health of the population, it is necessary to formulate, promote, and enforce
sound health policies to prevent and control disease and to reduce the prevalence of factors
impairing the health of the community. These include policies requiring reporting of highly
transmissible diseases and health threats to the community and control of environmental threats
through the regulation of environmental hazards (e.g. water and air quality standards and
smoking). It is important to recognize that influencing politics, particularly in a democracy, is an
essential function of public health.

There are limited resources that can be devoted to public health and the assurance of high-quality
health services. Thus, an essential function of public health is to effectively plan, manage, and
administer cost-effective health services, and to ensure their availability to all segments of
society.

In every society, there are health inequalities that limit the ability of some members to achieve
their maximum ability to function. Although these disparities primarily affect the poor, minority,
rural, and remote populations and the vulnerable, they also impact on society as a whole,
particularly in regard to infectious and/or transmissible diseases. Thus, there is not only an
ethical imperative to reduce health disparities, but also a pragmatic rationale. Technological
advances and increasing commerce have done much to improve the quality of life, but these
advances have come at a high cost to the environment. In many cities of both the developed and
developing world, the poor quality of air—contaminated by industry and commerce—has
affected the respiratory health of the population, and has threatened to change the climate, with
disastrous consequences. We have only one world. If we do not take care of it, we will ultimately

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have difficulty living in it. Through education of the public, formulation of sound regulations,
and influencing policy, public health must restore and monitor the environment to ensure that the
population can live in a healthy environment.

To ensure that each individual in the population functions to his or her maximum capacity,
public health needs to educate the public and stimulate the community to take appropriate actions
towards the optimal conditions for the health of the public. Ultimately, public health cannot
succeed without the support and active involvement of the community.

We cannot predict, and rarely can we prevent, the occurrence of natural and man-made disasters,
but we can prepare for them to ensure that the resulting damage is minimized. Thus, disaster
preparedness is an essential component of public health, whether the disaster is an epidemic such
as influenza or the occurrence of typhoons.

Unfortunately, in the modern world, interpersonal violence and war have become common. In
some segments of society (particularly among adolescent and young adult minority males),
violence has become the leading cause of death and productive years of life lost. Public health
cannot ignore that violence and wars are major factors dramatically reducing the quality of life
for millions.

Many of the advances in public health have become possible through research. Research will
continue to be essential for identifying health problems and the optimal strategies for confronting
public health problems. Strategies that seem very logical may, in fact, not succeed for a variety
of unforeseen reasons. Therefore, public health systems and programmes cannot be assumed to
function cost-effectively without continuous monitoring and evaluation. Thus, it is essential that
new public health strategies undergo rigorous evaluation before being scaled up, and once scaled
up, periodically reviewed to ensure their continuing effectiveness.

Over the last century, the quality of research has been enhanced by the development of new
methodologies, particularly in the fields of epidemiology, biostatistics, and laboratory sciences.
The development of the computer has increased our ability to analyze massive amounts of data,
and to use multiple strategies to aid in the interpretation of data. As new technologies continue to
be developed, it is essential that public health continues to use these new technologies to develop
more sophisticated research strategies in order to address public health issues.

The quality of public health is dependent on the competence and vision of the public health
workforce. Thus, it is an essential function of public health to ensure the continuing availability
of a well-trained, competent workforce at all levels, including leaders with the vision essential to
ensure the continued well-being of society and the implementation of innovative, effective public
health measures.

1. Prevent disease and injuries.

2. Promote healthy lifestyles and good health habits.

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 3. Identify, measure, monitor, and anticipate community health needs.
4. Formulate, promote, and enforce essential health policies.
5. Organize and ensure high-quality, cost-effective public health and health-care services.
6. Reduce health disparities and ensure access to health care for all.
7. Promote and protect a healthy environment.
8. Disseminate health information and mobilize communities to take appropriate action.
9. Plan and prepare for natural and man-made disasters.
10. Reduce interpersonal violence and aggressive war.
11. Conduct research and evaluate health-promoting/disease-preventing strategies.
12. Develop new methodologies for research and evaluation.
13. Train and ensure a competent public health workforce.
Source: Adapted from Offi ce of the Director, National Public Health Performance Standards
Program. 10 essential public health services. [Online]. Centers for Disease Control; 1994.
(Available from: http://www.cdc.gov/od/ocphp/nphpsp/ EssentialPHServices.htm) and Pan
American Health Organization. Essential public health services. [Online]. 2002. (Available
from: http://www.sopha.cpha.ca/english/ephf_e.html)

The Public Health Principles

 The Principle of the Aggregate

 The Principle of Prevention
 The Principle of Community Organization
 The Principle of the Greater Good
 The Principle of Leadership
 The Principle of Epidemiology

Historical development of public health

The different events in the history of health led to the birth of public health concept in England
around 1840. Earlier Johanna Peter Frank (1745-1821) a health philosopher of his time,
conceived public health as good health laws enforced by the police and enunciated the principle
that the state is responsible for the health of its people. The public health act of 1848 was a
fulfillment of his dream about the state’s responsibility for the health of its people.

Cholera, which is often called the “father of public health”, appeared time and again in the
western world during the 10th century. An English Epidemiologist-John Snow, studied the
epidemiology of cholera in London from 1848 to 1854 and established the role of polluted
drinking water in the spread of cholera.

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  Public health in the global context
 The Pre-Christian period
 The middle ages
 The age of the black death
 The Renaissance period
 The 18th and 19th centuries (enlightenment period)
 Modern age

Development of public health in global context

Development of public health can be described under the following headings:

The pre-Christian or primitive period

In ancient time human believed that disease was produced when the God became angry. The
people used to believe that disease might be produced by human energy possessing supernatural
power. Another way of looking at disease was that a disease resulted from the actions of
offended spirits of the deed, whether of a human or an animal. We can find traditional healers
everywhere whose treatment was based on various combinations of religion, magic, and
empirism, mesmerism.

People had little knowledge about personal or community hygiene. The Eskimos (primitive tribe)
had a certain amount of knowledge about community hygiene. Many Americans and Indians had
a custom of using river’s or stream’s sides of excretory purpose. Burial of excreta was not
uncommon but the practice was based more on superstitions than for sanitary reasons.

The Humorus (3000-1500 BC) and the Gretans (3000-1000 BC) had advanced to the point of
constructing drainage system and water flushing system.

The Egyptians of about 1000 BC were described as the healthiest of all the other civilized part of
the world. They had marked sense of personal hygiene, numerous pharmaceutical preparations
and had constructed public drainage pipe. They had built planned cities, public baths and
underground drains. They had also some knowledge of inoculation against smallpox, the value of
mosquito net and association of plague with rats.

The Jews extended the Egyptian and hygiene thought. It dealt with individual cleanliness of the
body protection against the spread of contagious diseases, isolation of lepers, disinfection of
dwellings following illness, sanitation of camping sites, disposal of excreta and refuse, protection
of water and food supplies and the hygiene of maternity.

The Chinese were the early pioneers of immunization. They practiced vaccination to prevent
smallpox. (Dr. Jenner developed smallpox vaccine in 1798 A.D.)

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The Greek civilization was also toward in public health. Main concern was given to personal
cleanliness, exercise and dietetics rather than the matters of environmental sanitation. Another
point of interest was that the weak, the ill and the crippled were ignored and in some instance
destroyed. Hippocrates, also known as the father of medicine, distinguished between diseases,
which were epidemic and those, which were endemic.

The Roman Empire is well known for its administrative and engineering achievements. This
civilization started the registration of the citizens, taking of the periodic census, prevention of
nuisance. They had some sense of sanitation. Public health was born in Rome with the
developments of baths and rewash. Many streets were paved. Provisions were made for cleaning
and repairing streets, removing garbage and rubbish.

The middle age

The period from 500 A.D to 1500 AD is generally referred as the middle age. With the fall of
Roman Empire, the medical schools established in Roman time also disappeared. Whole Europe
was ravaged by disease and prevalence of plague, smallpox, leprosy, and tuberculosis. The
practice of medicine reverted to primitive medicine dominated by superstitions and dogma. The
medieval period is therefore called the “Dark Ages” of medicine.

The reaction was so intense that it even included the marked change in attitude towards
sanitation and personal hygiene.

Leprosy spread from Egypt to Asia and Europe. The lepers were separated from the society and
misbehaved. It was one of the most effective isolation so far. This measure practically eradicated
leprosy in Europe by the 16th century.

The Age of Black Death

No sooner had leprosy declined, than even more dreadful nuisance appeared in the form of
bubonic plague. The spread was largely the result of the development of trade contact between
Europe, Middle East and Asia. Due to that, 13 million people died in china alone. It affected
India, Mesopotamia, Syria, Armenia, Cyprus etc. resulting in high mortality. Ships without crews
were often seen in the Mediterranean Sea. All together there were about 25 million deaths due to
plague.

The Renaissance period

The period from the 14th century to 16th century is termed as the Renaissance period. It was seen
that the great pandemics of the Middle ages must have caused considerable social and political
frustration. By the end of middle age, a number of diseases had been found, among those
leprosy, influenza, trachoma, scabies, anthrax, plague, syphilis, smallpox, diphtheria were of
great importance.

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The few outstanding thinkers like Descorts, Lemmarck, Benthom, Smith, Darwin etc put their
efforts in the improvement of medicine especially in the late 18 th century and throughout the 19th
century.

Paracelsus (1493-1541):-revived medicine.

Francatonous (1483-1553): put forward the ‘theory of contagion’, found the epidemic of syphilis
and became the founder of epidemiology.

Thomos Sudenham (1624-1689) was also regarded as the distinguished epidemiologist. He made
a differential diagnosis of scarlet fever, malaria, dysentery and cholera.

The age of individual scientific endeavour

The 17th and 18th century:

The 17th and 18th century, there had been a lot of exciting discoveries giving a Cornerstone in the
development of public health:

• Harvey discovered blood circulation.

• Leewen Hoek invented microscope.
• Edward Jenner prepared a vaccine against smallpox in 1798.
• James Lind discovered screening in 1759.
• Louis Pasteur demonstrated the presence of bacteria in air. Germ theory of diseases also
found in this period.

The modern age (18th and 19th century)

In this period, the realm of medicine progressed faster than ever before. A great sanitary
awakening in England in mid 19th century has been another milestone in the field of medicine.
Because of the cholera epidemic in 1832, Edwin Chadwick (1800-1890) investigated the health
of the inhabitants of the large towns with a view to improving their living conditions.

Some years of great achievements:

• Birth of public health concept-1840

• Public health act in England -1848
• John Snow established the role of polluted drinking water in the spread of cholera.
• William Budd studied typhoid in 1856 and established the fact that it can spread through
drinking water.
• Public health act 1857 in England for the control of man’s physical environment.
• Robert Koch postulated that bacteria cause anthrax.
• Louis Pasteur gave his Germ theory of disease.

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 • 1892-cholera vaccine was invented.
• 1883-Anti-rabies vaccine by Pasteur.
• 1896- Bruce found sleeping sickness due to tsetse fly. Thus public health has come a long
way from primitive age to modern age. It is gradually changing in concepts.
• During 1880-1920 it was disease control phase;
• During 1920-1960 acted as health promotion phase;
• During 1960-1980 it become social engineering phase and
• From 1980-2000 it was referred as health for all phase.

Public health in Nepalese context.

 Ancient and pre-unified period

 After Unification and during Rana period
 From 2007 and during Panchayat period
 After 2047 BS

Public health is a continuous process by which people are getting health care. It determines the
health status of people and suggests solution for betterment of health.

Public health is not a modern story of recent decades. It has been continuing from the ancient
period, but definitely the concept of public health is changing from time to time. Today public
health has its own identification and reputation in Nepal.

(Development of Public Health in Nepal on period basis)

i. Pre-unified period:
Before unification of Nepal by Prithvi Narayan Shah, the Malla kings used to rule over
the Kathmandu valley. At that time health care delivery system was traditional along with
a few practices of modern public health such as practice of western allopathic medicine
through missionaries.

ii. Prithivi Narayan Shah:

After unification, Prithvi Narayan Shah had promoted traditional health care delivery
system. He had banned the missionaries and had chased away them from Nepal but he
had also used western medicine during battle of Kirtipur when Surpratap Shah had got
eye injury. Some evidences show that allopathic medicine was used to treat the victims of
“kirtipur Battle” and the nose cut wounded. Finally Prithvi Narayan Shah blamed the
missionaries of spreading their religion through providing health care.

iii. Rana period:

The 104 year Rana period started from 1903 BS and ended in 2007 BS, is remembered as
crucial period in the history of Nepal. Jung Bdr Rana was main conttributer in that
period. In fact he was follower of Ayurveda. He believed in Ayurveda but after the visit
of the UK, he tried to flourish the modern medicine. Then, he brought a program to

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 immunize the Rana Family in 1850 AD. That period was the beginning of western
medicine in Nepal. They started curative and preventive medicine with the establishment
of Bir Hospital in 1947 BS and other hospitals like leprosarium in Tokha, transmitted
disease hospital in Teku etc. They also started vaccine of smallpox for the preventive
purpose. But their activities cannot be taken as start of public health because that
facilities and health care were only prevailed for the ruling class.

iv. 1951-1990 (2007 -2046 BS):

This time period can be classified as breakdown of the 39 years. In this time period, 11
plan period are contained
1951-1956 - the pre plan period
1956-1961 - First five year plan
1962-1965 -Second five year plan
1965-1970 -Third five year plan
1970- 1975 - Fourth five year plan
1975-1980 -Fifth five year plan
1980-1985 -Sixth five year plan
1985-1990 Seventh five year plan
1992-1996 (049-54) -Eighth five year plan
1997- 2002 (054-059) –Ninth five year plan
2003-2007 (060-064) – Tenth five year plan
This period is initial period for development of public health system. In 1952 Insect born
disease control project (IBDCP) was established by USAID, so that year has been
supposed as the year when public health was started in Nepal. Moreover, Ministry of
Health was established in 2013 BS as a public health service unit.
2015 BS-2029 BS- In this period many vertical projects (Family Planning, Tuberculosis,
Leprosy, and Malaria etc.) emerged with different objectives and strategies. But they
were less effective because they were not equally distributed.
So, in 2029 BS HMG Nepal had brought the concept of integrated health services. This
year can be considered as the start of ‘modern public health era’ in Nepal. The basic unit
of integrated health services was health post. All vertical projects were brought under
MOH and decentralized nationwide in 1975. After the Alma Ata Declaration in 1978 the
concept of ‘Health For All’ (HFA) by 2000 was started.

Conclusion

i. Expansion of services, expansion of Ayurveda, homeopathy, Naturopathy, more

Hospitals-Health posts.
ii. Development/training of health related manpower in country
iii. Planned Development-establishment of MOH, Department of Health (DOH) and
Directorate of Health Services (DOHS)
iv. Last 10 years a lot of

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 – International influences
– Primary Health Care existence
– Beginning of privatization
– Development of health plan
– Basic minimum standard PHC,HP,SHP
– MBBS Program started in IOM
– Increase demand
– Inadequate supply by government
– Innovative community medicine
– Epidemiological transition
– Accessible people afford for abroad
v. Post Democracy (after 2046 BS)
Primary health care should be accessible to all people but that was not, so sub health post
concept was developed. This has reduced the catchment’s area of health posts. Each VDC
has one SHP. For further improvement of implementation, the concept of out reach clinic
and PHC was developed. Second long term health plan was also developed in that period.
Conclusively, they are:

a. Inside the country

– Democracy, open market, increase demand and inadequate supply
– Concept of private and public participation
– Concept of globalization
– Concept of sub health post
b. Internal policies
– Funding raise
– NGO/INGO promotion
– Privatization raise
c. Rising cost of health service
– Market criteria
– Business of individual
– Lots of technical import
– Irrational use of technology
– Quality satisfaction
– Intensive-serve few earn more
– Extensive-serve more earn few

Concept of health and Diseases

Concept of health

Health is human’s normal condition, which has been regarded as his birth right also. It is the
result of living in accordance with the natural laws pertaining to the body, mind and
environment. These laws relate to fresh air, sunlight, diet, exercise, rest, relaxation, sleep,
cleanliness, elimination, right attitude of mind, good habits and above all life style.

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During the past few decades, there has been a reawakening that health is fundamental human
right and worldwide social goal; it is essential to the satisfaction of basic human needs and to an
improved quality of life, and that it is to be attained by all people. In 1977, the 30 th World Health
Assembly decided that the main social target of governments and WHO in the coming decades
should be “the attainment by all citizens of the world by the year 2000 of a level of health that
will permit them to lead a socially and economically productive life”.

Changing Concept of Health

A brief account of the changing concepts health is given below:

i. Biomedical concept: health is defined as “absence of disease” and disease as

deviation from a biochemical norm. This concept was based on the germ theory of
disease, which dominated medical thought at the turn of the 20th century. This model
was found inadequate to solve some major health problems of mankind such as the
population problem, problem of malnutrition etc.
ii. Ecological concept: The ecologists viewed health as a harmonious equilibrium
between man and his environment and disease as a maladjustment of the human
organism to the environment.
iii. Biosocial and Bio-cultural concept: Development of social sciences revealed that
disease is both a biological and social phenomena. There are not only biological
factors but also social, cultural and psychological factors (non-medical dimension),
which must be taken into consideration while defining health and illnesee.
iv. Holistic concept: The holistic view is a synthesis of all the above concept. It
recognizes the strength of social, economic, political and environmental influences on
health and describes health as a unified and multi-dimensional process involving the
well being of the whole person in the context of his environment. The holistic
approach implies that all sectors of society have an effect on health (in particular,
agriculture, animal husbandry, food industry, education, housing, public works,
communication etc.). This emphasis is on the promotion and protection of health.

Definition of health

 Many definitions
 Widely Variable – sometimes contradictory
 Worthwhile exercise to look at some of them

I. The condition of being sound in body, mind and spirit specially freedom from physical
disease or pain.-Webster
II. Soundness of body or mind, that condition in which its functions are duly and efficiently
discharged.- Oxford English Dictionary
III. Health is a state of equilibrium between humans and the physical, biologic and social
environment, compatible with full functional activity.- Last

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IV. Health is a state of complete physical, mental, and social well-being, and not merely the
absence of disease or infirmity. It is the extent to which an individual or group is able, on
the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or
cope with the environment.
Health is therefore, seen as a resource for everyday life, not the objective of living.
Health is a positive concept emphasizing social and personal resources, as well as
physical capabilities. Therefore, health promotion is not just the responsibility of the
health sector, but goes beyond healthy lifestyle to well-being. – WHO in 1948

• In recent years, this statement has been amplified to include the ability to lead a “socially
and economically productive life”.

Description of WHO definition/criticism of WHO definition- Operational Definition:

• The WHO definition of health has been criticized as being too broad. Some argue that
health can not be defined as a state at all, but must be seen as a process of continuous
adjustment to the changing demands of living and of the changing meanings we give to
life. It is dynamic concept, which helps people live well, work well and enjoy themselves.
• The WHO definition of health is therefore considered by many as an idealistic goal than a
realistic proposition. It refers to a situation that may exist in some individuals but not in
everyone all the time; it is not usually observed in groups of human beings and in
communities.
• Some consider it irrelevant to every day demands, as nobody qualifies as healthy, i.e.
perfect biological, psychological and social functioning. That is, if we accept the WHO
definition, we all are sick.

A WHO study group in 1957, defines health as operational definition i.e. “A condition or
quality of the human organism expressing the adequate functioning of the organism in given
conditions, genetic or environment”.

Dimensions of health

1. Physical dimension: Optimal physical state normally proper functioning of body, cell,
tissue, organ and system. Dominated by mechanical and biomedical model.
2. Mental dimension:- Optimal harmony between both the individual and the surrounding
leading to state of non-conflicting situation.
3. Psychological, Emotional and Spiritual dimensions:- State of positive human emotion-
kindness, sympathy, love and affection etc.
4. Socio-cultural dimension:- State of social, harmonious relationship with the members of
the society.
5. Others:-

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Positive health: The state of positive health implies the notion of “perfect functioning” of the
body and mind. It conceptualizes health biologically as a state in which every cell and every
organ is functioning at optimum capacity and in perfect harmony with the rest of the body;
psychologically as a state in which the individual feels a sense of perfect well-being and of
mastery over his environment, and socially as a state in which the individual capacities for
participation in the social system are optimal. These ideas were widely ventilated some years ago
but now appear slightly ridiculous.

Dubos said, “The concept of positive health cannot become a reality because man will never be
so perfectly adapted to his environment that his life will not involve struggles, failures and
suffering.

The positive health not only depends on medical actions but on all the economic, cultural and
social factors operating in the community.

Concept of diseases

Webster defines disease as “ a discomfort, a condition in which bodily health is seriously

attacked, deranged or impaired, a departure from a state of health, an alteration of human body
interrupting the performance of vital functions”.

The oxford English Dictionary defines disease as “a condition of the body or some part, or organ
of the body in which the functions are disturbed or deranged”.

Impairment: Impairment is any loss or abnormality of psychosocial, physiological or anatomic

structure or function.

Disability: A disability is any restriction or lack (resulting from an impairment) of ability to

perform an activity in a manner within the range considered normal for a human being.

Handicap: A handicap is a disadvantage for a given individual resulting from an impairment or

disability that limits or prevents the fulfillment of a role that is normal (depending on age, sex
and social and cultural factors) for that individual.

• Accident ................... Disease

• Loss of Foot ............. Impairment
• Cannot Walk ............ Disability
• Unemployed ............ Handicap

1. Disease
Disease is a process that creates a state of physiological and psychological dysfunction
confined to the individual.

2. Illness

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 Illness is a subjective state, a psychological awareness of dysfunction, also confined to
the individual

3. Sickness
A state of social dysfunction; a social role assumed by the individual that is defined by
the expectation of society and that, thereby, affects the state of his relations with others.
Susser

4. Wellness
Wellness is a concept which considers health in broad terms. It is a way of living each
day that includes choices and decisions based on healthy attitudes. Equally paying
attention to your physical, emotional, and social development will help individuals to
function at a high degree of wellness.

- Merke and Merke. Health: A Guide to Wellness. Glencoe, 1987

Concept of being healthy

Being healthy means physically fit and of sound mind.

Being healthy means that my life is balanced, physically, spiritually, emotionally. When balance
is found then health abounds even in the midst of struggle, disease or disaster.

Healthy to me means eating well, feeling strong and fit, being well rested, and feeling happy.
Being healthy means taking care of yourself, body and mind; achieving a balance in the day-to-
day and feeling good about the choices we make for ourselves on a regular basis. being healthy
means feeling good, both physically and mentally.  It is about positive energy and having an
overall good balance across the elements of your life.

Spectrum of Health and Disease

Condition that is not limited to a specific set of value but can vary infinitely within a continuum
Positive Health
Better Health
Freedom from sickness
Unrecognized sickness
Mild sickness
Severe sickness
Death

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Natural history of disease

Natural history of disease refers to the progression of a disease process in an individual over
time, in the absence of treatment. The natural history of disease is a description of how that
disease ‘behaves’ and what factors affect its incidence and distribution. It refers to a description
of the uninterrupted progression of the disease in an individual from the moment of exposure to
the causal agents until recovery or death. The knowledge of the natural history of disease ranks
alongside causal understanding in importance for prevention and control of disease. It is one of
the major element of descriptive epidemiology. The following figure shows time frame for
development of disease in individual. As seen in this figure, an individual is healthy (i.e, without
disease) and at some point the biologic onset, disease occurs. The person is often unaware of
when the disease began. Later, the symptoms develop and lead the patient to seek medical care.
In certain situations, hospitalization may be required, either for diagnosis, for treatment or for
both. In any case, at some point a diagnosis is made and treatment is initiated. One of several
outcomes can then result: cure, control of the disease, disability or death. This figure shows the
development and course of a disease in an individual over a period of time.

Healthy Outcome:
Outcome: Cure,
Cure/Control/
control of disease,
Disease Symptoms Seek care Diagnosis Treatment Disability/
disability Death
or death

Natural history of disease has two phases: Pre-Pathogenesis phase is the process in the
environment and Pathogenesis phase is the process in host. These two phases are the main core
component of natural history of disease.
1. Pre-pathogenesis phase:
It is the process which is usually occurs in environment. This phase is preliminary to the onset of
disease in man. In this stage, the disease agent has not entered in man, but many interactions with
the human host already exists in the environment. In this stage, man is exposed to the risk of
disease. Potentially we all are in the pre-pathogenesis phase of many communicable and non-
communicable diseases. The interaction between the three factors: Agent, Host and Environment
initiate the disease process in man.
2. Pathogenesis phase:
This phase begins when the disease agent enters in human host. The further growth and
development of disease agent in pathogenesis phase are clear cut as in the infectious diseases. At
the growth and multiplication process, the related tissues and organs undergoes physiological
and pathological changes passing through the incubation period. The final outcome of the disease
may be recovery, disability or death. The pathogenesis phase of disease can be interrupted by
conducting intervention measures such as immunization, chemotherapy and secondary or tertiary
prevention.
The study of the pathogenesis phase in natural history of disease is important because it helps to
know where and how the stage of disease is going on. We can prevent the patient to undergo the

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further worsening by disease. We can organize intervention program in time. We can identify in
what situation the disease is running on.

Pre-pathogenesis phase Pathogenesis phase

Disease Before man is Disease occurs in man

process involved
Death

Agent Host Chronic state

Defect
Disability
Illness
Clinical features Sign & Symptoms

Environment Tissue and Immunity &

Physiological changes resistance

Stimulus or agent becomes

established & increases by
Imbalance between multiplication Recovery
them produce a
disease In the human Interaction of host Host
Host & stimulus reaction

Early Discernible Advanced

Pathogenesis early lesions disease Convalescence

Level of Primary prevention Secondary prevention Tertiary prevention

preventive
measure
Modes of Health promotion Specific Early Disability Rehabilitation
interventio protection diagnosis and limitation
n treatment

Preventive health and levels of prevention

 Concept of Prevention
 Concept of Preventive Health

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  Level and scope of preventive health - Primordial Prevention -
Primary Prevention - Secondary Prevention - Tertiary Prevention

Prevention refers to the goals of medicine that are to promote, to preserve, and to restore health
when it is impaired, and to minimize suffering and distress.

Level of prevention and specific preventive/intervention measures

1. Primordial prevention
2. Primary prevention
3. Secondary prevention
4. Tertiary prevention
Primordial prevention

Primordial prevention, a non specific and new concept, is receiving special attention in the
prevention of chronic diseases. This is primary prevention in its purest sense, that is, “prevention
of the emergence or development of risk factors in countries or population groups in which they
have not yet appeared. For example, many adult health problems (e.g. obesity, hypertension)
have their early origins in childhood, because this is the time when life styles are formed (for
example smoking, eating patterns, physical exercise). In primordial prevention efforts are
directed towards discouraging children from adopting harmful life styles. The main intervention
in primordial prevention is through individual and mass education.

Primary prevention

It is both non specific and specific (biomedical immunization, chemo prophylaxis) prevention,
which can be defined as “action taken prior to the onset of a disease, which removes the
possibility that a disease will ever occur”. It signifies intervention in the pre-pathogenesis phase
of disease or health problem (e.g. LBW) or other departure from health. Primary prevention may
be accomplished by measures designed to promote general health and well-being and quality of
life by specific protective measures. Primary prevention is far more than averting the
occurrence of a disease and prolonging life. It includes the concept of “positive health”, a
concept of maintenance of “an acceptable level of health that will enable every individual to lead
a socially and economically productive life”. It concerns an individual’s attitude towards life
and health and the initiative he takes about positive and responsible measures for himself, his
family and his community.

The concept of primary prevention is now being applied to the prevention of chronic diseases
such as CHD, HTN and cancer based on elimination or modification of “risk factors” of disease.
The WHO has recommended the following approaches for the primary prevention of chronic
diseases the risk factors are established: a) population (mass) strategy and b) high risk strategy.

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In summary, Primary prevention is holistic approach. This approach is directed towards socio-
economic behavior and life style change. It relies on measures designed to promote health or to
protect against specific disease “agents” and hazards in the environment.

Secondary prevention

Secondary prevention can be defined as “action, which halts the progress of a disease at its
incipient stage and prevents complications’. The specific interventions are early diagnosis (e.g.
screening tests, case finding programs) and adequate treatment. Secondary prevention attempts
to arrest the disease process; restore health by seeking out unrecognized disease and treating it
before irreversible pathological changes have taken place; and reverse communicability of
infectious disease. It may also protects others in the community from acquiring the infection and
thus provide at once secondary prevention for the infected individuals and primary prevention
for their potential contacts.

Secondary prevention is largely the domain of clinical medicine. The health programs initiated
by governments are usually at the level of secondary prevention. The drawback of secondary
prevention is that the patient has already been subject to mental anguish, physical pain and the
community to loss of productivity. It is an imperfect tool in the control of transmission of
disease. It is often more expensive and less effective than primary prevention. In the long run,
human health, happiness, and useful longevity will be achieved at far less expense with less
suffering through primary prevention than through secondary prevention.

Tertiary prevention

When the disease process has advanced and beyond its early stages, it is still possible to
accomplish prevention by what might be called “tertiary prevention”. It signifies intervention in
the late pathogenesis phase. It can be defined as “all measures available to reduce or limit
impairments and disabilities, minimize suffering caused by existing departures from good health
and to promote the patient’s adjustment to irremediable conditions”. For example, when defect
and disability are more or less stabilized, rehabilitation may play a preventable role. Modern
rehabilitation includes psychosocial, vocational, and medical components based on team work
from a variety of professions. Tertiary prevention extends the concepts of prevention into fields
of rehabilitation.

Rehabilitation: It is defined as “the combined and coordinated use of medical, social, educational
and vocational measures for training and re-training the individual to the highest possible level of
functional ability”.

Concept of community health, community medicine and clinical medicine

 Concept of Community Health

 Concept of Community medicine

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  Concept of Clinical Medicine
 Relation and difference between them

Community health

The term “community health”, in some countries, has replaced the terms public health,
preventive medicine and social medicine. It is because of the changing nature of public health,
which has now entered an era of individual responsibility and community participation.
‘Community health’ is more broadly defined which encompasses the entire gamuts(ranges) of
organized community efforts for maintaining, protecting and improving the health of the people.
It involves motivating individuals and groups to change patterns of behavior as to take such
action, including seeking of medical care, as would enable them to achieve optimum health. In
short, there has been a redefinition of the traditional role assigned to a doctor- a shift from a
diagnosis and treatment of individual illness to one of community diagnosis and treatment.

Community medicine

It is the field concentrated on the study of health and disease in the population of defined
community or group. Its goal is to identify the health problems and needs of defined population
and to plan, implement and evaluate the extent to which health measures effectively meet these
needs:

i. Diagnosis of the state of health of a community is an important foundation of community

medicine.
ii. As used in the present context community medicine is the practice, which focuses on the
health needs of the community as a whole.
iii. The combination of community medicine with “primary health care” extends the
functioning of both elements to a health care system, which aims at changing the state of
health of the community by intervention, both at the individual and group level.
The foundation of community is epidemiology, biostatistics, social science and organization of
health care, which includes planning, implementation and evaluation.

Clinical medicine versus public health? What Dr. Bechara Choucair said?
From the Commissioner of public health of the city of Chicago in his Commencement Address at
Feinberg School of Medicine at Northwestern University on May 4, 2011
Any intersection between clinical medicine and public health?
Clinical medicine and public health are often seen separate.
We often understand these two words as different disciplinary silos in which many of us spend
entire careers. Ted Schettler, the Science Director of the Science and Environmental Health
Network, frames both disciplines with respect to focus, scale, ethics, education and the nature
of the science.
1. Focus: Clinical medicine focuses primarily on the individual, while public health focuses on
the community.
2. Time frame: Relevant time frames in Clinical Medicine are usually single lifetimes, while
public health thinks in terms of generations.

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3. Ethics: From an ethics perspective, clinicians advocate for individual people. Public health
practitioners advocate for the community, for a group of people.
4. Rights: In clinical medicine we focus on individual rights of a patient. In public health, we
think about human rights, social justice, and environmental justice.
5. Education: From an education perspective, in clinical medicine we focus on the biomedical
model with more emphasis on cure than prevention (although this is shifting now). In public
health, we learn more about sociology, epidemiology, cultural anthropology, economics and
more.
Think for a moment about the evidence of the science.
In clinical medicine we love to talk about controlled, double-blind clinical trials. We don’t find
that type of approach often in public health.
Clearly, there are differences: differences in focus, differences in scale, differences in ethics,
differences in education and differences in the nature of science.
But the reality is that the health of the individual and the health of the community are inter-
related and inter-dependent. Maintaining two disciplinary silos is NOT the answer.
Bridging the gap is critical if we are serious about improving the quality of life of our residents.
Bridging the gap starts with education.
We have to enhance the understanding of public health principles among our students in the
clinical field and we have to enhance the understanding of clinical medicine principles among
our public health students.

Unit 2:

Situation and Efforts in Public Health

Methodologies (approaches) in Public Health

Public health works in policy formulation, planning of the programs and program development
and implementation of program. The methodologies or approaches of public health are as
follows:-

1. Epidemiological approach:
– Problem magnitude (how big the problem?)
– Problem distribution (comparison)
– Program evaluation
– Causes of the problem

2. Sociological and anthropological research approach:

– Assessing underlying causes of behavior
– Acceptability of program
– Designing specific programs

3. Economic approach:
– Cost effectiveness of programs

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 – Cost benefit of the program

4. Bio-statistical approach
Testing of hypothesis (null and research hypothesis)

5. Public Health laboratory science approach:

Screening programs

6. Biological approach:
HRH planning

7. Other approaches:
Political approach
Medical laboratory approach
Clinical approach
Behavioral science approach (HIV/AIDS)

Interdisciplinary Approach in Public Health 6 Hours

 Epidemiological approach

Epidemiologists are those scientists who examine the distribution of health and disease in person,
place, and time. Epidemiology combines the biological sciences with research methodology and
statistics. In addition to making health findings, it is often the job of epidemiologists to act as
translators and communicators, helping the public to understand health research and its
implications. Undergraduate majors that would prepare a person to study epidemiology include
biology, pre-professional health (medicine or nursing), mathematics, and communication.

Epidemiological approach is used to the investigation of disease problems. We also implied that
such investigations usually have the basic objective of describing and quantifying disease
problems and of examining associations between determinants and disease. With these objectives
in mind, epidemiological investigations are normally conducted in a series of stages, which can
be broadly classified as follows:

1. A diagnostic phase, in which the presence of the disease is confirmed.

2. A descriptive phase, which describes the populations at risk and the distribution of the disease,
both in time and space, within these populations. This may then allow a series of hypotheses to
be formed about the likely determinants of the disease and the effects of these on the frequency
with which the disease occurs in the populations at risk.

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3. An investigative phase, which normally involves the implementation of a series of field
studies designed to test these hypotheses.

4. An experimental phase, in which experiments are performed under controlled conditions to

test these hypotheses in more detail, should the results of phase 3 prove promising.

5. An analytical phase, in which the results produced by the above investigations are analysed.
This is often combined with attempts to model the epidemiology of the disease using the
information generated. Such a process often enables the epidemiologist to determine whether any
vital bits of information about the disease process are missing.

6. An intervention phase, in which appropriate methods for the control of the disease are
examined either under experimental conditions or in the field. Interventions in the disease
process are affected by manipulating existing determinants or introducing new ones.

7. A decision-making phase, in which a knowledge of the epidemiology of the disease is used to

explore the various options available for its control. This often involves the modelling of the
effects that these different options are likely to have on the incidence of the disease. These
models can be combined with other models that examine the costs of the various control
measures and compare them with the benefits, in terms of increased productivity, that these
measures are likely to produce. The optimum control strategy can then be selected as a result of
the expected decrease in disease incidence in the populations of livestock at risk.

8. A monitoring phase, which takes place during the implementation of the control measures to
ensure that these measures are being properly applied, are having the desired effect on reducing
disease incidence, and those developments that are likely to jeopardise the success of the control
programme are quickly detected.

The following two sections are concerned with describing ways in which epidemiological
investigations can be designed and implemented, and the data produced analysed.

There are three main types of epidemiological study:

i. Prospective studies, which look forward over a period of time and normally attempt to
examine associations between determinants and the frequency of occurrence of a disease
by comparing attack rates or incidences of disease in groups of individuals in which the
determinant is either present or absent, or its frequency of occurrence varies.

ii. Retrospective studies, which look backward over a period of time and normally attempt
to compare the frequency of occurrence of a determinant in groups of diseased and non-
diseased individuals.

iii. Cross-sectional studies,  which attempt to examine and compare estimates of disease
prevalence between various populations and subsets of populations at a particular
point in time.

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Frequently, however, these approaches may be combined in a general study of a disease
problem. In such studies, other morbidity and mortality rates may be compared as well as other
variables such as weight gain, milk yield etc. depending on the objectives of the particular study.

 Biostatistics Approach

Statistical methodologies are among the most important tools used by researchers in any field.
The past several decades have marked the discovery of increasingly more powerful, and
complex, statistical tools. These days many research scientists turn to experts in the field of
statistics to help them design and evaluate their studies. Biostatisticians are trained in the
structure and analysis of the study designs employed in modern research, and help the research
team to identify what conclusions they can draw from a study and with how much certainty. A
person wishing to become a biostatistician should consider an undergraduate major such as
mathematics or statistics.

Biostatistics is the application of statistical procedures, techniques, and methodology to identify

health trends. Biostatistics are an integral part of public health as it forecasts scenarios, identifies
health trends within the community, explains biological phenomena, and determines the cause(s)
of disease and injury. Examples of careers in this field are: survey statistician, health data
analyst, research data coordinator, biostatistician.

 Public Health Laboratory Science Approach

Public health laboratory science approach deals with microbes which both cause and prevent
disease. Microbes cause infections resulting in diseases among human and animals. On the other
hand, they help in creating a disease free world where people are saved from the pain of being
born with physical and mental deformities. The control of infectious diseases has been greatest
achievement of medical science. Screening programs, vaccination and antibiotics are effective
against various microorganisms. Antibiotics are produced from the microorganisms for example,
Penicillin notatum, Cephalosporium acrimonium, Strptomycin orientalis are used to produce
antibiotics.

 Sociological and Anthropological Approach

Social & Behavioral Sciences (SB) focuses on identifying and analyzing the social determinants
and behavioral risk factors that are associated with public health problems, and using this
knowledge to understand and promote healthy behavior within communities. Faculty have
testified on behalf of plaintiffs seeking to curb destructive marketing practices by tobacco
companies, and they have advocated for stricter gun control and drunk driving laws. Together
with social service organizations, faculty provide outreach and advocacy services to substance
abusers and survivors of dating, domestic, and sexual violence, and they have helped public
health officials and the private sector coordinate a nationwide program designed to help smokers
overcome their habit.

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  Cultural and Behavioral Approach

Health Education/Behavioral Science – Workers in the field of health promotion seek to apply
the knowledge of epidemiologists to improve the health of populations. Knowing what impacts
health is of little use if those factors cannot be changed. It is those working in health promotion
that design effective interventions to help people improve their health by eating healthier foods,
quitting smoking, or getting more exercise. As an undergraduate, a person could study nursing,
dietetics, psychology, sociology, or the related social sciences in preparation for a career in
health behavior and health promotion.

 Environmental Health Approach

Environmental Health – This portion of public health draws strongly on the natural sciences.
Environmental health scientists monitor the levels of contaminants in the environment and seek
to understand the impact of environmental factors on health. The classic example of a
practitioner of environmental health is a sanitarian working for the local or state health
department. Undergraduate majors in chemistry, biochemistry, biology, and physics would help
prepare a person to study environmental health science.

Environmental health improves public health through identifying and addressing environmental
risk factors. Settings include: air quality, food protection, radiation protection, solid waste
management, hazardous waste management, water quality, noise control, environmental control
of recreational areas, housing quality, and vector control. Examples of careers in this field are:
ecologists, environmental consultant, oceanographer.

 Veterinary Science Approach

Veterinary research has the potential to immensely impact the fields of comparative medicine,
public health and food safety, and animal health. All activities of veterinary scientists affect
human health either directly through biomedical research and public health work or indirectly by
addressing domestic animal, wildlife, or environmental health. Moreover, veterinary scientists
have a responsibility to protect human health and well-being by ensuring food security and
safety, preventing and controlling emerging infectious zoonoses, protecting environments and
ecosystems, assisting in bioterrorism and agroterrorism preparedness, advancing treatments and
controls for nonzoonotic diseases (such as vaccine-preventable illnesses and chronic diseases),
contributing to public health, and engaging in medical research (Pappaioanou, 2004).

Transmission of diseases between animals and human (zoonoses) occurs daily around the globe,
whether through agricultural practices or everyday activities. Zoonoses consist of a wide range of
diseases and range from endemic zoonoses such as brucellosis, anthrax, bovine tuberculosis,
parasitic diseases (hydatic disease, echinococcosis, trichinellosis) and rabies to emerging
zoonoses as highly pathogenic avian influenza, and Bovine Spongiform Encephalopathy.

25
 The impact on public health and on productive activities is considerable. Veterinary Science
Approach should therefore aim at preventing or decreasing the transmission of zoonoses,
through adequate policy frameworks, prevention and control measures, and education. Attention
should also be paid to ecological, cultural, social and ethical aspects regarding the
implementation of control programmes. Besides zoonoses prevention and control, it also aims at
minimizing the risk of contamination (biological, chemical and physical) entering the food chain
trough animal products. It is committed to prevent and control the spread of zoonoses and food
borne diseases and contamination through appropriate control measures.

National and International Public Health Problems 6 Hours

 Current International Problems, Burden and Effects

Globally, the rate of deaths from non-communicable causes, such as heart disease, stroke, and
injuries, is growing. At the same time, the number of deaths from infectious diseases, such as
malaria, tuberculosis, and vaccine-preventable diseases, is decreasing. Many developing
countries must now deal with a “dual burden” of disease: they must continue to prevent and
control infectious diseases, while also addressing the health threats from noncommunicable
diseases and environmental health risks. As social and economic conditions in developing
countries change and their health systems and surveillance improve, more focus will be needed
to address noncommunicable diseases, mental health, substance abuse disorders, and, especially,
injuries (both intentional and unintentional). Some countries are beginning to establish programs
to address these issues. 

The difficulties of providing health services for the people of the developing nations involve a
cluster of interrelated problems. These arise from the nature of the diseases and hazards
to health, insufficient and maldistributed resources, the design of health service systems, and the
education of health personnel in those systems. 

There are differences not only in the kinds of diseases of different countries but also in the rates
at which they occur and in the age groups involved. Life expectancy in some countries is less
than half that in others, principally because of high death rates among small children in the
developing countries. In Southeast Asia, for example, children under age five are between three
and four times more likely to die than children of the same age group in the Americas. The infant
(under one year of age) mortality rate in Africa is about six times that in Europe, and the death
rate in children under age five (under-five mortality rate) is more than eight times greater.

26
The principal causes of sickness and death among small children in the developing world are
diarrhea, respiratory infections, and malnutrition, all of which are intimately related to culture,
custom, and economic status. Malnutrition may result from food customs when taboos and
simple oversight lead to deprivation of children. Gastroenteritis (inflammation of the lining of
the stomach and intestines, usually with accompanying diarrhea) and respiratory infections are
often due to infectious organisms, some of which may be resistant to antimicrobial drugs. The
interrelationships of these diseases increase the complexity of treating them. Malnutrition is
often the underlying culprit; not only does it cause damage itself, such as retardation of physical
and mental development, but it also seems to set the stage for other illnesses. A malnourished
child develops gastroenteritis, inability to eat, further weakness, and then dehydration. The
weakened child is susceptible to a lethal infection, such as pneumonia. Or, to complete the
vicious circle, infection can affect protein metabolism in ways that contribute to malnutrition.
Another factor that contributes to this is family size. Malnutrition, with associated death and
disability, occurs most often in children born into large and poorly spaced families. The resulting
high death rate among small children often reinforces the tendency of parents to have more
children. People are not inclined to limit the size of their families until it is apparent that their
children have a reasonable chance of survival. Thus, there is a fertility–mortality cycle in which
high fertility, reflected in large numbers of small children crowded into a poor home, leads to
high childhood mortality, which, in turn, encourages high fertility. This is the basis of the belief
that population-control programs should include effective means of reducing unnecessary deaths
among children.
Among limitations of resources, shortages of trained personnel are among the most important;
ratios of population to physicians, nurses, and beds provide an indication of the seriousness of
these deficiencies and also of the great differences from country to country. Thus, the proportion
of population to physicians in developing countries varies drastically.

Money is a crucial factor in health care—it determines how many health personnel can be
trained, how many can be maintained in the field, and the resources that they will have to work
with when they are there. Governmental expenditures on health care vary greatly from country to
country.
 Mental health, Psychiatry problems and Addictive Problems

27
Mental health has a place in the preventive services. Improvements in arrangements for mental
health include the provision of outpatient clinics and inpatient accommodations at general
hospitals for early mental cases, an increase in child-guidance and marriage-guidance clinics, and
schemes for the care of alcoholics and drug addicts. There have also been significant
developments in the treatment of maladjusted members of society. Gains in understanding of
psychoneuroses by general practitioners and the development of research facilities are also
noteworthy.

Mental Health is the preventive, protective and promotive measures to balance the mental status
or to correct the mental disorders. Mental disorders are some sort of schizophrenia like
disturbances of thinking, feeling, and acting which have a proximate cause in the human brain
and emotional problems like mood and anxiety disorders. Mental disorders also include dementia
which is the decline in all areas of mental ability (not remembering recent events – confused over
days and dates) and with sudden emotional outbursts or embarrassing behavior.

•Impairments like mental retardation.

•Disturbances of behavior include misuse of alcohol, use of illicit drugs, and violence. 
•The expression of mental and behavioral problems in humans is diverse.
•Most disorders  involve problems of varying intensity in all three areas of cognition,
emotion, and behavior.
• Mental disorders typically involve disruption of the social relations of the individual, and
are associated with neurological changes. 
• Mental disorders occur at all ages and in all social groups.
Prevention and control of mental disorders

•Design and execute intervention trials to prevent disorder in individuals who are currently
healthy
• Minimize future consequences for those with current disorder or a history of disorder.
• Interventions for promotion of mental health are part of the mission because good mental
health protects against onset of a variety of mental disorders, as well as being a valued
outcome in itself.
Treatment and its progress

•Meyer (Dr. Adolf Meyer, pragmatic psychiatrist, JHSPH, John Hopkins University)
believed that mental disorders occurred in the context of brain physiology and one’s
home and social environment
• Critical clues to treatment and community based prevention of psychiatric disorders are
to review the individual’s life story and social
Epidemiologists are working together:

•to develop research methods and educational materials not only for the examination of
conditions in the community, such as family, education, employment and economics,
• but also for conditions inside the body—such as neurological disturbances and genetic
influences—that serve as risk factors for mental disorders.
Challenges of Epidemiology in Mental Health

28
The epidemiology of mental disorders is somewhat handicapped by the difficulty of identifying a
“case” of a mental disorder. “Case” is an epidemiological term for someone who meets the
criteria for a disease or disorder. It is not always easy to establish a threshold for a mental
disorder, particularly in light of how common symptoms of mental distress are and the lack of
objective, physical symptoms. It is sometimes difficult to determine when a set of symptoms
rises to the level of a mental disorder, a problem that affects other areas of health (e.g., criteria
for certain pain syndromes). In many cases, symptoms are not of sufficient intensity or duration
to meet the criteria for a disorder and the threshold may vary from culture to culture.

 Adolescents and reproductive health Problems

Adolescence is a remarkable period of development and change in the life-course of boys and
girls, filled with vulnerabilities and risk, as well as incredible opportunities and potential. 

Adolescents (10-19 years of age) around the world face tremendous challenges in meeting their
sexual and reproductive health needs. Inadequate access to health information and services, as
well as inequitable gender norms, can have serious implications on their health and welfare, as
well as economic development and poverty reduction.

Globally, adolescents (age 10-19) and young people (age10-24) account for nearly one-fifth (18
percent) and one-quarter (26 percent) of the total population, respectively (UN, 2011.) In Nepal
adolescents (age 10-19) and young people (age 10-24) comprise an even larger proportion of the
population—adolescents 24 percent and young people 33 percent, respectively (MoHP, 2011).
This sizable group faces unique emotional and physical health challenges. For Nepal’s health
system to meet these needs, the context and situation of adolescents and youth must be better
understood. The global community, first at the International Conference on Population and
Development (ICPD) held in Cairo in 1994 and then at the Fourth International Conference on
Women (ICW) in Beijing in 1995, resolved to protect and promote the rights of adolescents and
youth to sexual and reproductive health information and services (UN, 1994; UN, 1995).

In Nepal the practice of early marriage is common and is deeply rooted in the culture. The legal
minimum age at marriage in Nepal is 18 with the guardian’s consent and 20 without the need for
the guardian’s consent (the Muluki Ain (General Code), 2019 BS). In fact, however, most
women have married at younger ages. For women age 25-49 the median age at first marriage
was 17.5 years, and for men age 25-49 it was 21.6 years (MoHP et al., 2012). Early marriage and
resulting early sexual debut can lead to a number of potentially adverse outcomes, including
unplanned pregnancy and exposure to sexually transmitted infections (STIs) (WHO, 2011).

 Major communicable and Non-communicable Diseases

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However, the burden of disease in developing countries is still dominated by infectious diseases -
all of them so-called diseases of poverty. 

According to the World Health Organization (WHO), non-communicable diseases (NCDs), such
as cardiovascular diseases (CVD), cancers, diabetes, chronic lung diseases and their underlying
causes are a growing threat to the health and prosperity of individuals living in all regions of the
world. WHO estimates that 63 percent of the 57 million deaths each year are linked to NCDs.
What was once considered a burden of the developed world is now disproportionately affecting
low- and middle-income countries, in 2008 accounting for 29 million of the total 36 million
NCD-related global deaths. Changing smoking and diet/nutrition habits, urbanisation, social
disruption and unhealthy lifestyles - often linked to poverty- are just some of the explaining
factors. Accidents and violence are of increasing concern in causing injuries, disabilities and
deaths. This invisible epidemic is a seriously under-appreciated cause of poverty, hindering the
economic development of many countries. The burden is growing – and the number of people,
families and communities afflicted constantly increasing. Without an effective response, WHO
estimates that by 2030 cardiovascular disease alone will cause more deaths in low- and middle-
income countries than the combined number of deaths caused by AIDS, tuberculosis, malaria,
maternal and perinatal conditions, and nutritional disorders.

More than 75% of all deaths worldwide are due to noncommunicable diseases (NCDs). NCD
deaths worldwide now exceed all communicable, maternal and perinatal nutrition-related deaths
combined and represent an emerging global health threat. Every year, NCDs kill 9 million people
under 60 years of age. The socio-economic impact is staggering.

These NCD-related deaths are caused by chronic diseases, injuries, and environmental health
factors. Important risk factors for chronic diseases include tobacco, excessive use of alcohol, an
unhealthy diet, physical inactivity, and high blood pressure.

Importantly, deaths due to NCDs are becoming more common in low- and middle-income
countries, where the majority of NCD deaths occur and where health systems are often not
equipped to respond. The WHO reported in 2010 that 31% of deaths in developing countries are
caused by communicable disease, while the remainders of deaths are caused by these non-
communicable diseases and injuries:
• Cardiovascular disease – 25%
• Cancer – 12%
• Injury  - 11%
• Chronic Respiratory Disease – 8%
• Diabetes – 5%
• Other - 8%

 Emerging Health Problems such as HIV and AIDS, and others

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  Re-emerging Health Problems such as Malaria and others

Infectious diseases are a continuing danger everyone. Some diseases have been effectively
controlled with the help of modern technology. Yet new diseases—such as SARS and West Nile
virus infection—are constantly appearing. Others, such as malaria, tuberculosis, and bacterial
pneumonias, are now appearing in forms that are resistant to drug treatments.

The theme of the World Health Day on 7 th April 1997 was “Emerging infectious diseases-Global
response, global alert”. The reemergence of disease thought to be well under control in large
parts of the world and emergence of new infections with high case fatality rates and the potential
of their rapid spread has led the WHO to issue a wakeup call. The eradication of smallpox and
effective control of many communicable diseases, has led to a false sense of security and
complacency in many countries. Resources for public health were curtailed as more immediate
priority areas were identified for financial support.

The outbreaks of plague in 1994, cholera in 1995 and dengue hemorrhagic fever in 1996, among
many others, have highlighted the urgency for strengthening the disease surveillance system so
that early warning signals are recognized and appropriate control measures are initiated in a
timely manner.

Various factors are responsible for the emergence and reemergence of communicable diseases.
These multisectoral factors will need to be addressed while developing strategies for their
prevention and control. Some of these factors, apart from weak public health system, include
rapid urbanization, industrial and other developmental activities, encroachment by humans of
areas so far uninhabited leading to ecological changes and rapid means of transportation to and
from any part of the world. Improvements in living standards are sometimes accompanied with
potential health hazards.

Emerging infectious diseases have been defined by WHO as those infections the incidence of
which in human has either increased during the last two decades or threatens to increase in near
future. The term includes newly-appearing infectious diseases or those spreading to new
geographical areas. It also refers to those diseases which were previously easily controlled by
antimicrobials but have now developed resistance to these drugs.

Reemerging infectious diseases are those that have reappeared after a significant decline in their
incidence. Appearance of plague in an explosive form in 1994 after a period of quiescence of
almost 27 years is an important example of reemerging infections.

List of some emerging diseases, main reasons for emergence and some potentially emerging
diseases are given in Table.

Emerging diseases
 AIDS
 Cholera- due to Vibrio cholera O 139
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  Tuberculosis-especially multidrug resistant organisms
 Malaria
 Kala-azar
 Dengue, DHF, and DSS
 Hepatitis B, C and E
 JE
 Rabies
 Antimicrobial resistance
Reasons for emergence
 Environmental degradation
 Uncontrolled urbanization
 Unhygienic living conditions
 Migration of population
 Natural disasters
 Growing international trades, tourism, and rapid travel
 Alterations in micro-organisms
 Resistance to antimicrobials
 Insecticides resistance
 Weak public health system
Potentially emerging diseases
Infection Reported in
Hanta virus Myanmar, Sri Lanka, USA
Yellow fever Kenya, many African and Latin American countries
Ebola virus Zaire, South Africa
E. coli O 157:H7 Australia, South Africa, Japan, USA

 New mores and New Freedoms

 Economically and Culturally Deprived Population

 Public health problems and Issues in Nepal 4 Hours

 Communicable Diseases (types, burden causes and effects)

Measles and polio are examples of communicable diseases that have been brought under close
control throughout the world. Smallpox, once a dreaded infectious disease of children, was
officially declared eradicated in 1980. For other diseases, such as cholera and meningitis, there
has been important growth in understanding that may contribute to their eventual control.
Likewise, greater access to drug therapies and prevention awareness in the early 21st century

32
contributed to a decline in new AIDS (acquired immunodeficiency syndrome) cases and a
decline in deaths from the disease, which was first detected in 1981. Certain parasitic diseases
have spread as humans have brought about changes in their environment—the increase in
schistosomiasis (infestation with blood fluke by means of snails as the intermediate hosts) in
irrigation and human-made lake areas is an example.

 Non-communicable Diseases (types, burden causes and effects)

 Nutritional Deficiency Disorders (types, burden causes and effects)

In last 15 years, Nepal has shown notable decrease in under 5 mortality rate, infant mortality rate
and maternal mortality ratio. These steep declines in mortality rates have been attributed to
strong public health interventions including the control of the micro‐nutrient deficiencies during
the same period. However, the neonatal mortality rate has remained stagnant over the same time
period and accounts for more than two‐third of infant deaths.   
The prevailing high rate of child under‐nutrition in the country is one of the major contributing
factors of under‐five mortality. Despite a steady, but slow, decline in reduction of maternal and
child under‐nutrition, Nepal still faces high chronic as well as acute under‐nutrition in children.
The NDHS2011 has shown 41 percent of children less than 5 years of age suffering from chronic
under‐ nutrition (stunting) while more than 10 percent are acutely under‐nourished. Additionally,
it estimates low birth weight (i.e. “very small” or “smaller than average”) at 12 percent.
Furthermore, national nutrition status estimates mask wide inequities. Children from the lowest
quintile or whose mother has no education are more than twice likely to be stunted than those
from richest quintile or whose mother has secondary level or more education.   The mountain
zone has the highest stunting rate of 56 percent, while the Terai has the lowest rate (37.4%).   
The same DHS study in 2011 showed 18.2 percent of non‐pregnant women are undernourished
or chronically energy deficient (BMI<18.5kg/m2) and 14 percent are overweight or obese which
is in increasing trend (NDHS 2011).The prevalence of both underweight and overweight among
women is indicative of a potential double burden of malnutrition in the country. At particular risk
for chronically energy deficiency are girls 15‐19 years of age, women living in the Terai,
Western Mountains, Far Western Development Region and women with no formal schooling and
from the lowest wealth quintiles. Women in Nepal are generally of short stature. 12 percent of
women in Nepal are less than 145 cm. Risk factors for short height include living in a rural area,
having limited schooling and coming from the lowest wealth quintiles. In terms of etiology, short
stature is likely consequence of the high prevalence of stunting in childhood. Babies who grow
poorly and become stunted are likely to continue being stunted thus perpetuating the
intergenerational cycle of malnutrition in the population. Adolescent girls in Nepal fair worse as

33
25.8 percent of them have a low body mass index less than 18.5 kg/m2.
Compared to improvement in macronutrient deficiency status, Nepal is globally recognized in
reducing the high rate of micronutrient deficiencies (IDA, IDD and VAD) through its successful
community based supplementation programs. Nepal has reduced the prevalence of anaemia
among women of reproductive age by almost half from the 1998 level. From 68 percent in 1998
to 35 percent in 2011, Nepal has made a remarkable progress in the reduction of anaemia,
however, this reduction has ceased in the last five years. In the same duration, the prevalence of
anaemia in the pregnant women has increased by 6 percent. Anaemia rates were higher among
pregnant women (48%) and breastfeeding women (38%) compared to women who were neither
pregnant nor breastfeeding (33%).   The prevalence of anaemia among adolescent girls has
remained stagnant at around 39 percent over the last five years. Similarly, 46 percent of children
under‐five years of age still remain anaemic, with younger children under 2 years of age having
the highest burden (69%), which is a very serious concern.

 Trauma and Injuries (types, burden causes and effects)

Significant Forces Influencing Public Health 8 Hours

 Public Health in National Planning of Nepal

Planning is a future oriented process of setting goals/objective/target and choosing the best way
to achieve these goals. It is forward looking in nature. It attempts to describe the future road map
of an organization. Planning is a various forms of decision making process.

Planning steps to organize health services

1. Analysis of health situation

2. Establishment of objectives and goals
3. Assessment of resources
4. Fixing priorities
5. Write-up of formulated plan
6. Programming and implementation
7. Monitoring & Evaluation

Methods of planning

1. Top-down method
2. Bottom-up method
3. Participatory method
34
 4. Team method

Top-down method: Top management determines goals and formulates plans. The plans are
communicated to middle and lower level management for implementation and control. It is
generally used in highly centralized organizations. Only top level managers have a role in
planning. Those who are responsible for implementation are not involved in the planning
process. It may not be sensitive to local conditions.

Bottom-up method: The plans are formulated at the operational level. They travel up to top level.
It is decentralized approach of planning.

Participatory method: This method is a blend of top-down and bottom-up methods of planning.
The top management provides broad premises, parameters and guidelines for planning to
operational level management. Then operational level formulates the plans and forwards to the
top level which reviews and finalize the plans.

Team method: The job of planning is entrusted to a team. The members of the team posses
multiple skill in planning. The prepares draft plans which are forwarded to the top management,
which are reviewed and finalized by top management.

Health planning system in Nepal:

Ministry of National Planning Commission

Finance Final recommendation for budgetary allocation
Resource allocation
Line agencies/Ministries:
INGOs/Donor recommendation for budget
agencies
Resource allocation District council: Prioritization,
coordination, interaction, fund Top-
allocation, forwarding down
process
Illaka Planning Workshop:
Coordination between projects,
interaction, & Prioritization

VDC Council: VDC plans, prioritized

projects, resource allocation
Bottom
-up
Settlement: process
Need collection
35
Process of Central/national level planning in Nepal

Macro level planning process of central level planning:

 National planning Commission (NPC) is the apex body for formulating, development
plans under the direction of the National Development Council.
 NPC prepares the draft of Approach Paper for the forthcoming development plan.
 Initially, the main objective and targets are determined for the plan period.
 Financial plan is prepared.
 Preparation of sector planning, the principal outputs of sector planning becomes the
sectorial chapter in the Five Year Plan or may be Interim plan.
 Sectorial chapters lay the basic foundation of the plan’s objectives and sectorial targets.
 A draft Approach Paper prepared and presented to the NDC for suggestions.
 NPC revise the Approach Paper according to the suggestions given by the NDC.
 The detailed plan document is prepared based on the Approach Paper.

Micro level planning process of central level planning

 Basic sectorial planning process is undertaken by the respective development related

ministry based on the plan document.
 NPC’s various sectorial task forces review the plan and present sectorial report.
 After the preparation of the detailed plan document, it is put forward to the Cabinet for its
approval.
 The plan is executed after the Cabinet approval.

 Public health programs in Nepal

Programs under different Health Organization in Nepal

1. Child Health Division: Established in 1995 AD. Before establishment of CHD, child
health program were conducted by FHD.
Immunization
Nutrition
CBIMCI
CDD/ARI
CBNCP: Now CBNCP and CBIMCI has been merged and the program is called
CBIMNCI program
2. Family Health Division: Established in 1993 AD.

36
 FP program
PHC ORC program
Safemotherhood (BPP, Rural Ultra sound, Uterine prolapsed, Emergency referral fund,
SAS, Aama, ANC, PNC, Delivery care, Emergency obstetric care program),
FCHV Prgogram
Demography and Reproductive Health Services
Population program
ASRH program
3. Epidemiology & Disease Control Division: Established in 2050 B.S.
Malaria, Kala-azar, Lymphatic Filariasis
Dengue, Tuberculosis, Leprosy,
HIV/AIDS and STI control, Eye care
4. Logistic Management Division: established in 2050/51 (1993).
LMIS, Procurement
Store construction
Telemedicine
5. Management Division: before establishment of MD, it was called Planning and Foreign
Aid Division (PFAD)
a. Organizational arrangement: division has six sections, three units and one Upachar Kosh
i. Health Management Information Section
ii. Budget & Planning Section
iii. Program Monitoring and Evaluation Section
iv. Health Facilities & Quality Assurance Section
v. Information Technology (IT) Section  
vi. Nursing Service Development Section
vii. Oral Health Unit
viii. PAM Unit
ix. Mental Health Unit
x. Impoverished Citizens Service Unit (Upachar Kosh)
xi. ENT Unit (proposed)
b. Others
GIS mapping: Health Facility Mapping Survey (HFMS)
Performance based management (PBMS):
Health care waste management (HCWM)
Health Infrastructure Information System (HIIS)
Health Sector Information System (HSIS):
Building Construction and Maintenance
Health facility upgrading
Approval to private health facility
6. PHCRD: established in 2009 (2065 Jestha)
National Free health care services
37
 Essential health care services
Urban health program
Community health insurance program:
Rural community health, basic health and model healthy village program.
Basic health and access program
Equity and access program
Social audit program
Environmental health program
Community Drug Program (CDP)

Important Public health programs are:

Family Planning, Safe Motherhood, Immunization Program, Nutrition, Integrated management

of Childhood illness (IMCI), Malaria, Tuberculosis, Leprosy, Sexually transmitted Infections
(STI) and HIV/AIDS

Family Planning program

The main thrust of the National Family Planning Programme is to expand and sustain adequate
quality family planning services to communities through the health service network such as
hospitals, primary health care (PHC) centres, health posts (HP), sub health posts (SHP), primary
health care outreach clinics (PHC/ORC) and mobile voluntary surgical contraception (VSC)
camps. The policy also aims to encourage public private partnership. Female community health
volunteers (FCHVs) are to be mobilized to promote condom distribution and re-supply of oral
pills. Awareness on FP is to be increased through various IEC/BCC intervention as well as active
involvement of FCHVs and Mothers Groups as envisaged by the revised National Strategy for
Female Community Health Volunteers program.

In this regard, family planning services are designed to provide a constellation of contraceptive
methods/services that reduce fertility, enhance maternal and neonatal health, child survival, and
contribute to bringing about a balance in population growth and socio-economic development,
resulting in an environment that will help the Nepalese people improve their quality of life.

Objectives

Within the context of reproductive health, the main objectives of the Family Planning
Programme are to assist individuals and couples to:

• Space and/or limit their children

• Prevent unwanted pregnancies
• Improve their overall reproductive health
Targets

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Periodic and long-term targets for the Family Planning Programme have been established as
follows:

1 Total Fertility Rate (TFR)

To reduce TFR from 3.1 children per women in 2006 to 3.0 by the end of the Three Year Interim
Plan (2064/65 to 2066/67) and further to 2.5 by 2015 (MDG).

2 Contraceptive Prevalence Rate (CPR)

• To increase the Contraceptive Prevalence Rate (CPR) from 48 % in 2006 to 51 % by the

end of 3 Year Interim Plan period (2064/65 to 2066/67), and to 67 % by 2015 (MDG).
(All methods)
• To increase the Contraceptive Prevalence Rate (CPR) from 44 % in 2006 to 55 % in
2015. (Modern Contraceptive Methods)

Safe Motherhood

The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal
mortalities by addressing factors related to various morbidities, death and disability caused by
complications of pregnancy and childbirth. Global evidence shows that all pregnancies are at
risk, and complications during pregnancy, delivery and the postnatal period are difficult to
predict. Experience also shows that three key delays are of critical importance to the outcomes of
an obstetric emergency: (i) delay in seeking care, (ii) delay in reaching care, and (iii) delay in
receiving care. To reduce the risks associated with pregnancy and childbirth and address these
delays, three major strategies have been adopted in Nepal:

• Promoting birth preparedness and complication readiness including awareness raising

and improving the availability of funds, transport and blood supplies.
• Encouraging for institutional delivery.
• Expansion of 24-hour emergency obstetric care services (basic and comprehensive) at
selected public health facilities in every district
Since its initiation in 1997, the Safe Motherhood Programme has made significant progress in
terms of the development of policies and protocols as well as expands in the role of service
providers such as staff nurses and ANMs in life saving skills. The Policy on Skilled Birth
Attendants endorsed in 2006 by MoHP specifically identifies the importance of skilled birth
attendance at every birth and embodies the Government’s commitment to training and deploying
doctors and nurses/ANMs with the required skills across the country. Similarly, endorsement of
revised National Blood Transfusion Policy 2006 is also a significant step towards ensuring the
availability of safe blood supplies in the event of an emergency.

In order to ensure focused and coordinated efforts among the various stakeholders involved in
safe motherhood and neonatal health programming, government and non-government, national
and international, the National Safe Motherhood Plan (2002-2017) has been revised, with wide

39
partner participation. The revised Safe Motherhood and Neonatal Health Long Term Plan
(SMNHLTP 2006-2017) includes recent developments not adequately covered in the original
plan. These include: recognition of the importance of addressing neonatal health as an integral
part of safe motherhood programming; the policy for skilled birth attendants; health sector
reform initiatives; legalisation of abortion and the integration of safe abortion services under the
safe motherhood umbrella; addressing the increasing problem of mother to child transmission of
HIV/AIDS; and recognition of the importance of equity and access efforts to ensure that most
needy women can access the services they need. The SMNHLTP identifies the following goal,
purposes and outputs.

Goal

Safe-motherhood and neonatal health aims at improving maternal and neonatal health and
survival, especially of the poor and excluded. The main indicators for this include reduction in
maternal mortality ratio and neonatal mortality rate. The detail indicators are given in Table
3.2.1.

Immunization Program
The National Immunization Program (NIP) is a high priority program (P1) of Government of
Nepal. Immunization is considered as one of the most cost‐effective health interventions. NIP
has helped in reducing the burden of vaccine preventable diseases (VPDs) and child mortality
and has contributed in achieving the Millennium Development Goal on child mortality reduction
(MDG4). Currently NIP provides vaccination against TB, (BCG), diphtheria‐pertussis‐tetanus‐
hepatitis B and haemophilus influenza (DPT‐HepB‐HiB), poliomyelitis (OPV) and measles-
rubela throughout the country and JE vaccine in high risk post campaign districts through routine
immunization. TT vaccination is provided to all pregnant women. The routine immunization
services are provided through health facilities (fixed clinic), private, NGO or INGO clinics,

40
urban clinics, outreach session and mobile team in geographical inaccessible areas. All vaccines
under NIP are provided free of cost. Since the past decades new vaccines are available in the
markets, and the Government is keen to provide all available vaccines to reduce morbidity and
mortality. Since last 10 years several new vaccines (hepatitisB, Hib and JE) were introduced into
routine immunization. In addition to routine immunization services NIP carries out several
supplementary immunization activities either to eradicate, eliminate or control vaccine
preventable diseases (VPDs). The NIP has comprehensive multiyear (5 year) immunization plan
(cMYP) which outlines goal, objectives, activities with milestones and financial plan. The
current cMYP runs from 2007‐2011. NIP is also guided by NHSP 2.

The National Immunization Program under the Child Health Division has a lead role in all
immunization related activities at the national level. The NIP works closely in coordination with
other divisions of DoHS, Regional Health Directorates and Districts. The Regional Health
Directorate (RHD) acts as a facilitator between the centre and the districts and carries out
periodic review of district performances and conduct supportive supervision to strengthen
immunization services. It is the responsibility of the D/PHO to ensure that a successful
immunization program is implemented at the district and below level. PHCCs, HPs, and SHPs
implement immunization programs in their respective municipalities and Village Development
Committees (VDCs) ensuring all target children receive immunization services especially
marginalized and hard‐to‐reach population.

Immunization data generated at the service level are reported to the district, region and the
central level (HMIS) on monthly basis. The information received is verified, analyzed followed
by corrective actions at different levels. Based on immunization data received from HMIS, NIP
monitors the coverage by antigens, dropout rate for different antigens (DPT‐HepB‐Hib1 vs DPT‐
HepB‐HIb3, and BCG vs Measles) and vaccine wastage rate (particularly for MDVP vaccines ‐
DPT‐HepB‐Hib, OPV, TT) by districts and provides feedback. In addition to HMIS, surveillance
data on certain vaccine preventable diseases (AFP, Measles like illnesses, MNT, pneumonia for
AI and AES) are reported through integrated Acute Flaccid Paralysis (AFP) surveillance system
from weekly zero reporting sites supported by WHO/IPD. Similarly outbreaks of VPDs are
reported through both the HMIS and integrated AFP network.

Several activities were carried out in achieving objectives and milestones set in cMYP (2007‐
2011) and NHSP2. Vaccination of every eligible child is important especially marginalized and
hard‐to‐reach children. Access to routine vaccination has improved in villages and municipalities
through REC micro planning, advocacy and social mobilization activities, capacity building
trainings, logistics supply, data analysis review meeting at various level etc. Supplementary
immunization activities were carried out to achieve or sustain eradication (polio), elimination
(MNT) or control (measles & JE) of targeted VPDs. Several rounds of polio campaigns were
carried out in high risk districts and JE campaign in 4 districts in this FY. Only one wild
poliovirus was detected in last FY in Rauthaut district with date of onset in August 2011. Nepal

41
continue to sustain MNT elimination status, has achieved the objective of reducing measles
mortality by 90 % compared to 2003 data by 2009, has reduced mortality from JE. The issues,
challenges and recommendations made by the districts during the regional performance review
meeting has guided NIP to better organized immunization related activities in order to achieve its
goal and objectives.

Goal

The goal of National immunization Program is to reduce child morbidity, mortality and disability
associated with vaccine‐preventable diseases.

Objectives

The objectives of the National Immunization Program are as follows:

• Achieve and sustain 90 % coverage of DPT3 by and of all antigens

• Maintain polio free status
• Sustain MNT elimination status
• Initiate measles elimination
• Expand vaccine preventable disease (VPDs) surveillance
• Accelerate control of other vaccine preventable diseases through introduction of new
vaccines
• Improve and sustain immunization quality
• Expand immunization services beyond infancy

NHSP2 targets to achieve 85 % of children under 12 months of age immunized against DPT3
and measles.

Table 2.1.1 presents the immunization schedule of NIP. The target population for NIP include:

• All infants (under 12 months) for BCG, DPT‐HepB‐Hib, OPV, and measles vaccines
and 12‐23 months children for JE vaccine
• All pregnant women for TT vaccine
• All grade 1 student for School TT immunization

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Nutrition
The National Nutrition Program under Department of Health Services has laid the vision as “all
Nepali people living with adequate nutrition, food safety and food security for adequate physical,
mental and social growth and equitable human capital development and survival” with the
mission to improve the overall nutritional status of children, women of child bearing age,
pregnant women, and all ages through the control of general malnutrition and the prevention and
control of micronutrient deficiency disorders having a broader inter and intra‐sectoral
collaboration and coordination, partnership among different stakeholders and high level of
awareness and cooperation of population in general.

Malnutrition remains a serious obstacle to child survival, growth and development in Nepal. The
most common form of malnutrition is protein‐energy malnutrition (PEM). The other forms of
malnutrition are iodine, iron and vitamin A deficiency. Each type of malnutrition wrecks its own
particular havoc on the human body, and to make matters worse, they often appear in
combination. Even moderately acute and severely acute malnourished children are more likely to
die from common childhood illness than those adequately nourished. In addition, malnutrition
constitutes a serious threat especially to young child survival and is associated with about one
third of child mortality. Major causes of PEM in Nepal is low birth weight of below 2.5 kg, due
to poor maternal nutrition, inadequate dietary intake, frequent infections, household food
insecurity, feeding behaviour and poor care and practices leading to an intergenerational cycle of
malnutrition.

An analysis of the causes of stunting in Nepal reveals that around half is rooted in poor maternal
nutrition and half in poor infant and young child nutrition. Around a quarter of babies are born
low birth weight. As per the findings of Nepal Demographic and Health Survey (NDHS, 2011),
41 % of children below 5 years of age are stunted. The survey also showed that 29 % of the
children are underweight and 11 % of the children below 5 years are wasted. Malnutrition is not
evenly distributed throughout Nepal; it varies both ecologically and regionally. The report has
shown stunting, underweight and wasting being more common in mid and far west hills and
mountain areas than other part of the country. All three indicators are also poor in the central
Terai. In order to address the under nutrition problem in young children, Government of Nepal
(GoN) has implemented community Infant and Young Child Feeding (IYCF), Community
Management of Acute Malnutrition (CMAM) and hospital based nutrition management and
rehabilitation. The program treats severe malnourished children at Out‐patient Therapeutic
Program (OTP) centres in Health Facilities and prevent from further deteriorating mild
malnutrition through IYCF counselling at community. As per requirement, the package was
linked with the other nutrition programs like Child Nutrition Grant, MNP distribution to young
children (6‐23 months) and food distribution in the food insecure areas. Based on the package,

43
MoHP organised an Infant and Young Child Feeding Counselling Training in 17 districts of
Nepal. Nutritious food for 6‐23 months children was also distributed in Karnali districts.

Iodine Deficiency Disorder (IDD) was another endemic problem in Nepal, especially in the
western mountains and mid hills for which Ministry of Health and Population adopted a policy to
fortify all edible common salt with iodine and decided to celebrate February as ‘the month to
create general awareness about the use of adequately iodized salt through mass campaign to
contribute in the prevention of Iodine Deficiency Disorders. With an objective to increase the
demand and use, GoN endorsed two child logo iodised packet salt in the Eastern Terai Region,
iodised salt social marketing campaign was conducted in Jhapa, Sunsari and Saptari districts.
Well-equipped modern warehouses have been constructed in various parts of the country for
safeguarding buffer stock of iodised salt.

Another problem among school-aged children and women is the Vitamin A deficiency leading to
night blindness both in children and women. No cases of night blindness are reported so far
among children below 5 years due to a regular semi‐annual supplementation of high dose
Vitamin A supplementation to preschool children (200,000 I.U.). The National Vitamin A
Supplementation Program with community support is considered as the one of the internationally
recognized successful program. Nepal Government also completed the piloting of new‐born
Vitamin ‘A’ dosing program in four district of Nepal (Nawalparasi, Tanahun, Bardiya and
Sindhuli). A high dose of vitamin A supplementation for mother during post‐partum period is
also on-going throughout the country.

The prevalence of worm infestation in Nepal remaining still high leading to decreased resistance
to infection and contributing to anaemic status, which in turns induces malnutrition, and also,
leads to anaemia impairing cognitive function in children. Therefore, deworming of children one
to five years of age is incorporated into the national biannual Vitamin A supplementation
program which has been implemented in the entire country. Similarly, de‐worming of all
pregnant women with single dose of albendazole tablet after first trimester of pregnancy is being
routinely practiced through all health facilities in Nepal. In addition, under School Health and
Nutrition (SHN) Program biannual school deworming is also launched to the school students
studying at government schools throughout the country. GoN is planning to up‐scale deworming
chemotherapy to students from grade 1 to 10 of all public and private schools of the country.

Anaemia caused by iron deficiency is also a major public health problem in Nepal affecting all
segments of the population. As per findings of NDHS 2011, 46 % of children ages 6 to 59
months are anaemic. The majority of children who suffer from anemia are classified as having
mild or moderate anemia (27% and 19%, respectively) while less than 1 % are severely anemic.

Anemia is less common among women; 35 % show evidence of anemia, and the majority is
mildly anemic (29%). Anemia among both children and women is especially prevalent in rural
areas, where nearly half of the children (46%) and more than one third of women (36%) have

44
some degree of anemia. The NDHS 2011 found more than 70 % of children aged 6 to 23 months
are anaemic compared with 25 % of children aged 48 to 59 months. Anaemia is most common
among children less than 5 years in the far-western terai (60%) compared to central mountain
(33%). Overall, there has been no significant improvement in the anemia status of children and
women in Nepal between 2006 and 2011.

As per the government policy, all pregnant women and postpartum mothers are given iron tablet
starting from second trimester to post-partum period free of cost. In order to increase coverage
and compliance of iron tablets among pregnant and postnatal mothers ‘Intensification of
Maternal and Neonatal Micronutrient Program (IMNMP)’ is implemented through the existing
health facilities and community-based outlets like FCHVs with special emphasis on creating
awareness. Awareness raising activities mainly include advocacy, information through public
media and training of health workers/volunteers at all levels. IEC materials such as flip chart and
posters are also being distributed for this purpose. By the end of fiscal year 2067/68, the program
has been introduced in 70 districts (Out of total 75 districts).

Food fortification with iron is a low cost intervention for providing iron rich nutrients to a larger
population without changing their food consumption patterns. In view of this, wheat flour
fortification program has been launched with support from Micronutrient Initiative (MI).
Similarly, a pilot project has also been launched in a VDC of Lalitpur with MI support where
cereal flours (mainlymaize) are being fortified with iron, folic acid and vitamin A at small water
mills. Now, Ministry of Agriculture and Cooperatives (MoAC) has made a mandatory provision
of fortification in wheat flours produced by roller mills.

Goal

The overall goal of national nutrition program is to achieve nutritional well being of all people in
Nepal to maintain a healthy life to contribute in the socio‐economic development of the country,
through improved nutrition program implementation in collaboration with relevant sectors.

The program aims to achieve the following targets:

• Reduce IMR 36/1,000; <5 mortality rate 54/1,000 and MMR 250/100,000 live births by
2015 (MDGs)
• Reduce IMR 34.4/1,000 LB and <5 mortality rate to 62.5/1,000 LB by the end of 2017
(SLTHP)
Nutrition Specific MDGs Goal

The following Nutrition Specific Goals are to be achieved by the end of 2015 (MDGs):

• Reduce sub‐clinical VAD to 7 %

• Reduce anaemia in pregnant women to 43 %
• Reduce anaemia in all age women to 42 %
• Reduce anaemia in children to 43 %

45
 • Increase consumption of adequately iodized salt (≥ 15 PPM) at HHs level to 88 %
• Reduce prevalence of night blindness in pregnant women to 1 %
• Reduce prevalence of underweight in <5 years children to 27 %
• Reduce prevalence of stunting in <5 years children to 28 %
• Reduce prevalence of wasting in <5 years children to 5 %
• Increase exclusive breast‐feeding in <6 months children to 88 %
• Reduce prevalence of thinness (BMI 18.5 – below 25) in women to 15 %
• Reduce worm infestation rate in children (Pre‐school) to less than 15 %
Objectives

General Objective

The general objective of the National Nutrition Program is to enhance nutritional well‐being,
reduce child and maternal mortality and is to contribute for equitable human development.

Specific Objectives:

• Reduce general malnutrition among women and children

• Reduce Iron Deficiency Anaemia among children and pregnant mother
• Maintain and sustain Iodine Deficiency Disorder (IDD) and Vitamin A Deficiency
Disorder (VAD)
• Improve maternal nutrition
• Align with Multi‐sectoral Nutrition Initiative
• Improve Nutrition related Behaviour change and communication
• Improve Monitoring and Evaluation for Nutrition related Programs/Activities
Targets

In order to improve the overall nutritional status of children and pregnant women, the national
nutrition program has set the following targets:

• To reduce PEM in children under 5 years of age and reproductive aged women to half of
the 2000 level by the year 2017.
• To reduce the prevalence of anaemia among women and children to less than 40 % by
2017.
• To virtually eliminate IDD and sustain the elimination by 2017.
• To virtually eliminate vitamin A deficiency and sustain the elimination by 2017.
• To reduce the infestation of intestinal worms among children and pregnant women to less
than 10 % by 2017.
• To reduce the prevalence of low birth weight to 12 % by the year 2017.
• To improve household food security to ensure that all people can have adequate access,
availability and utilization of food needed for healthy life in order to reduce the %age of
people with inadequate energy intake to 25 % by 2017.
• To improve health and overall nutritional status of school children through the
implementation of School Health and Nutrition Program.
• To reduce the critical risk of malnutrition and life during exceptionally difficult
circumstances.
• To strengthen the system for analyzing, monitoring and evaluating the nutrition situation.

46
 • To promote exclusive breastfeeding till the age of six completed months. Thereafter,
introduce complementary foods along with breast milk till the child completes 2 years or
more.
• To reduce the Infestation of intestinal worm among Children and Pregnant Women to
less than 10 % by 2017.

Integrated management of Childhood illness (IMCI)

Community Based Integrated Management of Childhood Illness (CB‐IMCI) Program is an
integrated package of child‐survival interventions and addresses major childhood killer diseases
like Pneumonia, Diarrhoea, Malaria, Measles, and Malnutrition in 2 months to 5 year children in
a holistic way. CBIMCI also includes management of infection, Jaundice, Hyperthermia and
counseling on breastfeeding for young infants less than 2 months of age. With the
implementation of this package children are diagnosed early and treated appropriately for major
childhood diseases at the health facility and community level. At the community level FCHVs
are the main vehicle of service delivery and also plays key role to increase community
participation.

In 1997, the program was initiated in Mahottari as a piloting district for IMCI. Based on the
recommendations it was decided to include a community component, enabling mobilization of
community health workers (VHWs and MCHWs) and FCHVs to provide CDD, ARI, Nutrition
and Immunization services to the community. As a result the Community based ARI and CDD
(CBAC) program was merged into IMCI in 1999 and is now called the Community Based IMCI
(CB‐IMCI). At the end of fiscal year 2066/67 (2009/2010) CB‐IMCI Program has covered 75
districts. In 2004, Newborn component was added to CB‐IMCI.

Vision

• Contribute to survival, healthy growth and development of under five children of Nepal.
• Achieve MDG Goal 4 by 2015.
Goal

To reduce morbidity and mortality among children under‐five due to pneumonia, diarrhoea,
malnutrition, measles and malaria

Targets

•To reduce neonatal mortality from the current rate of 33/1,000 live births to 17/1,000 live
births by 2015.
• To reduce neonatal morbidity among infants less than 2 months of age.
Objectives

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 • Reduce frequency and severity of illness and death related to ARI, Diarrhoea,
Malnutrition, Measles and Malaria.
• Contribute to improved growth and development.

Malaria
Malaria control project was first initiated in Nepal in 1954 with the suppot from USAID (then
USOM). The objective of the project was to control malaria mainly in southern Terai belt of
central Nepal. In 1958, national malaria eradication program, the first national public health
program in the country was launched with the objective of eradicating malaria from the country
within a limited time period. Due to various reasons the eradication concept was reverted to
control program in 1978.

Following the call of WHO to revamp the malaria control programs in 1998, Roll Back Malaria
(RBM) initiative was launched to address the perennial problem of malaria in hard‐core forested,
foot hills, inner Terai and valley areas of the hills, where more than 70 % of the total malaria
cases of the country prevail. The high risk of getting the disease is attributed to the abundance of
vector mosquitoes, mobile and vulnerable population, relative inaccessibility of the area, suitable
temperature, environmental and socio‐economic factors. Currently malaria control activities are
carried out in 65 districts at risk of malaria. The districts are divided into four different categories
as follows:

•High risk districts (13): Ilam, Jhapa, Morang, Sindhuli, Dhanusa, Mahottari, Kavre,
Nawalparasi, Banke, Bardiya, Kailali, Kanchanpur, Dadeldhura
• Moderate risk districts (18): Panchthar, Dhankuta, Sunsari, Saptari, Siraha, Udayapur,
Sarlahi,
• Rautahat, Bara, Parsa, Makawanpur, Chitwan, Sindhupalchowk, Rupandehi, Kapilvastu,
Dang, Surkhet, Doti
• Low risk 34 Districts (Minimal transmission) (34)
• No risk Districts (10)
The Global Fund is supporting malaria control program in the high risk 13 endemic districts and
moderate risk 18 endemic districts.

Objective

• Overall incidence of (probable and confirmed) malaria in ‘population at risk’ brought

below 2 cases per 1,000 by 2011. (2005 baseline: 4.1 cases per 1,000)
• Hospital‐based severe malaria case fatality rate reduced to below 15% by 2010.

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 •By 2010, weekly incidence of malaria (probable and confirmed) in all outbreak wards
brought below outbreak threshold level within 6 weeks of detection.
• Community mobilization and community partnership in malaria control.
Targets

• 80 % of people in high risk areas (stratum 1 VDCs) sleeping under LLIN (last night) by
2011.
• 80 % of malaria cases reported by public sector health facilities in high risk areas
(stratum 1) confirmed by microscopy or RDT by 2011.
• 80 % of care providers at rural public sector health facilities providing appropriate
treatment for malaria by 2011.

Tuberculosis
Tuberculosis (TB) is a major public health problem in Nepal. About 45 % of the total population
is infected with TB, of which 60 % are adult. Every year, 40,000 people develop active TB, of
whom 20,000 have infectious pulmonary disease. These 20,000 are able to spread the disease to
others. Treatment by Directly Observed Treatment Short course (DOTS) has reduced the number
of deaths; however 5,000‐7,000 people still die per year from TB. Expansion of this cost
effective and highly successful treatment strategy has proven its efficacy in reducing the
mortality and morbidity in Nepal. By achieving the global targets of diagnosing 70 % of new
infectious cases and curing 85 % of these patients will prevent 30,000 deaths over the next five
years. High cure rates and Sputum conversion rate will reduce the transmission of TB and lead to
a decline in the incidence of this disease, which will ultimately help to achieve the goal and
objectives of TB control.

DOTS have been successfully implemented throughout the country since April 2001. The NTP
has coordinated with the public sectors, private sectors, local government bodies, I/NGOs, social
workers, educational sectors and other sectors of society in order to expand DOTS and sustain
the present significant results achieved by NTP. By 16th July 2011 NTP has 1,118 DOTS
treatment centres with 3,103 sub centres. The treatment success rate stands at 90 % and case
finding rate of 73 %. At the national level 36,951 TB patients have been registered of whom
15,000 infectious (sputum smear positive new cases) and are being treated under the DOTS
strategy in NTP during the FY 2067/68 (2010/2011).

Vision

The NTP’s vision is TB free Nepal.

Mission

• To ensure that every TB patient has access to effective diagnosis, treatment and cure
• To stop transmission of TB
• To prevent development of multi drug resistant TB
• To reduce the social and economic toll of TB
Goal
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 •To reduce the mortality, morbidity and transmission of tuberculosis until it is no longer a
public health problem in Nepal.
Objectives

• Achieve universal access to high‐quality diagnosis and patient‐centred treatment

• Reduce the human suffering and socioeconomic burden associated with TB
• Protect poor and vulnerable populations from TB, TB/HIV and multi‐drug‐resistant TB
• Support development of new tools and enable their timely and effective use
Targets

Targets linked to the MDGs and endorsed by the Stop TB Partnership:

• by 2005: detect at least 70 % of new sputum smear‐positive TB cases and cure at least 85
% of these cases
• by 2015: reduce prevalence of and death due to TB by 50 % relative to 1990
• by 2050: eliminate TB as a public health problem (<1 case per million population)

Leprosy
Leprosy has existed in Nepal since time immemorial and was recognized as a major Public
Health problem as early as 1950. Khokana Leprosarium near Kathmandu was established more
than 160 years ago to provide services to the leprosy patients. For ages, leprosy has been a
disease causing public health problem and has been a priority of the government of Nepal.
Thousands of people have been affected by this disease and many of them had to live with
physical deformities and disabilities.

Activities to control leprosy in an organized and planned manner were initiated only from 1960.
According to a survey conducted in 1966, an estimated 100,000 leprosy cases were present in
Nepal. Dapsone monotherapy treatment was introduced as a Pilot Project in the Leprosy Control
Program. Nepal Leprosy Control Program was started in the country in 1966. Multi Drug
Therapy (MDT) was introduced in 1982 in few selected areas and hospitals of the country. By
this time, the number of registered leprosy cases had reached 21,537 with a Prevalence Rate (PR)
of 21 per 10,000 population. Sixty‐two districts of the country had PR of over 5, while only three
districts had PR less than 1 per 10,000 inhabitants.

The program was integrated into the general health services in 1987. By 1996 MDT was
expanded to all 75 districts. The country conducted Leprosy Elimination Campaign in 1999
(LEC‐1) and again in 2001 (LEC‐2) which was an active case detection activity. In high endemic
pockets special interventions were undertaken for case finding. Community mobilization and
participation during LEC contributed to voluntary case reporting due to reduction of stigma and
discrimination against leprosy affected persons. High cure rates through flexible and patient‐
friendly drug delivery systems were ensured. Monitoring and supervision of the activities were
undertaken to keep track of progress towards elimination.

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All initiatives were coordinated amongst the national, international and local non‐governmental
organizations. Specialized care for leprosy affected persons was provided in Leprosy hospitals
and referral clinics run by NGOs and the government. WHO and other major partners supporting
the program are Sasakawa Memorial Health Foundation, The Nippon Foundation, Netherlands
Leprosy Relief, The Leprosy Mission, International Nepal Fellowship and Nepal Leprosy Trust.
Leprosy Control Division, the guiding body for leprosy control activity in Nepal, functions in
close coordination with the Regional Health Directorate, District Health System, donor agencies
and all the supporting partners. Regional Health Directorate (RHD) supervises and monitors the
program in all districts within the region. Disease control activities including leprosy control
activities are headed by respective officer as appointed by Regional Director in RHD. Regional
Tuberculosis and Leprosy Officer/Assistant (RTLO) is the focal person of leprosy in RHD. In
addition, District TB & Leprosy Officer/Assistant (DTLO), implement the program in respective
district.

MDT service is being delivered through all the public health facilities (Primary Health Centres,
Health Posts and Sub Health Posts) in Nepal. Majority of health care providers serving at
community based health facilities have undergone Comprehensive Leprosy Training (CLT) and
are effectively providing MDT service. In addition more than 90 % Female Community Health
Volunteers (FCHVs) have received orientation on leprosy and are suspecting and referring cases
to the nearest HF for confirmation of diagnosis and treatment. Capacity building is a key
intervention area and is conducted with support from the WHO and INGOs mentioned above. In
addition to capacity building INGO supported referral centres also provide primary, secondary
and tertiary level care to leprosy patients.

Evolution of Leprosy Control Program

 1960 Leprosy survey in collaboration with WHO

 1966 Pilot Project launched with Dapsone therapy
 1982 Introduction of Multi Drug Therapy
 1987 Integration of vertical program into general basic health services
 1991 National leprosy elimination goal was set
 1995 Focal persons (TLAs) appointed for districts & regions

Vision

To usher in a leprosy free society where there are no new leprosy cases and all the needs of
existing leprosy affected persons having been fully met.

Mission

To provide accessible and acceptable cost effective quality leprosy services including
rehabilitation and continue to provide such services as long as and wherever needed.

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Goal

Reduce further the burden of leprosy and to break channel of transmission of leprosy from
person to persons by providing quality service to all affected community.

Objectives

• To eliminate leprosy (Prevalence Rate below 1 per 10,000 population) and further reduce
disease burden at district level;
• To reduce disability due to leprosy;
• To reduce stigma in the community against leprosy; and
• Provide high quality service for all persons affected by leprosy.
Strategies

•Early case detection and prompt treatment of cases.

•Enable all general health facilities to diagnose and treat leprosy.
•Ensure high MDT treatment completion rate.
•Prevent and limit disability by early diagnosis and correct treatment.
•Reducing stigma through information, education, and advocacy by achieving community
empowerment through partnership with media and community.
• Sustain quality of leprosy service in the integrated set up.
Targets

• Reduce NCDR by 25 % at national level by the end of 2015 in comparison to 2010.

• Reduce PR by 35 % at national level by the end of 2015 in comparison to 2010.
• Reduce by 35 % GII disability amongst newly detected cases per 100,000 population by
the end of 2015 in comparison to 2010.
• Additional deformity during treatment <5 % by EHF score.
• 80 % health workers are able to recognize and manage /refer reaction/complications.
• Promote POD and Self care.

Sexually transmitted Infections (STI) and HIV/AIDS

History of Nepal’s response against HIV/AIDS begun with the launching of first National AIDS
Prevention and Control Program in 1988. In 1995, a National HIV/AIDS Policy with 12 key
policy statements and supportive structures like National AIDS Coordination Committee
(NACC) and District AIDS coordination Committee to guide and coordinate the response at
central and district level was endorsed. As directed by the National HIV/AIDS Policy, a multi‐
sector National AIDS Coordinating Committee (NACC) chaired by the Minister of Health, with
representation from different ministries, civil society, and private sector was established at centre
to build the coordination mechanism to support and monitor the activities implemented through
NCASC. Similarly, DACC was established to coordinate and monitor the activities at district
level.

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In 2002 a National AIDS Council (NAC) was established, chaired by the Prime Minister, to raise
the profile of HIV/AIDS. The NAC was intended to set overall policy, lead high level advocacy,
and provide overall guidance and direction to the national response to AIDS in Nepal.

The latest national policy on HIV and AIDS (2010) have envisioned a more concrete policy
framework for making AIDS free society with the overall policy aim of reducing impact of HIV
among people by reducing new HIV infections.

Recently Nepal has expressed its high level political commitment to Political Declaration on
HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS June 2011. The 2011 declaration
builds on two previous political declarations: the 2001 Declaration of Commitment on
HIV/AIDS and the 2006 Political Declaration on HIV/AIDS. At UNGASS, in 2001, Member
States unanimously adopted the Declaration of Commitment on HIV/AIDS. This declaration
reflected global consensus on a comprehensive framework to achieve Millennium Development
Goal Six‐: halting and beginning to reverse the HIV epidemic by 2015. Thus, to ensure the
effective response to the HIV epidemic in Nepal and so to fulfil the accountability of the
response, Nepal has already implemented three rounds national HIV/AIDS strategic plan. The
recent National HIV/AIDS Strategy 2011‐2016 has laid a concrete road map in planning,
programming and reviewing of the national response to the epidemic.

National HIV/AIDS Strategy (2011‐2016)

Vision

Nepal will become a place where new HIV infection are rare and when they do occur, every
person will have access to high quality, life extending care without any form of discrimination.

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Goal

To achieve universal access to HIV prevention, treatment, care and support.

Objectives

•Reduce new HIV infections by 50 % by 2016, compared to 2010;

•Reduce HIV‐related deaths by 25 % by 2016 (compared with a 2010 baseline) through
universal access on treatment and care services; and
• Reduce new HIV infections in children by 90 % by 2016 (compared with a 2010
baseline)
Guiding Principles, 2011‐2016

• Universal Access of Prevention, Treatment, Care and Support services for all people on
equitable basis
• Decentralized, integrated, multi‐sectoral and interdisciplinary engagement
• Evidence‐informed planning and programming
• Health System Strengthening and Community System Strengthening
• Service delivery based on the principle of Primary Heath Care Approach
• Equity and Human Rights
• Gender mainstreaming
• Greater involvement of people living with HIV/AIDS (GIPA) principle

The National HIV/AIDS Strategy is a national guiding document and a road map for the next
five years for all sectors, institutions and partners involved in the response to HIV and AIDS in
Nepal to meet the national goal; to achieve universal access to HIV prevention, treatment, care
and support with two major programmatic objectives (i) reduce new HIV infections by 50 %, and
(ii) reduce HIV related deaths by 25 %, by 2016. The strategy delineates the central role of the
health sector and the essential roles the other sectors play, in response to the HIV epidemic.

The current national HIV/AIDS Strategy, therefore, builds on two critical program strategies: (i)
HIV prevention, and (ii) treatment care and support of infected and affected. To ensure the
achievements of program outcomes, cross‐cutting strategies are devised to supports (i) creating
enabling environment: health system strengthening, legal reform and human rights and
community system strengthening (ii) strategic information (HIV and STI surveillance, program
monitoring and evaluation and research).

Building on the achievements, lessons and experiences of the past five years, the strategy (2011‐
2016) will focus on the following key points:

• Addressing the all dimensions of continuum of care from prevention to treatment care
and support
• Effective coverage of quality interventions based on the epidemic situation and
geographical prioritization

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 • Health system and community system strengthening
• Integration of HIV services into public health system in a balanced way to meet the
specific needs of target populations
• Strong accountability framework with robust HIV surveillance, program monitoring and
evaluation to reflect the results into NHSP‐II and National Plan.

 Efforts on Health Awareness and Health Habits

The National Health Education, information and Communication Centre (NHEICC) was
established under the MoHP in 1993 with following New Health Policy 1991. MoHP has given
structural mandate to this center in 2002    to support for health promotion, education and
communication activities of Department of Drug Administration and Department of Ayurveda.

Recently, the cabinet endorsed "National Health Communication Policy, 2012" which is the
milestone for health promotion, education and communication program under MoHP/GoN.

Since FY 2051/52, all of the districts health offices have organizational structure for Health
education, information and communication programs. There is health education and
communication section in the regional health directorates, regional training centres and health
information section in the district Health/Public Health Offices. The health education and
communication section implement health promotion, education and communication activities
utilizing various media and methods according to the needs of the local people for the health
awareness and health habits in the district as well as the health program and services objectives.

Major efforts are:

 Development, production and airing of short messages through Radio, Television and FM
 Development and publication of health messages through Newspapers
 Development, production and distribution of IEC materials to stakeholders and RMS,
DHO/PHO
 Program orientation to regional and district level program manager and focal person in five
regions
 Advocacy ‐  Global Hand Washing Day, World Health Day and World No Tobacco Day

55
 Celebration
 Coordination ‐  Technical committees meetings
 Capacity building   on health communication  
 Supervision, Monitoring and evaluation of health communication program
 Tobacco control act including tobacco product pictorial health warning Implementation
 Tobacco control strategic plan preparation and implementation
 Regional Orientation to Assistant CDO to implement tobacco control activities
 Conduction of environmental health, hygiene and sanitation activities  
 School Based Hand Washing with Soap and Water program  
 Public Private Partnership in Hand washing with soap programme
 Broadcasting health messages through Radio and Television in package

Roles of Resolution of Selected International Conferences Related to Health - Alma Ata

Declarations - ICPD (Cairo) Declarations - Beijing Conference Declarations - HABITAT
2nd (Istanbul, 1996) Declarations - SAARC Declarations - MDGs - Other Subsequent
Health Related Declarations

Alma Ata conference

In 1977 the World Health assembly decided that the main health targets of the governments and
WHO should be the attainment of a level of health, by all the people by the year 2000 that will
permit them to lead a socially and economically productive life, popularly known as “Health for
all by the year 2000”.

The essential concept of principle of HFA is ‘equity in health’ i.e. all people should have an
equal opportunity to enjoy good health.

‘Health for All by 2000 AD’ symbolizes the determination of the countries of the world to
provide and acceptable level of health to all people.

As decided by the Health Assembly of the WHO, the executive board of the UNICEF and at the
invitation of the government of the USSR, the international conference of primary health care
was held from 6 to 12 September 1978 in Alma Ata, capital of Kazakh Soviet Socialist Republic
where 134 countries participated. The conference was called for the acceptance of the WHO goal
of HFA by 2000 and proclaimed Primary Health Care as the strategy for obtaining it.

In 1979 the executive board of WHO issued guiding principles for formulating strategies for
HFA by 2000 AD. In this document, the board described a health strategy- primary health care is
the starting infrastructure for the promotion of world health. The program under primary health

56
care includes the measures for health promotion, disease prevention, diagnosis, therapy and
rehabilitation.

ICPD (Cairo) Declarations

In 1994 in Cairo, 179 nations committed to a 20-year comprehensive plan of action that
linked the reproductive health and human rights of women to the global struggle to reduce
poverty and achieve sustainable development. This backgrounder summarizes the key goals, core
agenda, and additional provisions of that agreement, known as the ICPD Programme of Action.
Additionally, it provides background on U.S. involvement in women's health and rights
worldwide.

What is the ICPD Programme of Action?

The ICPD Programme of Action contains 16 chapters of consensus recommendations and
commitments agreed to by 179 governments at the International Conference on Population and
Development, held in Cairo in 1994. These recommendations and commitments, strengthened
and updated at the ICPD five-year review (New York, 1999), range from basic principles that
guide population and development efforts to concrete steps each nation should take to make such
efforts successful by the year 2015. 
Key goals embodied in the Programme of Action

 The 1990 illiteracy rate for women and girls should be halved by 2005; and by 2010, the
net primary enrolment ratio for children of both sexes should be at least 90 percent.
 By 2005, 60 percent of primary health care and family planning facilities should offer the
widest achievable range of safe and effective family planning methods, essential obstetric
care, prevention and management of reproductive tract infections, including sexually
transmitted infections (STIs), and barrier methods to prevent infection; 80 percent of
facilities should offer such services by 2010, and all should do so by 2015.
 At least 40 percent of all births should be assisted by skilled attendants where the
maternal mortality rate is very high, and 80 percent globally, by 2005; these figures
should be 50 and 85 percent by 2010; and 60 and 90 percent by 2015.
 The gap between the proportion of individuals using contraceptives and the proportion
expressing a desire to space or limit their families should be reduced by half by 2005, by
75 percent by 2010, and by 100 percent by 2015.
 To reduce vulnerability to HIV/AIDS infection, at least 90 percent of young men and
women, aged 15-24, should have access by 2005 to preventive methods-such as female
and male condoms, voluntary testing, counseling, and follow-up-and at least 95 percent
by 2010.  HIV infection rates in persons 15-24 years of age should be reduced by 25
percent in the most affected countries by 2005 and by 25 percent globally by 2010.
 By 2015 all countries should aim to achieve an infant mortality rate below 35 per 1000
live births and an under-5 mortality rate below 45 per 1000.
 Countries should strive to reduce maternal mortality by 100 percent by 2015.

Principle (15)

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1. All human beings are born free and equal in dignity and rights. Everyone has the right to
life, liberty and security of person.
2. Human beings are at the centre of concerns for sustainable development.
3. People are the most important and valuable resource of any nation.
The right to development is a universal and inalienable right and an integral part of
fundamental human rights.
4. Advancing gender equality and equity and the empowerment of women, and eliminating all
forms of violence against women, are the cornerstones of population and development-
related programmes.
5. Population-related goals and policies are integral parts of cultural, economic and social
development, the principal aim of which is to improve the quality of life of all people.
6. Sustainable development requires that the interrelationships between population, resources
and development are fully recognized and brought into harmonious, dynamic balance.
7. All States and all people shall cooperate in the essential task of eradicating poverty.
8. Everyone has the right to enjoy the highest attainable standard of physical and mental health.
All couples and individuals have the basic right to decide freely and responsibly the number
and spacing of their children and to have the information, education and means to do so.
9. The family is the basic unit of society and, as such, should be strengthened. It is entitled to
receive comprehensive protection and support. Various forms of the family exist.
10. Everyone has the right to education. Education should be designed to strengthen respect for
human rights and fundamental freedoms.
11. The child has the right to an adequate standard of living, health and education and to be free
from neglect, exploitation and abuse.
12. Countries receiving documented migrants should provide proper treatment and adequate
social welfare services for them and their families, and should ensure their physical safety
and security.
13. Everyone has the right to seek and to enjoy in other countries asylum from persecution.
14. States should recognize and support the identity, culture and interests of indigenous people
and enable them to participate fully.
15. Sustained economic growth and social progress require that growth be broadly based,
offering equal opportunities to all people.

Beijing Conference Declarations

The Beijing Declaration was a resolution adopted by the UN at the end of the Fourth World

Conference on Women on 15 September 1995. The resolution adopted to promulgate a set of
principles concerning the equality of men and women.

The Governments participating in ‘The Fourth World Conference on Women’ gathered here in
Beijing in September 1995, the year of the fiftieth anniversary of the founding of the United
Nations.

58
The Governments determined to achieve the goals of equality, development and peace for all
women everywhere in the interest of all humanity. The status of women has advanced in some
important respects in the past decade but that progress has been uneven, inequalities between
women and men have persisted and major obstacles remain, with serious consequences for the
well-being of all people. This situation is exacerbated by the increasing poverty that is affecting
the lives of the majority of the world's people, in particular women and children, with origins in
both the national and international domains.

The participants declared to address these constraints and obstacles and thus enhancing further
the advancement and empowerment of women all over the world, and agree that this requires
urgent action in the spirit of determination, hope, cooperation and solidarity, now and to carry us
forward into the next century.

The government reaffirmed commitment to the equal rights and inherent human dignity of
women and men. The Convention emphasized on the Elimination of All Forms of Discrimination
against Women and the Convention on the Rights of the Child, as well as the Declaration on the
Elimination of Violence against Women and the Declaration on the Right to Development.

The participants committed to ensure the full implementation of the human rights of women and
of the girl child as an inalienable, integral and indivisible part of all human rights and
fundamental freedoms. The government promised to build on consensus and progress made at
previous United Nations conferences and summits - on women in Nairobi in 1985, on children in
New York in 1990, on environment and development in Rio de Janeiro in1992, on human rights
in Vienna in 1993, on population and development in Cairo in 1994 and on social development
in Copenhagen in 1995 with the objective of achieving equality, development and peace.

The government committed to achieve the full and effective implementation of the Nairobi
Forward-looking Strategies for the Advancement of Women; and their full participation on the
basis of equality in all spheres of society, including participation in the decision-making process.

The participants agree that equal rights, opportunities and access to resources, equal sharing of
responsibilities for the family by men and women, and a harmonious partnership between them
are critical to their well-being and that of their families as well as to the consolidation of
democracy.

Eradication of poverty based on sustained economic growth, social development, environmental

protection and social justice requires the involvement of women in economic and social
development. The explicit recognition and reaffirmation of the right of all women to control all
aspects of their health, in particular their own fertility, is basic to their empowerment.

It is essential to design, implement and monitor, with the full participation of women, effective,
efficient and mutually reinforcing gender-sensitive policies and programmes.

The governments ensure the full enjoyment by women and the girl child of all human rights and
fundamental freedoms and take effective action against violations of these rights and freedoms.
They are also determined to take all necessary measures to eliminate all forms of discrimination

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against women and the girl child by encouraging men to participate fully in all actions towards
equality.

The government also agreed to promote women's economic independence, including

employment, and eradicate the increasing burden of poverty on women. Further they were
determined to promote people-centred sustainable development through the provision of basic
education, and training, and primary health care for girls and women.

The governments are determined to take positive steps to ensure peace for the advancement of
women recognizing the leading role played by the women in the peace movement.

The governments are also determined to prevent and eliminate all forms of violence against
women and girls; and ensure equal access to and equal treatment of women and men in education
and health care and enhance women's sexual and reproductive health. They also determined to
promote and protect all human rights of women and girls; and to develop the fullest potential of
girls and women of all ages, and enhance their role in the development process.

The participants are determined to ensure women's equal access to economic resources,
including land, credit, science and technology, vocational training, information etc.

HABITAT 2nd (Istanbul, 1996) Declarations

The Heads of State or Government and the official delegations of countries assembled at the
United Nations Conference on Human Settlements (Habitat II) in Istanbul, Turkey from 3 to 14
June 1996, take this opportunity to endorse the universal goals of:

 Ensuring adequate shelter for all and

 Making human settlements safer, healthier and more liveable, equitable, sustainable and
productive.
 Improvement of the living environment.

Considerations:-with a sense of urgency:

 The continuing deterioration of conditions of shelter and human settlements.

 Recognize cities and towns as centres of civilization, generating economic development
and social, cultural, spiritual and scientific advancement.
 Must take advantage of the opportunities presented by our settlements and preserve their
diversity to promote solidarity among all our peoples.

Commitment:

 To better standards of living in larger freedom for all humankind.

 Recent UN world conferences have given agenda for the equitable attainment of peace,
justice and democracy built on economic, social development and environmental
protection into the Habitat Agenda.

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Declarations

1. Ensuring adequate shelter for all and making human settlements safer, healthier and more
livable, equitable, sustainable and productive in an urbanizing world.
2. Combating with the continuing deterioration of conditions of shelter and human settlements.
3. Commitment to better standards of living in larger freedom for all humankind including the
agenda of UN conference on environment and development.
4. Acknowledging that globalization of the world economy presents opportunities and
challenges for the development process, as well as risks and uncertainties. Our cities must be
places where human beings lead fulfilling lives in dignity, good health, safety, happiness and
hope.
5. Interdependency of rural-urban development, and providing settlement facilities adequately
in rural area to minimize rural to urban migration.
6. Identification of particular needs of particular group of individuals in improving living
conditions in human settlements.
7. Ensuring full and equal opportunities and hence participation of all women and men as well
as active participation of public, private and non-government partners for sustainable
development.
8. Commitments to full realization of the rights to adequate housing.
9. Expansion of the supply for affordable housing.
10. Sustaining the global environment and improving the quality of living in our human
settlements.
11. Promotion of conservation, rehabilitation and maintenance of buildings, monuments, open
spaces, lands copes and settlement patterns of historical, cultural, architectural, natural,
religious and spiritual value.
12. Development of strategies, principles of partnership and participation especially for the
democratic local authorities.
13. Provision of adequate funding for implementation of the Habitat Agenda.
14. Strengthening the role and functions of the UN centre for Habitat.
15. The conference marks a new era of co-operation by
– Offering a positive vision of sustainable human settlement.
– Sense of hope for our common future.
– It focuses on coping with the challenges and creating

A world where everyone can live in a safe home with a decent like of dignity, good health,
safety, happiness and hope.

SARCC Declarations

Eighteenth SAARC Summit Kathmandu, Nepal

26-27 November 2014

KATHMANDU DECLARATION

"Deeper Integration for Peace and Prosperity”

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The President of the Islamic Republic of Afghanistan His Excellency Mohammad Ashraf Ghani;
the Prime Minister of the People’s Republic of Bangladesh Her Excellency Sheikh Hasina; the
Prime Minister of the Kingdom of Bhutan His Excellency Tshering Tobgay; the Prime Minister
of the Republic of India His Excellency Narendra Modi; the President of the Republic of the
Maldives His Excellency Abdulla Yameen Abdul Gayoom; the Prime Minister of Nepal Right
Honourable Sushil Koirala; the Prime Minister of the Islamic Republic of Pakistan His
Excellency Muhammad Nawaz Sharif; and the President of the Democratic Socialist Republic of
Sri Lanka His Excellency Mahinda Rajapaksa;

Having met at the Eighteenth Summit meeting of the South Asian Association for Regional
Cooperation (SAARC) held in Kathmandu, Nepal on November 26-27, 2014;

Reaffirming their commitment to the principles and objectives of SAARC for ensuring the
welfare and quality of life of the peoples of South Asia; Recognizing that after nearly thirty years
of its existence, it is time to reinvigorate SAARC’s regional cooperation and revitalize SAARC
as an effective vehicle to fulfill the developmental aspirations of the peoples of South Asia;
Determined to deepen regional integration for peace and prosperity by promoting mutual trust,
amity, understanding, cooperation and partnership; Declared as follows:

Health

The Leaders recognized the importance of achieving universal health coverage (UHC),
improving health regulatory systems, preparedness for emerging and remerging diseases, and the
challenges posed by anti-microbial resistance and non-communicable diseases. They endorsed
the Male’ Resolution on Regional Health Issues adopted at the Fourth Meeting of the SAARC
Health Ministers. They urged to continue the remarkable progress by SAARC countries in the
last decade in response to AIDS with the aim to end AIDS epidemic in the region by 2030. They
also directed to complete all necessary processes for upgrading the SAARC TB Reference
Laboratory at SAARC TB and HIV/AIDS Centre (STAC), Kathmandu to Supra-national
Reference Laboratory with necessary funding from SDF.

The Leaders welcomed the offer of the Government of Islamic Republic of Pakistan to host the
Nineteenth Summit of SAARC.

MDG

The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that
respond to the world's main development challenges. The MDGs are drawn from the actions and
targets contained in the Millennium Declaration that was adopted by 189 nations-and signed by
147 heads of state and governments during the UN Millennium Summit in September 2000

Health and MDGs

 Goals - 8
 Targets -18
 Indicators- 48

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Three out of eight goals, eight of the 18 targets and 18 of the 48 indicators relate directly to
health. Health is also an important contributor to several other goals.

Goal 1: Eradicate Extreme Poverty & Hunger

Goal 2: Achieve Universal Primary Education
Goal 3: Promote Gender Equality & Empower Women
Goal 4: Reduce Child Mortality
Goal 5: Improve Maternal Health
Goal 6: Combat HIV/AIDS, Malaria and Other Diseases
Goal 7: Ensure Environmental Sustainability
Goal 8: Develop a Global Partnership for Development

Nepal is one of 189 countries committed to the Millennium Development Goals (MDGs), a
pledge it has renewed in its national development plans. The primary medium-term strategy and
implementation plan for reaching its MDGs, the Tenth Plan (Poverty Reduction Strategy Paper)
(2002/03–2006/07) incorporated the MDGs into its strategic framework. Other plans have done
the same. The Tenth Plan focused on reducing poverty through private sector-led economic
growth. The Three-Year Interim Plan (TYIP) (2006/07–2009/10) adopted after the Tenth Plan
maintained the focus on poverty reduction and growth but also stressed the need for the state to
assume a greater strategic presence in development, especially in remote areas, and for socially
marginalised groups to be included. The plan after that, the ThreeYear Plan (TYP) (2010/11–
2013/14), continued the call for strategic investment in areas in need of greater focus if Nepal’s
MDGs are to be achieved.

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Target4: Reduce the under-five mortality rate by two-thirds between 1990 and 2015

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Status and trends

Childhood mortality declined markedly over the past 20 years, between 1990 and 2011: the
infant mortality rate (IMR) declined from 108 to 46 and the under-five child mortality rate
(U5MR) from 162 to 54 per 1,000 live births. The rates of decline of both were significant,
57.4 and 66.6 percent for the IMR and U5MR respectively, but still one in 22 Nepali children
dies before the age of one and one in 19 before he or she turns five. The neonatal mortality rate
(NMR), is drop considerably between 2001 and 2006, from 43 to 33 per 1,000, it did not decline
any further between 2006 and 2011. The rate of decrease of the IMR also slowed in the later
period, its progress stymied by the stagnant NMR. Nonetheless, Nepal is on track to achieve its
MDGs related to child health before 2015. In fact, the target for the U5MR, 54 per 1,000 live
births, was achieved in 2011 and a new target, 38, set. The IMR target was also lowered, to 32
[Nepal Health Sector Programme-II (NHSP-II), 2010-2015], although just reaching the original
target of 36 will require increasing the rate of decline.

Target5a: Reduce maternal mortality by three-quarters between 1990 and 2015

Status and trends

After experiencing a drastic decline in MMR from 850 maternal deaths per 100,000 live births in
1990 to just 281 in 2006 (MoHP, New Era & ICF International, 2006), Nepal is well on track to
meet its targets for MDG 5. In fact, according to the maternal mortality and morbidity study
carried out in eight districts in 2009, the MMR was 229 per 100,000 live births, just slightly
above the 2015 target of 213; and, in 2012 it was estimated that Nepal’s MMR was 170 in 2010,
with a range between 100 and 290 (WHO, et al 2012). These low rates promoted the government
to lower its MMR target to 134 (NHSP-II 2010-2015). To reach the MDG goal, the MMR must
continue to decline, but only half as rapidly as it did after 1990, when it declined almost two-
thirds in 15 years. Even if the most conservative estimate of MMR−281 per 100,000 live
births in 2006 (MoHP, New Era & ICF International, 2006)−is taken into account, Nepal’s target
of 213 is readily achievable, requiring, as it does, just an additional 25 percent decline over a
decade.

The reasons for maternal death in Nepal are like those in many developing countries. Post-
partum hemorrhage is the main cause followed by pre-eclamsia/eclampsia, abortion
complications, obstructed labor, other direct causes and puerperal sepsis (FHD,2009).

TargeT5B:Achieve universal access to reproductive health by 2015

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Status and trends

Nepal considers family planning services as an integral part of maternal health, as they provide a
constellation of contraceptive methods and services that reduce fertility, enhance maternal and
neonatal health and child survival, reduce maternal deaths, and help balance population growth
and socio-economic development. The large reduction in the MMR between 1990 and 2006 has,
in part, been attributed to the increased use of family planning services. Under NHSP-II, the
government increased its investment in family planning and developed a strong policy
framework so that it could meet the MDG targets of 67 percent contraceptive prevalence and 2.5
total fertility by 2015.

TargeT6a: Have halted and begun to reverse the spread of HIV/AIDS by 2015

TargeT6B: Achieve universal access to treatment for HIV/AIDS for all those who need it by
2010

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