Health For All
Agenda For Action

By Jhabindra Bhandari

EVERY year, we mark World Health Day on 7th April. This year, the important day particularly addresses the importance of health as a fundamental human right and raise key health problems experienced globally. World Health Day more importantly, urges all sectors of development to respond these issues more creatively and innovatively so that rights of people to healthy life are ensured. In most of the developing countries, the scenario of public health poses many challenges such as poverty and illiteracy. High maternal and infant mortality and morbidity including other infectious diseases like HIV/AIDS have been emerging as more critical in the recent years.

Elusive

Like many other developing countries of the world, Nepal is also striving to achieve health for all. Though poverty is still persistent and has severe impacts on the livelihoods of the majority of the people who are poor, socially disadvantaged and lacking access to resources, the goal of health for all is still elusive.

With the support from External Development Partners (EDPs), ministry of health is committed to provide quality health services for entire population. Based on the primary health care principles, the government of Nepal has identified essential health care services that address the most essential health needs of population and are highly cost effective, as well.

The national health policy was adopted in 1991 to bring about improvement in the health conditions of the people. The primary objective of the policy is to extend the primary health care system to the rural population so that they benefit from modern medical facilities and trained health care providers. The policy particularly highlights preventive, promotive, curative and basic primary health care services.
In addition, community participation is increasingly felt crucial in health care planning and management of services. At the community level, participation of female community health volunteers (FCHVs), traditional birth attendants (TBAs), and other community leaders is very encouraging in terms of educating and empowering rural communities for improved health and sanitation. Their roles have been vital in referrals to peripheral health facilities like health posts and sub health post for health care.

The health ministry has developed a 20- year Second Long-Term Health Plan (1997-2017). This is a major landmark in health sector that serves as a roadmap in health sector development towards improvement of the health of the population, particularly those who are needy and lack access to basic health services. The plan has well addressed key issues like disparity in health care, gender sensitivity, and equitable community access to quality health care services. The plan also envisions a health care system with equitable access and quality services in the urban and rural areas.
According to annual report of department of health services, the long term plan targets to reduce the maternal mortality rate to 250 per hundred thousand births, infant mortality rate to 34.4 per thousand live births and reduce the under-five mortality rate to 62.5 per thousand. This further targets to increase the life expectancy to 68.7 years and also reduce the total fertility rate to 3.05. Undoubtedly, there are many challenges ahead to successfully meet these ambitious targets in the present context.

There have been significant progress in maternal and child health, family planning including other health care service delivery and management over the years. Over the past decades, maternal and child mortality and morbidity rates have been significantly reduced. Besides, the Ninth Plan in the health sector aimed at improving the health situation of the people providing them with preventive, supportive, curative, and rehabilitative health care services, and thus supported poverty alleviation programmes. The Tenth Plan has also set an objective of making health care services easily available, and developing human resources that support for poverty reduction.

Decentralisation in health sector is receiving an increasing priority to respond local health needs. It is very encouraging to note that in some selected districts, Sub-Health Posts have been handed over to Village Development Committees (VDCs). This will further facilitate VDCs in participatory planning in health care so that issues of community participation, local ownership, gender and health; and local health needs will be addressed and integrated into the VDCs' annual development plan.

In order to improve the accessibility and coverage of primary health care, Primary Health Care (PHC) Outreach clinics have been established in VDCs. Such clinics provide a basic minimum service package that includes: health education, counseling and Information Education and Communication (IEC), family planning services, such as pills, condoms, Depo Provera, basic maternity services, minor treatment, referral and follow up. It is learned that there needs more supportive supervision and monitoring from district health offices, health posts and sub-health posts to make the PHC Outreach more effective.

In the context of community health, Female Community Health Volunteer (FCHV) programme has been very effective in terms of empowering local communities with basic knowledge of primary health care, especially related to health of mothers and children. The purpose of this programme is to promote community participation by creating awareness of available health and family planning services in order to reduce infant, child and maternal mortality and the fertility rate.

Crucial

Despite significant progress in health sector, the Health Ministry in coordination and partnership with EDPs including civil society organisations is trying hard to achieve health for all. Coordination and partnership with EDPs and NGOs have been felt crucial and there are emerging needs of inter-sectoral collaboration to improve the health services more effectively. However, there are still challenges to reach the wider coverage due to geographical difficulties, rapid population growth, migration, political conflicts, and poor community awareness in health. The strong political will and commitment is extremely important to reach the goal of health for all.

World Health Day
Vector-Borne Diseases

IN principle, all vector-borne diseases are a serious threat to children's health. Some, however, pose a specific threat to children, because a child's immune system is unable to cope with the assault by the infectious agent, or because the way a child behaves may increase vulnerability to disease. These diseases include: Malaria, Lymphatic filariasis, Japanese Encephalitis (JE), Dengue Fever and Leishmaniasis.

Second

Malaria, which is transmitted by a mosquito, overwhelmingly kills children. Malaria is a major public health problem in South-East Asia Region, which reports about 3 million cases and 30,000 deaths annually. Lymphatic filariasis is an infection of parasitic worms lodging in the lymphatic system. The decrease in healthy life years caused by this disease is second only in its magnitude to malaria.
Japanese encephalitis is found in the irrigated rice production systems of South and South-East Asia. JE often causes nervous disorders and a life-long debility in the afficted patient. An average of 40,000 clinical cases are estimated to occur each year, with a case fatality rate of 20 per cent. Of the survivors, 50 per cent are affected mentally for life.

Dengue fever also affects young children disproportionately in high burden countries. The disease's most lethal form, dengue haemorrhagic fever, kills, on average, over 10,000 children each year. During major outbreaks, children's hospitals can come to a grinding halt as wards are overwhelmed by admissions.

Leishmaniasis, a parastic disease transmitted by sandflies, manifests itself either as skin lesions or as damage to internal organs - the latter form (called Kala azar) is life-threatening with an estimated 59,000 deaths in 2001. Every year an estimated 2 million cases of cutaneous leishmaniasis occur, and an estimated 95 per cent of patients are children under 5.

Mosquitoes that transmit diseases in the countries of the South-East Asia Region belong to genera Anopheles, Culex (house mosquito), Aedes (Asian tiger mosquitoe) and Mansonia. Many species of Anopheles transmit malaria from one person to another. Anopheles mosquitoes breed in clean water and females bite indoons and outdoors. The mosquito Aedes aegypti transmits dengue and dengue haemorrhagic fever (DHF). Aedes breeds in clean water stored in various man-made receptacles, pots, tanks, desert room coolers, flower vases, rainwater trapped in disused types and metal scrap. Aedes is mainly a day-biter and a split-biter (a single female tends to bite many persons until fully fed with blood). Dengue/DHF outbreaks occur in urban-semi-urban areas, but also in villages following water storage practices. Culex mosquitoes transmit lymphatic filariasis and Japanese encephalitis. They breed in clean as well as polluted waters Mansonia mosquitoes transmit another form of filariasis. They breed in water bodies infested with floating vegetation.

Sandflies cause itching on bite and transmit leishmaniasis from an infected person to another. Sandflies breed in damp and sheltered soils often at the base of walls, in damp cracks, in soil contaminated by animals and in the burrows of rats, gerbils and ground squirrels about 50 metres around human habitations.

Although malaria affects people of all ages, children in general and underprivileged children living in socio-economically deprived conditions in particular are at a greater risk. Malaria is one of the major causes of childhood anaemia and spleen entargement. It decreases cognitive abilities in children and is considered an important cause of school absenteeism. Malaria during pregnancy can lead to low-birth weight babies. Unprotected children and those going to bed early become more prone to mosquito bites in the early night-hours. Itching caused by mospuito bites can cause sleep disturbances.

Children who spend considerable time in schools, playgrounds and parks located in areas with plenty of surface water are prone to infective mosquito bites. Day-biting and split-biting habits of Aedes mosquitoes put the schoolchildren at a greater risk of getting Dengue fever.

Untreated infection with worms of filariasis during childhood can lead to development of elephantiasis (swollen legs, like an elephant), typical deformations caused by "lymphedema" and "hydrocoele" in children as young as 12. It can become a cause of social stigma affecting people of all ages including children.

Outbreaks of JE particularly affect children under five (about 90% of cases); JE also affects people of all ages and can mentally cripple the affected person for life.

Kala azar is a major cause of liver and spleen enlargement in affected children in endemic areas. It can lead to death if untreated.

How can we protect children from vector borne diseases? There are some preventive measures. As children usually go to bed earlier than adults, when mosquitoes become active, the use of insecticide-treated mosquito nets and the screening of windows, doors and eaves provide a very effective means of protecting them against malaria.

General environmental management, including improved water management in irrigated areas, placing cattle strategically between breeding places and homesteads, and drainage or filling of water collections, may help reduce transmission risks.

Combined irrigated rice production and pig rearing close to housing must be avoided to break the Japanese encephalitis cycle.

Hygiene education and designated safe places to swim as well as other environmentally sound measures will reduce the transmission risks of some parasite-transmitted disease and help control morbidity.

Breeding to mosquitoes in the house can be prevented by keeping water storage containers fully covered, and periodically emptying and drying out various containers that retain water including buckets, discarded food containers, drums, flower vases, and car tires (where water can collect). This will help reduce dengue transmission risks.

Success Stories

Changing the crop patterns helped Indonesia in controlling malaria-causing vectors. Synchronisation of rice culture, uniform quality of seed, regulation of the sowing time and harvesting of early-maturing variety contributed to vector control. Crop rotation was encouraged, and the farmers were asked to sow a non-rice crop after two rice crops. These practices led to enhanced rice productivity and controlled the malaria vector Anopheles aconitus. Prawn and fish cultures were further encouraged in the coastal areas with high water salinity. This controlled the breeding of Anopheles sundaicus and became an effective malaria-control tool. These practices had the dual benefit of disease control and increase in income and productivity, once again proving the importance of intersectoral collaboration.

WHO

Glimpses Of SLC

By Narayan Upadhyay

STUDENTS and even men and women in advanced ages wish to appear in and pass it. Parents crave to see their children through it. Teachers, educationists and policy makers hope that more students should get beyond it with flying colours. This is the one examination of which result all people wait with an abated breath.

The importance of the School Leaving Certificate (SLC) Examination is also reflected in the actions and behaviours of different people who are directly or indirectly related with the examination. The news coming from different parts of the nation regarding the SLC examinations this year has provided some attention-grabbing episodes.

A 50-plus grandmother sat for the examination and so that she could go to a college- at least once in her lifetime! On the very first day of the examination this year, four superintendents, responsible to check irregularities at the examination centres, indulged in helping examinees copy answers.
There are other interesting incidents that highlight the significance of the SLC, regarded an iron-gate by the students who want to cross it by any means. The number of students who studies less during the academic year and who wants to pass the examination is always higher. The dim-witted students secretly carry cheats, small papers full of answers, in the examination halls. Four sacks of cheats have recently been seized from the examinees in one of the eastern hill centres.

In another incident, policemen deployed in the examination centres helped students carry answers books so that the students' task of passing the subjects would become easier.

Some Terai districts such as Bara, Parsa, Mahottari, Rautahat and Dhanusha, witness parents and relatives flood the SLC examination centres with an aim to supply answer sheets to their children. The authority, in some cases, is forced to change the centres because of the overwhelming number of relatives arriving to the centres to supply answer books to their children attending the examinations.
Good performance, not only by students but also by schools in the number of percentage of students passed in the SLC with good marks, counts heavily in favour of the schools. Private schools all over the nation make it a point to advertise about the percentage of the students passed in the first divisions in the SLC exams. They apparently do so to impress parents who would later queue up to enrol children to their schools.

The Kathmandu based private schools, few years back, were rumoured to have gone a step further. They were blamed of bribing the SLC related officials to induce them to place some of their students in the top ten list of the SLC result. If the students of the school are placed in the top three in the SLC result, the image and rating of the school would increase tremendously which would help lure more number of students to the school. This would invariably give rise to income of private schools.
To stop the "scramble" of private schools for gaining their names in the top ten list, the government has scraped the provision of publishing the names of students and schools in the top ten list. Nowadays, students coming at top ten positions have to satisfy without the metioning of their names on the top ten list on the Gorkhapatra daily that publishes the annual SLC examination results.
The different episodes provide not only the interesting glimpses but also the importance of the SLC examination in our society. The method adopted by students, parents and schools to get at the top of the SLC examination may differ, but the motive of doing so is the same- passing the examination with good marks.