Highlights of Health Promotion in Nepal Dr BR

Highlights of Health Promotion in Nepal: Dr BR Marasini Ministry of Health and Population Kathmandu, Nepal 30 March 2013

Concept of Health Promotion It is any planned combination of health, educational, economic, political, spiritual and organizational initiative for actions to bring about positive, behavioral, social or environmental change conducive to improving the health of individuals, groups, or communities. Process of enabling people to increase control over and improve their health (WHO 1948) 2

Concept of Health Promotion Process of enhancing health and reducing risk of ill health through the overlapping spheres health education, health protection and disease prevention Health promotion is directed towards action on the determinants or causes of health Health promotion at first identifies the target population or the population at risk and then initiate the more appropriate action through several means.

Concept of Health Promotion Government at both local and national levels has a unique responsibility to act appropriately and in a timely way to ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health.

History of Health Promotion 1948: WHO established Health is a complete state of…. . Governments have a responsibility ……. adequate health and social measures. 1978: Alma-Ata Conference 1981: Global Strategy for Health for All by 2000 International Conferences on health promotion

Why we need Health Promotion? Promotes quality of life Reduce inequalities in health Reduces pressure on services “Adds life to year, Adds year to life”. “Health promotion is concerned with making healthier choices, easier choices”. It is cost effective and efficient 6

Health Promotion in Nepal 7

ANCIENT ERA Ayurveda: -Developed around 5000 BC, Ayurveda is believed to be the oldest formal health care system in Nepal and hence health promotion measures. Ayurveda focuses on building a healthy metabolic system and proper excretion of toxic elements, on top of regular exercise, yoga and meditation which ultimately enable people to increase control over and improve their health. The asset of ayurveda; yoga and meditation contribute to the development of a healthy body, a healthy mind, healthy thought leading to healthy living. 8

The Himalayan herbs and medicinal plants are used in different forms as health promoting agents such as toiletries, natural manures, pesticides, environmental cleaning and protection. Lichchhavi Kings also issued rules and directives to be followed by the general population on the safe motherhood practices. These directives were identifying husband responsible for care of the pregnant and post natal wife and warning punishment in case of negligent behavior or death (Narendra Dev). Cutting umbilical cord immediately after the baby is born and not to wait till the placenta is expelled (Amshu Verma). Traditional birth attendants denying to attend woman in labour should be punished-King Jayasthiti Malla, Kantipur 9

MEDIEVAL ERA In 1661 AD Jesuit Father Grueber and Dorville and associates entered Nepal via Lhasa from Christian Mission office in Peking, China and established missionary office in Kathmandu. Plague elimination: - The first noted health promotion activities during this period was elimination of plague by Christian missionaries in Kathmandu 10

MEDIEVAL ERA Pratap Malla the king of Kantipur (now Kathmandu) allowed the missionaries to stay in Kantipur for which one of the reason might be periodical epidemic of plague and cholera in Kathmandu, which were serious health problems, and the king might have heard about the prevention and treatment from the missionaries. The missionaries then started health promoting activities and their intervention played a great contribution in elimination of plague. 11

MODERN ERA: Rana Regime (1846 -1950 AD) Initiated environmental cleanliness campaign in 12 Kathmandu valley. Safe drinking water supply in Kathmandu Introduced School Health Programme (1 st health programme) in 1946 AD but was closed later. Dr. H. A. Oldfield appointed as the resident doctor in 1850 to 1863 AD introduced vaccination in 1850 AD in for first time , with vaccination of the children of the family of the Prime Minister Jung Bahadur Rana. Tuberculosis and Leprosy Sanatoriums started

Post -Democracy (1951 onwards) First Five Year Plan (1956 -1961): Emphasized on sanitation and hygiene. Foundation of preventive and promotive health care in Nepal started with opening of Insect Borne Disease Research and Control Project at Rapti Doon Valley by USAID in 1954. Family Planning Association of Nepal launched Family Planning services in 1956 Institutionalization of promotive health care by establishing the Health Education and Sanitation Section in 1961 under Department of Health Services. 13

Section The significance at the beginning of the program was as followso Target audience: general people and sick persons o Education methods: Mini-lecture, motivational question/answer or discussion, interpersonal sessions followed by instructional education o Media: Mass media i. e. radio, print materials, Cinema o Messages: mostly instructional, descriptive o Sanitation activities 14

Post-Democracy (1951 onwards) Second Three Year Plan (1962 -1965) 45, 000 people were inoculated against small-pox in Kathmandu. Initiation of vertical projects: malaria eradication, TB/Leprosy control project, FP/MCH projects. Third Five Year Plan (1965 -1970): More focus on prevention. Strengthening of vertical projects i. e. Leprosy Eradication Project 1965, Small Pox Eradication Project 1967, FP/MCH project 1968. 15

Health education and promotion program might have been priority component of those vertical program, but they had their own health education unit being operated from the center to the periphery within the project area only. It was learnt that, because of weak coordination and lack of needful provision, the process of health education program development, its expansion and overall responsibility management and sharing as well by relevant governmental /INGO/NGO and private remain deficient. 16

First Long Term Health Plan (1975 -1990): The first perspective health plan Fourth Five Year Plan (1970 -1975): Introduced Community Health and Integrated Division Fifth Plan Period: Nepal signed the Alma-Ata Declaration and adopted PHC for achieving HFA by 2000. Initiated integration of vertical health program into basic health services. Sixth Plan Period: Its real objective was Nepalese should not live by health interventions only. It stressed on increasing food supply and provision of safe drinking water. 17

Idea of COMBINA (Child spacing, Oral rehydration, Maternal Health, Breast Feeding, Immunization, Nutrition) was mooted. Seventh Plan period(1985 -1990): Emphasized on Basic Minimum Health Needs. During the Long Term Health Plan the Health education program was given due priority for health promotion and provided to people at doorstep covering all components of primary health care. Health education program was launched with specific strategic way, which was further named as health education, information and communication program. 18

National Health Policy 1991 One of the areas addressed by National Health Policy adopted in 1991 is the promotive health services. Promotive Health Services: The programme that enable people to live healthy lives will be given priority. The services includes such practices which are aimed not only at destroying the factors that may lead to specific disease but also at raising the health condition of the people to its maximum level. It includes health education, balanced diet, healthy living , regular health checkup, FP/MCH etc. 19

The components of health included in this services are: Health education and involvement of community from central to rural level Nutrition programme: Promotion of breast feeding, growth monitoring, prevention of iodine deficiency disorder, iron and vitamin A deficiency. Environmental sanitation programmes: Inform people about personal hygiene, inspect and examine hotel food, drinking water, manage solid waste, etc For this the National Health Policy 1991, has given ultimate mandate to HEIC authority, to plan, manage and implement health education and promotion program to encourage people to utilize best the health services so that their health standard would be upgraded by themselves and ultimately achieved productive, happiest and long life. 20

National Health Education Information and Communication Centre (NHEICC), 1993 NHEICC was established in 1993. The centre has been working as an institution for planning, implementation, monitoring and evaluation of advocacy, community mobilization and behavior change communication programs of all health services and programs at different levels in an coordinated approach and through one door system. Health education adopters are expected to inform, encourage, persuade and motivate to have positive behavior changes in the specific audiences and to adopt healthy behavior. 21

Second Long Term Health Plan 1997 -2017 Second Long Term Health Plan, 1997 -2017 has mentioned that National Health Education, Information and Communication Centre (NHEICC) is a focal point for Ministry of Health Population for planning, implementation, monitoring and evaluation of health promotional activities. The plan clearly states that NHEICC is responsible for the development, production, dissemination, publication and distribution of correct health messages through appropriate communication media in collaboration with other departments, divisions and centres. 22

Essential Health Care Services 2000 Areas addressed by EHCS with regard to health promotion are: Reproductive Health Services EPI including Hepatitis B Vaccine Condom Promotion and Distribution Leprosy Control TB Control Integrated Management of Childhood Illness Nutritional Supplementation, Enrichment, Nutrition Education 23

Essential Health Care Services 2000 Prevention and Control of Blindness Environmental Sanitation School Health Service Vector Borne Disease Control Oral Health Services Prevention of Deafness Substance abuse including Tobacco and Alcohol Control Occupational Health Emergency Preparedness and Management 24

Collapse of vertical projects and initiation of basic health services 8 th Plan period (1992 -1997) First time launched polio elimination campaign targeting to reach 3. 3 million children of 0 -5 years in 1996/1997 by organizing national immunization day to support polio eradication by 2000. Sin tax on tobacco and alcohol (now health tax) and ban on alcohol and tobacco advertisement through electronic media in 1996 Initiated improved cook stoves in rural areas 25

NHSP Nepal Health Sector Program: Implementation Plan (NHSP: IP) 2004 -2009 had recognized and accepted health communication as a cross cutting issue for all health programs. It has stated that behavioral change communication program to support Essential Health Care Service (EHCS) Package. The plan has also stressed on the importance of behavioral change communication to address non-communicable disease risk factors emphasizing on the reduction of tobacco and harmful use of alcohol. . 26

It has mentioned about integrating information, education and communication in all EHCS package and to use all possible mass communication media for health promotion. Nepal Health Sector Program II (NHSP II), 2010 -2015 has prioritized and included public health promotion programs under health education and communication heading. The program plan has emphasized on planning, implementation, monitoring and evaluation of advocacy, social mobilization and behavior change communication programs in an integrated manner to promote and increase utilization of all essential health services and programs, and control communicable and non-communicable diseases. 27

NHSP 2 The plan has focused on promoting healthy behavior by using all possible multi mass media and channels for health promotion and communication. 28

Health Promotion Current activities NHEICC act as a centre for the Ministry of Health and Population and have an integrated approach and one door system for advocacy, community mobilization, behavior change communication and health service and program promotion activities. The mission of Health Promotion or HEIC program is "Today's preparation determines tomorrow's achievements" in the shape of achieved healthier life style by Nepalese people. It has developed National Health Communication Policy 2012. 29

There are some objectively used key terms in health promotion in the following which mean that Information : Inform target groups about the cause of disease, its transmission and how to prevent the disease. Education : Educate target groups about techniques of disease prevention and mode of transmission. Communication : A process that informs, motivates and helps people to adopt and maintain healthy practices by using techniques to spread the knowledge on the disease prevention and health promotion 30

Health Education : Any combination of planned activities leading to a situation where people want to be healthy; know how to attain health; do what they can individually and collectively and seek help when needed. Health promotion: Social, educational and political actions that enhance public awareness of health, fosters healthy lifestyles and community action in support of health, and empowers people to exercise their rights and responsibilities in shaping environments, systems and policies that are conducive to health and wellbeing. 31

Activities of NHEICC Promotive health messages are broadcasted directly through radio programs , national television channels and published through paper media. Various public awareness programs are being conducted through district health and public health offices to disseminate health messages or information up to the rural level. Local media and languages are used in the district so that local people can understand health message clearly. 32

Established health education corner at health service delivery facilities, equiped with audio visual equipment and BCC materials. Health Education Technicians at District Health/ Public Health Offices assist in the implementation of these activities. Audio visual programs and IEC materials are produced and aired also for tobacco control and NCDs. Implement activities to create a supportive environment for health promotion and health education. 33

BCC program on different health issues. Conducts refresher program at various level for health 34 education and promotion Conducts capacity building activities to develop knowledge, attitude and skills individually and in groups for health education and promotion. Celebrate health event, days. Conduct different health promotional programs in hospitals, schools, communities, working places, industries and occupational settings. Plan, implement, monitor and evaluate policy, strategy, program and activities for prevention and control of using tobacco, alcohol and other addictives.

Health education and promotion Realizing the importance of health communication activities, different strategies which are related to reproductive health, child health, tuberculosis control, HIV/AIDS/STI Control, vector borne disease control, leprosy control and all other health service and programs have stated about the development, production and dissemination of health messages or information and materials and activities for health promotion. 35

Health education and promotion Some of these activities are: Celebration of Breast feeding, School Health and 36 Nutrition week School level adolescent focused peer group programme Ama Communication Programme National Immunization Day. School Immunization Programme against tetanus.

Health education and promotion Health education and BCC on essential new born care 37 practice. Infant Young and Child Feeding Practice promotional message. Health education message to promote community awareness about HIV and AIDS , Leprosy, Malaria etc. Family planning counselling. Promotion and Condom distribution. Mobilization of local bodies like consumer groups, mother groups, local clubs in health promotion activities.

Achievements Increase percentage of women and men (86 %of women and 97% men) of age 15 -49 who have heard about AIDS. Knowledge of at least one contraceptive method is nearly universal (99. 9%)to both male and female. 74% female and 85% male are exposed to family planning message in any specified media source. Knowledge of ORS is universal among women giving birth in the five year preceding Source: NDHS, 2011 38

Role of non-health sector in health promotion There are many factors outside the health system that influence people’s health. The Health sector alone cannot achieve a healthy society. This requires a close co-operation between sectors beyond health care reflecting the diversity of conditions which influence health. 39

Key Areas for inter-sectoral coordination for health promotion 40 Area Importance Non-health sector involvement Water and Sanitation Hygiene Address Main cause of child death are WASH related disease including skin disease, ARI and Diarrhoea Department of Water Supply and Sanitation Food and Nutrition To promote physical and cognitive development and to reduce malnutrition Ministry of Agriculture on food security and promotion of nutritious local foods, Ministry of Industry on food fortification Rural Infrastructure and Housing Reduce journey time and cost for accessing services Physical Planning ministry , local government Education and Information Source: NHSP-II, 2010 -15 Knowledge, Attitude and Ministry of education and Behaviour of people are key communication

41 Area Importance Non-health sector involvement Waste management Key to healthy environment and prevent health hazards Ministry of Local Development, local government Alternative fuels and cooking stove designs Reduce ARI, prevent indoor air pollution Ministry of Science and Technology Regulation and legislation on accidents, occupational hazards, smoking and alcohol Promotion of safety Department of Roads, measures such as use of traffic police, Ministry seat belts and helmets, of industry. occupational health, discourage alcohol and smoking consumption by a combination of regulation and tax measures Source: NHSP-II, 2010 -15

Contribution of Non-State Actors in Health Promotion Condom promotion Anti-tobacco campaign Drug abuse Anti-alcohol campaign Oral health Campaign against arsenic contaminated water in Terai Blindness prevention Help to install improved cook stoves in rural areas Sanitation Media-in many aspects of health promotions 42

Contribution of Public Sector Agencies in Health Promotion Green Energy Promotion-Install improved cook stoves in rural households, reforestation, micro-hydel, biogas, solar energy- Alternative Energy Promotion Center Anti-tobacco campaign- Ministry of Home and Nepal police Anti- alcohol campaign- Inland Revenue Department, Nepal Police Nutrition Promotion- Ministry of Agriculture, Ministry of Local Development 43

Contribution of Public Sector Agencies in Health Promotion Safe drinking water and sanitation- Department of Water Supply and Sanitation Solid waste management- Ministry of Local Development Meat hygiene- Department of Live Stocks Food hygiene- Department of Food Technology and Quality Control Outdoor air pollution-Ministry of Environment Education- Department of Education 44

Challenges in Health Promotion Coordination and collaboration with state and non- state organizations Control of risk factors through non-communicable diseases Increase investment in health promotion Language barrier –too many ethnic groups and languages 45

WAY FORWARD Though health promotion is recognized as priority program in health policies and plan more efforts is needed to apply it in practice. For this: Evidence based health promotion policy formulation and implementation. Community initiated approach addressing sociocultural, geographical, climatic, language diversity is needed to achieve sustainability of health promotion activities. Development of gender, and cultural sensitive and language appropriate 46

Coordinated and integrated approach both between inter and intra-sectoral organizations Strengthening public private partnership policy through joint action. Allocation of more health budget to health promotion activities (less than 1% of total health budget is allocated to NHEICC for FY 2069/70) Allocation of budget from earmarked health tax to promotional activities rather than to curative care such as in advertisement of NCDs. Designing effective strategies to implement health promotion in school, workplace and community so as to promote health behaviour and healthy lifestyle. 47

Reference Ministry of Health and Population Nepal Health Sector Programme-II 2010 -15. Kathmandu, Nepal: Ministry of Health and Population; 2010 National Health Education Information and Communication Centre, Ministry of Health and Population, Nepal. National Health Communication Policy 2012, Kathmandu, Nepal: National Health Education Information and Communication Centre; 2012 National Health Education Information and Communication Centre, Ministry of Health and Population, Nepal. Health Education Information and Communication Program in Nepal 2060. Kathmandu, Nepal: National Health Education Information and Communication Centre; 2060 B. S. 48

Thank you for your kind patience 49