Nepal Strategic Plan 2011 1016

Nepal Malaria Strategic
Plan 2011-2016
(Revised Version- December 2011)

Government of Nepal Ministry of Health and Population
Department of Health Services, Epidemiology & Disease Control Division
Teku, Kathmandu, Nepal

i

Table of Contents
FOREWORD .......................................................................................................................................................... IV
EXECUTIVE SUMMARY .........................................................................................................................................VII
ABBREVIATIONS ................................................................................................................................................... IX
I.

INTRODUCTION ..................................................................................................................................... 11

II.

COUNTRY PROFILE .............................................................................................................................. 13

II.1 SOCIO-POLITICAL SYSTEM .................................................................................................................................13
II.2 HEALTH POLICY ................................................................................................................................................13
II.3 FEDERALISM AND THE HEALTH SECTOR ...........................................................................................................15
II.4 DEMOGRAPHIC INFORMATION:..........................................................................................................................15
II.5 ECOSYSTEM, ENVIRONMENT AND CLIMATE .......................................................................................................15
II.6 SOCIO-ECONOMIC SITUATION ............................................................................................................................17

III. HEALTH SYSTEM ANALYSIS ................................................................................................................. 18
III.1 DECENTRALIZATION AND MANAGEMENT OF HEALTH FACILITIES ...................................................................20
III.2 ORGANIZATIONAL STRUCTURE OF EPIDEMIOLOGY AND DISEASE CONTROL DIVISION ....................................21
III.3 MALARIA CONTROL PROGRAM STAFFING .......................................................................................................21
III.4. VECTOR BORNE DISEASE RESEARCH AND TRAINING CENTRE (VBDRTC) ....................................................22
III.5 PUBLIC-PRIVATE PARTNERSHIPS .....................................................................................................................22
III.6 HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) .................................................................................22
IV. MALARIA SITUATION ANALYSIS ......................................................................................................... 22
IV.1 EPIDEMIOLOGY ................................................................................................................................................22
IV.1.1 Malaria species .......................................................................................................................................23
IV.1.2Malaria vectors ........................................................................................................................................23
IV.1.3 Malaria Dynamics ...................................................................................................................................23
IV.1.3.1 Age and sex wise Distribution of Malaria Cases ..................................................................................25

IV.2 MALARIA STRATIFICATION AND MAPPING ......................................................................................................25
IV.3 THE MALARIA PROGRAM PERFORMANCE DURING LAST FIVE YEARS ...............................................................27
IV.3.1 Entomology and Vector Control ..............................................................................................................27
IV.3.2 Early Diagnosis and Prompt Treatment ..................................................................................................30
IV.3.3 Surveillance and Epidemic Preparedness ...............................................................................................33
IV.3.4 Behavior change communication (BCC) .................................................................................................33
IV.3.5 Program Management .............................................................................................................................34
IV.4 SWOT ANALYSIS ............................................................................................................................................38
IV.4.1 SWOT Analysis (Vector Control) ...............................................................................................................38
IV.4.2 SWOT Analysis (Diagnosis and Treatment) ............................................................................................39
IV.4.3 SWOT Analysis (Surveillance, Epidemic Preparedness and Response) ..................................................40
IV.4.4 SWOT Analysis (Behavior Change Communication) ..............................................................................41
IV.4.5 SWOT analysis (Program Management) .................................................................................................42
V. NEPAL MALARIA STRATEGIC PLAN 2011 – 2016 ................................................................................. 43
V.1 VISION ..............................................................................................................................................................43
V.2 MISSION ............................................................................................................................................................43
V.3 GOAL ................................................................................................................................................................43
V.4 OBJECTIVES ......................................................................................................................................................43
VI. STRATEGIC INTERVENTION ................................................................................................................. 43
VI.1 MICRO STRATIFICATION ..................................................................................................................................43

VI.2 ENTOMOLOGY AND VECTOR CONTROL ...........................................................................................................44

ii

VI.3 DIAGNOSIS AND TREATMENT ..........................................................................................................................47
VI.4 SURVEILLANCE, EPIDEMIC PREPAREDNESS AND RESPONSE ............................................................................48
VI.5. BEHAVIORAL CHANGE COMMUNICATION (BCC) ...........................................................................................50
VI.6 PROGRAM MANAGEMENT ................................................................................................................................50
VI.7 BUDGET ...........................................................................................................................................................54
VII. MONITORING AND EVALUATION ....................................................................................................... 55
VII. 1 PERFORMANCE FRAMEWORK .........................................................................................................................55
VII.2 TRACKING PROGRESS .....................................................................................................................................57
VII.3 MONITORING OUTCOME INDICATORS .............................................................................................................58
VIII. BUDGET FOR NMSP 2011-2016 ............................................................................................................. 61
ANNEXES ............................................................................................................................................................. 65
ANNEX-1: AN OUTLINE OF THE LONG-TERM NATIONAL MALARIA ELIMINATION STRATEGY (2011/12 – 2025/26) 65
ANNEX-2: MALARIOMETRIC INDICATOR, NEPAL 2004-2010 ...................................................................................70
ANNEX-3: RANGE OF API BY VDC, 2010 (13 DISTRICTS) .......................................................................................70
ANNEX- 4: RANGE OF API BY VDC, 2010 (18 DISTRICTS) ......................................................................................70
ANNEX- 5: INDOOR RESIDUAL SPRAYING COVERAGE OF HIGH RISK AREA 2004-2009 ..........................................71

ANNEX-6: LLIN COVERAGE OF HIGH RISK AREAS, 2006-2010 ..............................................................................71
ANNEX-7: MALARIA PROFILE OF DIFFERENT MALARIA RISK AREAS, 2010 ............................................................71
ANNEX -8: STRATIFICATION OF MALARIA RISK IN NEPAL .......................................................................................72
ANNEX-9: ...............................................................................................................................................................76
ANNEX-10: ENTOMOLOGY /VECTOR CONTROL CAPACITY ASSESSMENT AND DEVELOPMENT................................78
ANNEX- 11: PLAN FOR THE DEVELOPMENT OF VECTOR BORNE DISEASE RESEARCH AND TRAINING CENTRE ........82
ANNEX-12: PARTNERS AND STAKEHOLDERS MEETING ON ROLES AND RESPONSIBILITIES IN THE IMPLEMENTATION
OF THE NEPAL MALARIA STRATEGIC PLAN 2011-2016 ........................................................................................... 85

iii

Foreword
Nepal has arrived at a critical junction in its fight against malaria. The country has set and
exceeded targets set at the World Health Assembly and by the Millennium Development Goals
to cut malaria morbidity and mortality by 2010 and the country is in a unique position to move
towards eliminating the local indigenous transmission of malaria. The Ministry of Health and
Population, with the support of its partners, has implemented a strong malaria control program,
steadily improving the coverage and quality of indoor residual spraying, introducing long lasting
insecticide-treated nets, and increasing access to rapid malaria diagnosis and new effective
Artemisinin-based combination treatment.

The Ministry of health and population, through its National Malaria Control Program, has
ambitious vision of a malaria-free Nepal by 2026. Over the next 5 years, our priority will be to
consolidate the gains we have made and sustain the downward trend in malaria morbidity and
mortality and maintain outbreak free status.
Review of the National Malaria Control Program in 2010 by a joint internal and external panel of
technical reviewers concluded that the program has progressed from control to pre-elimination
stage. Malaria preventive, diagnostic and curative services are free of charge in all health
facilities. Malaria elimination is an achievable ambitious goal. Activities need to be reoriented
according to the current epidemiology of malaria in Nepal and to fulfill gaps between control and
pre-elimination program. Sensitive surveillance system and appropriate response is one of the
key components and has to be strengthened to achieve this goal. Progress towards target needs to
be incorporated into a strong monitoring and evaluation system synchronizing the potentials of
the public sector and technical partners. As malaria is a focal disease in Nepal, activities and
strategies need to focus on halting indigenous transmission of malaria. The management of our
interventions must extend to the community level and household level in all malaria endemic
foci. Community participation and community mobilization therefore has a key role to play in
ensuring that all Nepalese own and take part in this national goal. As elimination is not possible
without coordination and concerted effort with India, advocacy at regional level and migrant
related malaria will receive specific focus in the strategy.
Finally, I would like to acknowledge the continuous support provided to the National Malaria

Program by the Global Fund and WHO. I would also like to express my sincere thank to all stake
holders including PSI. At this critical moment of embarking on the next stage in the fight against
malaria, I look forward to renewed commitment from all partners and urge all stakeholders to
support our national goal of “Malaria-free Nepal by 2026”.

..……………………….
Date

____________________________
Dr Praveen Mishra
Secretary
Ministry of Health and Population
Government of Nepal
iv

Foreword
It is my pleasure to write a few words about the Nepal Malaria Strategic Plan 2011-2016 with a
vision of malaria free Nepal by 2026. Malaria is endemic in 65 districts of Nepal and continues
to be one of the national priority public health programs. Majority (73%) of the national
population lives in malaria risk area. Malaria disproportionately affects the poor and socially

marginalized residing in malaria clusters and mobile population. The disease mainly affects
adults in productive age group and is a major cause of poverty.
Malaria burden in Nepal has declined as there has been a reduction of about 40% confirmed
cases during the last five years. National Malaria Control Program assessment by international
and national experts was undertaken in 2010. The experts have concluded that transmission of
malaria in Nepal is low and that the program has moved forward from control to pre-elimination
stage. They have suggested that it is now time for Nepal to adopt pre-elimination strategy and
prepare for malaria elimination from Nepal.
As malaria is a focal disease in Nepal, activities and strategies need to focus on halting
indigenous transmission of malaria. The management of our interventions must extend to the
community level and household level in all malaria endemic foci. Community participation and
community mobilization therefore plays a key role in ensuring that all Nepalese own and take
part in this national goal. As elimination is not possible without coordination and concerted
effort with India, advocacy at regional level and migrant related malaria will receive specific
focus in the strategy.
National Malaria Control Program has set an ambitious vision of a malaria-free Nepal by 2026.
Nepal Malaria Strategic Plan 2011-2016 has projected to reduce the number of indigenous cases
by 90% of the current levels. Over the next 6 years, our priority will be to consolidate the gains
we have made and sustain the downward trend in malaria morbidity and mortality and maintain
outbreak free status of the country.

Finally, I would like to acknowledge the continuous support provided to the National Malaria
Program by the Global Fund to Fight AIDS, TB, and Malaria, the World Health Organization
and Population Services International. At this critical moment of embarking on the next stage of
combating malaria, I look forward to a broad partnership from all partners and urge all
stakeholders to support our national goal of “Malaria-free Nepal by 2026”.
…………………
Dr. Y. V. Pradhan
Director General
Department of Health Services
MOHP, Kathmandu

Date ………………..

v

Foreword
Malaria control in Nepal has been identified as priority-I public health program under the
National Health Sector Program Implementation Plan-II (NHSP-II) 2010- 2015. Malaria control
services are rendered free of cost and emphasize on the accessibility of services by high risk and
vulnerable groups and marginalized remote populations.

The country has exceeded targets set in Millennium Development Goals (MDG) as well as the
targets of Global Roll Back Malaria (RBM). A comprehensive independent External Evaluation
of the National Malaria Program was conducted in June 2010. The review report recommended
to consolidate and sustain the achievements of malaria control program and suggested that the
country should embark upon pre elimination with an ultimate goal of elimination of malaria.
During the Joint Assessment of National Disease Strategy (JANS), an external independent
JANS team also suggested several actions and recommendations to improve the national
strategic plan. Based on these recommendations the Malaria Program has developed an outline of
a long term malaria elimination strategy.
Based on long term strategy 2011-2026, Epidemiology and Disease Control Division under the
Department of Health Services has taken a lead in the development of five year Malaria Strategic
Plan-2011-2016. This document has been updated through a consultative workshop attended by
representatives from affected community, DHOs, civil society, RHDs, CHD, FHD, NPHL,
VBDRTC, NHEICC, professional societies, health/academic institutions, External Development
Partners, INGO and malaria experts. Summary recommendations of these consultative meings
are provided in annexes. The draft document was also checked for appropriateness at local level.
This document will provide the key strategic direction that will reorient the program to gear up
for elimination. The country is in the process of restructuring the administrative setup and
moving towards federalism, as a result, there will be a political stability in near future. It also
considers the context in which this reorientation will occur and proposes ways in which the

opportunities and constraints of the external factors can be managed to achieve the larger vision
of elimination.
Main focus of pre-elimination program will be elimination of transmission foci. In this program,
systems must be strengthened to identify and treat all confirmed malaria cases including the
asymptomatic cases and significantly reduce human-mosquito contact. These two shifts will be
facilitated by the implementation of active surveillance and targeted interventions as outlined in
this Strategic Plan.
Finally, I would like to thank and acknowledge the efforts of the past and present health work
force of malaria, the donors and partners for contributing to outstanding results in malaria and
urge all to sustain the current momentum of malaria program to achieve further success. As we
move forward to malaria elimination we will continue to advocate securing financing for the
program from the government and urging for renewed commitment from partners.
…………………………..
Dr. G.D. Thakur
Director
Epidemiology and Diseases Control Division
Department of Health Services
Ministry of Health and Population

…………………….

Date

vi

Executive Summary
Malaria control in Nepal has been identified as priority-I public health program under the Nepal
Health Sector Program Implementation Plan-II (NHSP-II) 2010- 2015. Second Long Term
Health Plan 1997-2017 has indicated disease management, vector control and epidemic
prevention and control and community participation as broad strategies and Three Years Interim
Plan guides implementation of malaria control. Malaria control services are rendered free of cost
and emphasize on the accessibility of services by high risk and vulnerable groups like pregnant
women, children and marginalized remote populations.
Malaria control program has already achieved MDGs goals, universal coverage of malaria
control interventions and RBM targets of 2010. Nepal Malaria Strategic Plan 2011-2016 has a
vision of malaria free Nepal by 2026 and is based on the Long Term National Strategy of
Malaria Elimination. The immediate task before the program is to consolidate the gains achieved
so far and reorient the program from control to elimination.
This strategic plan will steer intensified malaria control viz a viz pre- elimination phase. Micro
stratification of malaria endemic areas of the country will be carried out. The impact target of
this plan is to consolidate and sustain the achievement of API below 1 per 1000; 90% reduction
in the incidence of indigenous malaria cases by 2016. Similarly by 2016, at least 90% vector
control coverage in high risk areas, 90% parasitological diagnosis of all suspected cases; 100%
effective treatment of all confirmed malaria cases; introduction of notification and active
surveillance; ensure 90% of population at malaria risk adopt at least one malaria preventive
measures by BCC approach by 2016 are major outcome targets of this strategic plan.
WHOPES certified quality LLIN distribution, good quality IRS, social mobilization, good
quality malaria microscopy, quality bivalent RDTs, WHO prequalified antimalarials and
laboratory equipment are the basic tools for strategic intervention. Intensified surveillance
including notification, active case detection, and gradual elimination of active malaria foci and
management of imported cases are keys to pre-elimination.
Strong administrative and technical management are key essential factors for effective and
efficient delivery of services. Program management capacity will be boosted up through high
level advocacy to establish key positions in National Malaria Program. Besides that, holistic
package of carefully tailored technical and management training towards reorientation of the
staff will be developed and implemented to strengthen the delivery of services at all levels.
The program will foster partnership with WHO and other international and national
organizations. Inter-sectoral collaboration with other line Ministries of the Govt. of Nepal would
be further strengthened as they are crucial for program implementation.
The total estimated funds required for effective implementation of the Nepal Malaria Strategic
Plan 2011-2016 is US$68,675,668. Government of Nepal is contributing a cash of US$ 3.6
million and GFATM through its R7 and RCC has agreed to contribute US$ 42,042,951. In this
context, financial gap to implement the Nepal Malaria Strategic Plan 2011-2016 is US$
23,019,003. The program has no other alternative sources of funds other than depending on the
GFATM support. If, due to some unforeseen reasons, the anticipated funds envisaged in the
financial gap analysis are not allocated, the malaria program will face a setback in attaining the
vii

goal of elimination of malaria within the set time frame, and the program will be at risk of
maintaining the achievements gained so far. To combat this issue the program will make special
efforts not to let the disruption of essential services jeopardize the gains of the program; and gear
up the surveillance for prevention and control of outbreaks.

High level advocacy is also expected to secure government financing for malaria at a minimum
current level and increase proportionately in the future to achieve malaria free Nepal by 2026.
However, it is obvious that the funds required for the implementation of the program, which are
based on international principles and best practices is quite high and may not be met by current
resources of the National Malaria Program. Therefore, the support of all stake holders, national
and international partners (WB,GF,WHO,DFID,and others), is solicited for the implementation
of the program.
Monitoring of the performance of the program is geared up by using standard performance frame
work and specifically developed indicators. The program expects to contribute to the
strengthening of national health system.

viii

Abbreviations
ABER
ACT
ANC
APMEN
BCC
CCM
DCS
DDA
DHO
DoHS
DPHO
EDCD
EDPs
EHS
EWARS
FCHV
GMP
GoN
HFMC
HMD
HMIS
HP
IEC
INGO
IRS
ISO
IVM
LLIN
LMD
M&E
MoH
MoHP
MI
NGO
NHEICC
NHTC
NPHL
PHC
PMU
PSI
RBM
RDT
RHSD
SHP

Annual Blood Examination Rate
Artemisinin Combination Therapy
Ante-Natal Care
Asia Pacific Malaria Elimination Network
Behavior Change Communication
Country Coordination Mechanism
Disease Control Section
Department of Drug Administration
District Health Office
Department of Health Services
District Public Health Office
Epidemiology and Diseases Control Division
External Development Partners
Essential Health Care Services
Early Warning and Reporting System
Female Community Health Volunteer
Good Manufacturing Practice
Government of Nepal
Health Facility Management Committee
Health Management Division
Health Management Information System
Health Post
Information Education and Communication
International Non-Government Organization
Indoor Residual Spraying
International Standards Organization
Integrated Vector Management
Long Lasting Insecticidal Net
Logistics Management Division
Monitoring and Evaluation
Ministry of Health
Ministry of Health and Population
Malaria Inspector
Non-Government Organization
National Health Education, Information and Communication Centre
National Health Training Center
National Public Health Laboratory
Primary Health Center
Program management Unit
Population Services International
Roll Back Malaria
Rapid Diagnostic Test
Regional Health Services Directorate
Sub-health Post
ix

SWAp
TA
TB
TWG
VBDRTC
VCA/I
VCO
VDC
WHO
WHOPES
WP

Sector Wide Approach
Technical Assistance
Tuberculosis
Technical Working Group
Vector Borne Disease Research and Training Centre
Vector Control Assistant/Inspector
Vector Control Officer
Village Development Committee
World Health Organization
World Health Organization Pesticide Evaluation Scheme
Wettable powder

x

I.

INTRODUCTION

Nepal is a landlocked sovereign state in South Asia. It is located in the Himalayas and bordered
to the north by the People's Republic of China, and to the south, east, and west by the Republic
of India with an area of 147,181 square kilometers (56,827 sq mi) and a population of
approximately 27 million. Nepal is divided into three physiographic areas: Mountain, Hill and
Terai. These ecological belts run east-west and are vertically intersected by Nepal's major, north
to south flowing river systems.
Malaria is predominantly found in Terai belt bordering India. There are altogether 75 districts
and malaria is endemic in 65 districts and about 73% population of the country are at malaria
risk. In 2010 indigenous transmission was reported from 40 districts, and population with
indigenous transmission will be substantially reduced after micro-stratification which is starting
soon. Malaria mainly affects adults in productive age group and has direct impact on national
economy. Malaria is one of the first priority public health programs as explained in Nepal Health
Sector Program – Implementation Plan (NHSP-IP). Government of Nepal also has prioritized
malaria program in its Second Long-Term Health Plan (SLTHP) 1997-2017.
Due to successful malaria control program, malaria cases dramatically decreased over the years
and there were only 2,787 malaria cases in the country in 1971. Due to resurgence of malaria in
the South-east Asia Region during mid-seventies, the malaria eradication program was converted
to control in 1978. During the control period highest numbers of laboratory confirmed cases42,321 were recorded in 1985. Over the years, due to deployment of strategic interventions,
malaria cases have steadily declined with minor out breaks and during 2010, only 3,115 cases
were reported.
The country has exceeded targets set in Millennium Development Goals (MDG) as well as the
targets of Global Roll Back Malaria (RBM). A comprehensive independent External Evaluation
of the National Malaria Program was conducted in June 2010. The review report recommended
to consolidate and sustain the achievements of malaria control program and suggested the
country should embark upon pre elimination with an ultimate goal of malaria elimination.
A long term malaria elimination strategy with defined milestones and targets has been
developed. Based on long term strategy 2011-2026, Epidemiology and Disease Control Division
under the Department of Health Services (DoHS) has taken a lead in the development of five
years malaria strategic plan-2011-2016. This document has been updated through a consultative
workshop attended by representatives from affected community (VDC/local health post in
charge), District Health Office (DHO), District Public Health Office (DPHO), Female
Community Health Volunteers (FCHV), civil society, Regional Health Directorate, Child Health
Division, Family Health Division, National Public Health Laboratory, Vector Borne Disease
Research and Training Center (VBDRTC), Vector Control Inspectors, professional societies,
health institutions, External Development Partners, GF, WB, DFID,WHO, INGO and malaria
experts. The draft document was also checked for appropriateness at local level (Annex 1)

11

This document will provide the key strategic direction that will reorient program to gear up for
elimination. The Strategic Plan (together with the Monitoring and Evaluation Plan) will also
serve to assist with benchmarking, monitoring, and periodic evaluation of performance, based on
the goals, objectives, and target areas outlined in this strategy. The country is in the process of
restructuring the administrative set up and moving towards federalism, as a result, there will be a
political stability in near future. It also considers the context in which this reorientation will
occur and proposes ways in which the opportunities and constraints of the external factors can be
managed to achieve the larger vision of elimination.
Main focus of pre-elimination program will be elimination of transmission foci. In this program,
systems must be strengthened to identify and treat all confirmed malaria cases including the
asymptomatic cases and significantly reduce human-mosquito contact. These two shifts will be
facilitated by the implementation of active surveillance and targeted interventions as outlined in
this Strategic Plan.
This Strategic Plan will answer the following key questions.
1. What is the current malaria situation in Nepal and how has it evolved over the duration of
the expiring Roll Back Malaria Strategic Plan 2007 – 2011. What was the performance
of the expiring Strategic Plan and what are the best practices and lessons learned?
2. What are the strengths, weaknesses, opportunities, and threats of the current approach
towards malaria control, and what are the implications for elimination?
3. What factors, external to the NMCP, will affect reorientation to elimination? (Health
systems – public and private delivery of health care)
4. Which evidence-based interventions will be used to achieve the strategic shift, and how
will they be adapted for different transmission risk areas?
5. What are the goals, objectives, and targets of Nepal with regards to pre-elimination by
2016?
6. What are the national policies that are in place (or need to be revised) to support this
strategic shift?
7. How will this strategy be managed by the MoHP and its malaria program partners? How
will partnerships be coordinated?
8. How will performance be monitored?

12

II.

COUNTRY PROFILE

II.1 Socio-political system
Nepal is a landlocked country having area 147,181 square kilometers. It has border with India to
the south, east and west and China to the north, at the southern flank of the Himalayas. The
country’s geographic zones vary greatly and represent one of the challenges for development of
the nation. The majority of the country remains under-developed and over 80% of the
population lives in rural areas. Nepal is ecologically divided into three distinct ecological zones:
the Mountains to the north, the Hills, and the Terai to the south. The country is divided into 5
development regions (Eastern, Central, Western, Mid-western and Far-westerner), 14 Zones and
75 Districts. Districts are further divided into VDCs and Municipalities. There are altogether
3,912 VDCs and 58 municipalities including one metropolitan and three sub metropolitan cities.
Each VDC is divided in 9 wards which sum up to 36,000 wards countrywide. Figure1 shows the
main topographical features of the country.
Figure1. Transect of Nepal (Schematic) showing main topographical features

II.2 Health Policy
The Government of Nepal’s National Health Policy of 1991 has sought “to upgrade the health
standards of the majority of rural population by strengthening the primary health care system and
making effective health care services readily available at the local level.” Access to essential
health care services (EHCS) was increased by establishing health posts in villages and an
extensive work force of female community health volunteers. The Geography of Nepal poses
serious challenges in delivering health services to all. In the Mountain Region, 40% people have

13

to travel 1-4 hours to reach the nearest health or sub-health post. In the Hill Region, 30% people
have to travel 1-4 hours to reach the nearest health post or sub-health post.
A large number of health institutions have been established by the private sectors to train health
care professionals and the numbers of private hospitals are growing quickly thereby greatly
expanding secondary and tertiary care in urban areas. Nepal’s pharmaceutical industries also
grew in the last twenty years and now produces one-third of the national requirement for
medicines.
In 2004, the Government of Nepal (GoN) introduced a “Health Sector Strategy: An Agenda for
Reform” and the first “Nepal Health Sector Program 2004-2009”. Recognizing that external
development partners finance over 40% of public-sector health expenditure, Government
adopted a Sector Wide Approach (SWAp) for NHSP, to improve assistance effectiveness by
coordinating the efforts of Government and External Development Partners (EDPs) in support of
a single Government-owned and led program that aimed to put the country on track to achieve
Millennium Development Goals for health by 2015.
With the popular people’s movement of April 2006 came a period of transition that led to an
Interim Constitution, electing a constituent assembly, and formation of a federal democratic
republic of Nepal. The Interim Constitution established the right of all Nepali citizens to free
basic health services, the right to a clean environment, access to education and a means of
livelihood, in a social environment free of discrimination and institutionalized inequality.
During the past two decades, amidst profound political change and instability, and with a largely
poor, rural population living among formidable natural barriers to public services, Nepal has
taken initiatives that have achieved significantly improving equity of access to health services,
beginning to reduce the extreme disparities between the poor and rich, to improve the access of
the marginalized castes and ethnic groups. The improvement in the health status of the poor and
marginalized people is notable because it has taken place in a context in which the incidence of
poverty decreased markedly between1996-2004 from 41% to 31 %, but the overall disparity
between rich and poor has increased. The wealthiest consume eight times more than the poorest,
and 3 of 10 Nepali citizens remain below the poverty line.
Today, essential health care services at Health Posts, Sub-health posts and Primary Health
Centers are free of charge to all. At district hospitals, outpatient, in patient and emergency
services are free of charge to poor, vulnerable, and marginalized groups, including medicines,
and 40 essential medicines are free of charge to all. Institutional deliveries are free of charge to
all pregnant women nationwide.
The current health policy has become success in increasing utilization of health facilities by the
poor and disadvantaged groups. More women appear to be using inpatient care for deliveries as a
result of the safe delivery incentive program, and the increase is greater among the poor, albeit
starting from a very low base. Institutional deliveries—normal, complicated or caesarean
section—also became free of charge in all government facilities in the year 2009.

14

II.3 Federalism and the Health Sector
In the present context, Nepal’s constituent assembly established by the interim constitution
(2006) based on the principle of federalism, is working to have a full fledged constitution with
clear structures of federalism and its operational modality.
Whatever form of federal system Nepal will adopt in its new constitution, the need for preparing
the country's institutions for the transition to federalism has already arisen. Notably, the federal
structure will affect every area of the health system, from planning to service delivery and
overall health governance. However, basic elements of structure and function may remain same
and only the governance may change, which is yet to be defined by the Constituent Assembly.
Therefore, at this time the future functions of different levels of government are yet to be
decided, but malaria pre-elimination with the aim of elimination by 2026 shall be in accordance
with the National Malaria Strategic Plan.
II.4 Demographic Information:
The demographic information at a glance, in the table below, clearly shows the current status in
term of population growth, mortality and median ages.
Table 1: Nepal Demographic Information 2008

Total Population

Median Age
Population Growth rate
Probability of Not Surviving past age 40
Adult Literacy Rate (15 yrs and older)
Net Primary Enrollment Rate (2006)*
Net Secondary Enrollment Rate (2006)*
Fertility Rate
Birth rate
Maternal mortality rate
Infant mortality rate
Under-five mortality Rate
Population Growth

Total Population: 28,563,377
Ages 0-14: 37%
Ages 15-64: 58%
Ages 65 and above: 4%
Population density: 190/sq kilometer
22 years
1.4%
17.4%
51.4%
86%
47
3 children born/woman
23 births per 1000 person
320 per 1000 live births
48 per 1000 live births
68 per 1000 live births
1.4%

Sources: Human development Report 2007/2008, Country Fact Sheets
* Nepal Demographic and Health Survey, 2006

II.5 Ecosystem, environment and climate
The country’s geographic zones vary greatly and represent one of the challenges to development
across the nation. The majority of the country remains under-developed and over 80% of the
population lives in rural areas. Repetition

15

The Hill region, situated south of the Mountain Region, this zone ranges in altitude from
between 700 and 4,000 meters. This region begins at the Mahabharata Range. These steep
southern slopes are nearly uninhabited, thus an effective buffer between languages and culture in
the Terai and Hill regions. Northern slopes are gentler and moderately well populated. The
increasingly urbanized Kathmandu and Pokhara valleys fall within this region. Beyond
microclimates suited to rice cultivation and proximity to water for irrigation, these cultivate
maize, millet, barley and potatoes as staple crops. Temperate and subtropical fruits are grown as
cash crops. Outside the rice-growing lower valleys, hill populations suffer chronic food deficits.
Hills comprise of 41.7% of Nepal’s land surface and contain 44.3% of the population. Although
there is malaria transmission in the valleys, but these valleys are included in the high risk areas.
Transportation and communication facilities are much more developed here than in the mountain
region.
Terai region in the southern part of the country can be regarded as an extension of the relatively
flat gigantic plains, and comprises only 23.1% of the total land area but contains over 48.4% of
the population. Terai is vital to the nation as it contains the most fertile agriculture land and
forests. Because of its flat terrain, transportation and communication facilities are more
developed than in the other two regions of the country. Eco-system of this belt is very favorable
for breeding of mosquitoes the proven vectors of malaria, Japanese encephalitis, dengue and
Lymphatic filariasis. Malaria cases are found in Terai all over including the towns. So far there
was no intervention in the towns, but all towns in Terai have been included for intervention
under the malaria elimination strategy.
In Terai, the minimum and maximum temperature in winter fluctuates between 19°C and 38°C
respectively. In Hills, mean temperature declines during winter as low as 15°C, and it is still
much lower at higher altitudes of the mountain areas. Rainy season starts with the onset of south
west monsoon, with heavy precipitation from July to mid September. Rainfall during the other
season is generally scanty. Relative humidity varies between 80% and 90% during the monsoon
but declines in other months. Malaria cases are reported throughout the year. However, malaria
transmission increases after monsoon due to innumerable streams where the An. fluviatilis breed
profusely. The anopheline density begins to increase after May and peak density is observed in
June and July and by August vector density declines (Figure 2). Malaria cases however start to
increase from March and majority of malarial cases are reported between April through October
and peak in July (Figure 3).With the increase in anopheline density, increase in the reporting of
malaria cases is observed in Nepal. In Gumgadhi (6,500ft MSL) of Mugu district, Mid-western
Region, such kind of transmission was proved in 1969 incriminating An. maculatus willmori in
July, August and September.

16

Figure 3. Monthly distribution of malaria cases in different stratum

II.6 Socio-economic situation
Nepal is among the poorest and least developed countries in the world with almost one-third of
its population living below the poverty line and with an unemployment rate of 46%. It is ranked
144 out of 177 nations on the United Nation’s Human Development Index (HDI) and falls well
short of recent HDI gains made by the South Asia region as a whole. The gross domestic product
(GDP) per capita (PPP) was $1,100 in 2008. The total literacy rate for male is 81.0% and for
female is 54.5% (Human Development Report 2009).The life expectancy at birth is 70.18 and
66.19 years for female and male respectively (HDR 2009).
It has been observed from the past that migration of the people from non- malarious region to
malarious region for the development projects , migration to India for economic purposes and
migration of people to endemic region for rice paddy cultivation facilitates malaria transmission.
The urban housing scenario is not encouraging in Nepal. More number of people are living in
rented houses, the overcrowding indices is high; the infrastructure is not meeting the need of the
people whether it be water supply or sanitation. The number of squatted is increasing and the
slum areas are also following the same trend.
About 80% of the Nepal population live in rural areas and depends on subsistence farming for
their livelihood. Household food security and poor nutrition are still major concerns in rural
areas. Most household have little or no access to basic social services such as clean drinking
water and sanitation. Rural poor people generally have large families with small houses and
majority of the houses in the rural areas are walled with mud bonded bricks and stones, and the
houses are roofed over with straw or thatch.

17

Malaria is being reported from 65 districts in Nepal and continues to be one of the priority public
health problems. Majority (73%) of the population live in malaria risk area. Malaria
disproportionately affects the poor and socially marginalized people. Malaria and poverty are
intimately connected and malaria affects mainly the ethnic minorities, poor, mobile population
groups, young adults and those living in border areas. Malaria is both a cause and a consequence
of poverty slowing economic growth in endemic areas.

III. HEALTH SYSTEM ANALYSIS
Govt. of Nepal has 22 ministries. Ministry of Health & Population is mandated with the
development of policies, plan; monitoring & supervision of the activities implemented through
different tiers of the health system including Department of Health Services, Regional Health
Directorate, District Public Health Offices and regulating the activities related to health sector.
The Department of Health Services is responsible for the implementation of preventive and
curative health services throughout the country planned and budgeted by the MoHP and is one of
the three departments under the Ministry of Health. All preventative health programmes are
carried out by the DPHO/DOHs, headed by a Public Health Officer/Medical Officer. The other
staffs in DPHO/DHO include vector-control assistant, malaria inspector, laboratory technician
and laboratory assistant. DoHS, it’s Divisions, RHDs, DPHOs, Hospitals and peripheral health
facilities spread throughout the country
Under the Department of Health Services (DHS) there are 5 Regional Health Directorates, each
located at the headquarters of each of the five development regions of Nepal. In 62 of the 75
districts, there is a District Health Office (DHO) with a District Hospital and a District Public
Health Office (DPHO) under its umbrella.

18

Figure 4. Organizational Structure of Department of Health Services

At the district level, each Ministry has offices that manage the planning and implementation for
their respective sector. The DHO co-ordinates health development activities in the district
through the District Development Committee (DDC) and is responsible for all health-related
activities in the district including the organization and management of district hospitals, Primary
Health Care Center (PHCC), Health Posts (HP) and Sub-Health Posts (SHPs).
There is one Primary Health Care Center (PHCC) at each of the 205 electoral constituencies and
approximately 100,000 population, one health post (HP) for 3-5 Village Development
Committees (VDCs) and one sub-health post (SHP) for each VDC. The SHPs are the first
facility-based contact point for basic health services and serve as the referral centre for volunteer
health workers, such as Female Community Health Volunteers (FCHVs). A total of 15,115
Traditional Birth Attendants (TBAs), 48,850 FCHVs, several thousand mothers' group (MGs)
Village Health Workers (VHWs) and Maternal and Child Health Workers (MCHWs) are
working in SHPs. There is one FCHV in each ward for VDC. The SHPs serves as venue for
19

community-based health activities and as a referral point for patients to HPs and PHCs, and
district, zonal and regional hospitals, and finally to the specialty tertiary care centres in
Kathmandu. The referral system was designed to ensure that the majority of population has
access to public health care facilities and affordable treatment. Public health facilities face
constant resource constraints, poor facilities management, planning, and poorly trained staff.
There is one health committee in each VDC. Recently the VDC health committee is made
responsible to run the sub-health post within the VDC. The number and types of health facilities
with regards to the service delivery level and the three ecological zones are demonstrated in
Tables 2 and 3.
Table 2: Types of service delivery level and number of public sector health facilities in Nepal
Service Delivery Level
Type of Facility
Number
Specialized
Hospital
3
Capital
Hospital
5
Region (5)
Hospital
2
Sub Region
Hospital
1
District (75)
PHOs/DHOs/ Hospitals
14/61/67
Electoral Constituency (205) PHCs/HPs
193/701
Village
Development SHPs
3,129
Committee
Ward (Community)
Female Community Health Volunteers
48,550
(FCHV)
TBAs
>12,000
Outreach Clinics
15,248
Immunization Centres
15,532
Source: DHS Annual Report 2001-2002

Table 3: Topographic distribution of the health care facilities in Nepal
Type of institution
Hospital
PHCC/HC
Health Post
Sub-Health Post

Total
85
193
701
3,129

Mountain
16
20
152
387

Hill
45
94
379
1,606

Terai
24
79
170
1,136

Source: DHS Annual Report 2001-2002

III.1 Decentralization and Management of Health Facilities
The District Health Office/ District Public Health Office manage the public health program in the
district through a network of Primary Health Care center, Health Post and Sub health post. It is
important to highlight that in every Village Development Committee of Nepal, there is at least
one health facility serving the catchments area. The Community level health facilities are
managed by the Health Facility Management Committee chaired by the VDC president.
According to the category of the health facility, the number of health staff is different.
Every day, each health facility delivers health facility based services beside that they also
provide 3-5 outreach services (Once a month). Outreach sites will differ according to the
20

epidemiological situation and intervention type. For example, in the malarious areas the services
concentrate to identifying malaria cases early and treating them. At the community level the
district public health network is supplemented by the network of Female Community Health
Volunteers (At least 9 /VDC) and mothers group. The local health facility in partnership with
community participation implements all the public health programs in the community.

III.2 Organizational Structure of Epidemiology and Disease Control Division
At the Central level, Epidemiology and Disease Control Division (EDCD) under the Department
of Health Services is responsible for developing strategies, guidelines, plan and monitoring of
the implementation of the vector borne diseases: Malaria, Kala-azar, Dengue, Chickunguniya,
Filariasis and Japanese encephalit