Oasis Health, Population & Environment Education Book 10

8.4.2 Care of Pregnant Woman, Neonatal and Postnatal Mother and Newborn Child a) Care of pregnant women As we discussed earlier, pregnancy is a complicated period, which requires conscious care with a balanced diet, reproductive knowledge, love and sympathy. The conscious care provided to a pregnant woman is described below: i. Nutritious food Nutritious food contains all types of nutrients in appropriate proportion. Nutrition includes vitamins, proteins, minerals, carbohydrates, fats, etc. Nutrition taken by the mother is the only source of nutrition for the fetus. It is utilized for the proper growth and development of the fetus. A pregnant mother must take cereals, meat, fish, milk, eggs, green vegetables, fruits in proper amounts. She should not take alcohol, tobacco, drugs, junk and adulterated foods as well as other harmful food items. Haphazard intake of medicines by oneself or instructions of quacks should be restricted strictly by a pregnant woman. ii. Health check-up There are various ups and downs during the period of pregnancy. A pregnant woman needs more health care and check-up because of the complex biological processes within her body. Regular health check-up helps the mother to diagnose health problems earlier and to save the lives of the fetus and herself. The health check-ups of a pregnant mother must be according to the followings: • Once a month up to the seventh month of pregnancy • Twice a month in the eighth month of pregnancy • Once a week after the eighth month of pregnancy The above-mentioned information is not sufficient for mothers in abnormal cases. If there is any unexpected and abnormal symptom during pregnancy, she should consult the doctor immediately. iii. Cleanliness Cleanliness is one of the important preventive measures to stay safe from infections and infestation by disease germs and parasites. A clean body and surroundings prohibit diseases. Pregnant body becomes dirty faster than in normal conditions. There is production of dandruff on the face Health, Population and Environment - 10 201

and discharge of fluids from the vaginal openings. Therefore, efforts at cleanliness should be increased in pregnant women. Cleanliness includes clean body, clean surroundings, a clean home, clean food items, and clean dresses. iv. Physical exercise and rest A pregnant woman neither needs total rest nor excessive physical exercises. There must be normal and light physical exercises on a daily basis. Morning walk, light jogging and simple yoga exercises are beneficial for a pregnant woman. Heavy exercise contracts the abdominal muscles and may cause harm to the uterus and fetus. The pregnant woman should not carry heavy loads. She should take proper rest and a sound sleep to refrain from mental tensions and sleeplessness. It is the duty of all the family members to create a peaceful and harmonious family environment for the pregnant woman. v. Vaccination/Immunization The pregnant woman is vulnerable to tetanus. Therefore, she must take two doses of immunization (TT-Tetanus Toxoid vaccination) against tetanus between the seventh month of pregnancy and two weeks before childbirth. Time lag between two doses of TT vaccination must be one month. This vaccination saves the mother and fetus against tetanus. b) Care of the mother during childbirth and neonatal period Pregnancy ends after the birth of the baby. The fetus becomes mature and ready for independent survival in the external environment after a certain period. The period is of about 280 days from the last menstrual flow of the mother. After maturity, the baby is expelled from the womb. This process is called labor. There are three stages of labor. The amniotic fluid which surrounds the baby inside the womb is expelled in the first phase. The baby gets birth by rhythmic contractions of the muscular wall of the uterus in the second phase. The third phase ends with the expulsion of the placenta. The following must be considered for caring the mother during childbirth and neonatal period. • Immediately after the onset of symptoms of labor, the pregnant woman should be taken to a hospital or provided with a Trained Birth Attendant (TBA). • She should be cared with consolations, sympathy and psychological 202 Health, Population and Environment - 10

assistance. • She should be provided with light fruit juice, milk, glucose solution or other nutritious fluids. • Suggestion to urinate is useful for the mother to reduce pressure and pain in the lower abdomen. Urination decreases the fluid pressure in the lower abdominal site. c) Care of neonatal/postnatal mother It is the care given to the woman after delivery of the child. The period of about two months after childbirth is regarded as postnatal period. Childbirth brings declination in various aspects in the body of the mother. Due to childbirth, there is sore and pain around the vagina. The perineum membrane may be torn due to passage of the child through the vaginal canal. Anemia is a common problem in neonatal period due to excessive loss of blood. The following points should be considered for the care of the mother during this period: i. Dietary intake should be increased with nutritious food, including protein- rich and iron-rich foodstuffs. ii. Milk, fish, meat, eggs, cereals, green vegetables, fruits should be given more during this period. iii. It is better to clean her body with a clean towel soaked with lukewarm water. iv. After about one week, she can take normal body bath. v. Breastfeeding must be started from the day of delivery. The breast area should be cleaned properly. d) Infant health care A newborn baby is called an infant. The baby has a normal weight of about three kilograms and normal height of about 50 centimeters. The weight of the infant reaches about three multiples of the weight at birth and the height reaches about 75 centimeters after one year. The 1,000 days between a woman’s conception and her child’s second birthday (270 days of pregnancy+365 x 2 days=1000 days) is termed ‘Sunaula Hazar Din’ or ‘Golden 1000 Days’ in Nepal. The Government, with coordination of NGOs Health, Population and Environment - 10 203

and INGOs, has launched various programs incorporating awareness, nutrition, cleanliness, immunization etc. for infants and children. It is believed that it is an unique period that shapes a healthier and more prosperous future of the child. Right nutrition and care during this \"1,000 days window\" can have a profound impact on a child’s ability to grow, learn, and rise long-term health, stability and prosperity. A newborn cannot express desires and problems. Therefore, we must understand the problems and desires properly. Infant health care can be given as follows: i. The baby should be kept in an upside down position to discharge the mucous and water inside the nose and mouth. ii. The mucous, membranes and fluids that have accumulated inside the mouth and nose should be cleaned thoroughly. iii. The baby should be kept at a lower level from the body of the mother before tying the umbilical cord. It prevents the back flow of blood of the infant towards the placenta. iv. The baby should be kept warm by wrapping with clean and soft clothes. v. A blade or scissors used to cut the umbilical cord must be clean, sharp and sterilized. vi. The cord should be tied with a clean and sterile thread. vii. Breast milk contains a nutritious component called colostrum. It strengthens the immunity power of the infant. Therefore, it should be fed to the infant as soon as possible. viii. Frequent health check-ups should be done for monitoring and treatment of health problems. e) Infant and child nutrition An infant is not capable of obtaining foodstuffs needed for survival with its own effort. It is the duty of the mother and family members to manage appropriate food for infants and children. Breastfeeding is the most appropriate food for infants up to five months of age. Colostrum found in breast milk strengthens the immune power of the infant and provides the necessary nutrition. Artificial and marketed milks do not contain all the components needed for the growing infant and 204 Health, Population and Environment - 10

child. Therefore, breastfeeding should be encouraged instead of giving bottled milk purchased from the market. Benefits of breastfeeding i. Breast milk is naturally produced for infants. Therefore, it is the best food for them. ii. It is ready-made, and it can be provided to the infant at any time. iii. It contains all the nutrients in appropriate proportion. iv. Breast-milk contains Colostrum, which adds immunity power to the infant. v. It is easy to digest. Diarrhea and other gastrointestinal problems are prevented by breast-milk. vi. It builds a cordial relationship between the mother and the child. vii. Regular breastfeeding prevents hardening of the breasts and breast cancer. viii. Breastfeeding increases the production of progesterone hormone. This hormone prevents conception and helps in birth spacing. ix. It saves extra expenses to purchase bottled and marketed milk. Selection of appropriate foods stuffs for infants and children up to two years should be done as per the following table: Selection of food stuffs for infants and children Age Foodstuffs Up to 5 months Mother’s breast milk 5-6 months Breast milk, animal milk, soft meal, mashed vegetables 6-9 months Breast milk, animal milk, soft meal, mashed vegetables and soft fruits 9-12 months Breast milk, animal milk, soft meal, mashed vegetables, soft fruits, rice and eggs 1-2 years Breast milk, animal milk, soft meal, mashed vegetables, soft fruits, rice, egg, cereals, normal and soft meal As mentioned in the table, there is a need of supplementary food for the infants after crossing five months of age. On the one hand, there is rapid growth and development of the child with the increased need of dietary intake. On the other hand, there is declined production of breast milk from the mother. Therefore, addition of supplementary food plays a vital role Health, Population and Environment - 10 205

in the growth and development of children. The supplementary foodstuffs must be easily digestible, clean and nutritious. f) Immunization Immunization is the process of increasing the immunity power against germs by administering the related immunizing vaccination. If there is a vaccination against any disease, the chances of the onset of the disease are less. Immunization helps the body to develop the capacity to fight and kill the causative germs. The table below gives information about immunization against different diseases: Immunization schedule Name of Diseases con- Age at first Number of Time interval vaccina- trolled dose doses tion Tuberculosis Within 4 to One - B.C.G. (TB) 5 days after (Bacillus birth One/One Calmette Diphthe- month Guerin) ria, Pertusis 6 weeks-1 year Three (Whooping Second dose D.P.T. cough, and after one Tetanus) month of the Hepatitis first dose and B Hepatitis B 6 weeks-1 year Three third dose af- ter six months. Polio Poliomyelitis 6 weeks-1 year Three One/One month Measles Measles 9 months-1 One - year One/One Pregnant month T.T. women (Two (Tetanus Toxoid) Tetanus doses in the Five first pregnancy and a single dose in others) 206 Health, Population and Environment - 10

The immunization schedule should be followed in a proper way for the development of effective immunity power. The following points should be considered in immunization: i. There must be three doses of immunization for DPT and polio at appropriate time intervals. ii. The time schedule should be followed strictly. iii. A child may fall sick after immunization. We should not worry about it because minor illnesses are common symptoms. iv. There may be a minor wound after the administration of BCG vaccination. The wound heals itself after a few days. Massage on the wound becomes harmful. It is better to cover the wound with a clean piece of cloth. v. Immunization can be administered even if there are minor illnesses. vi. Basic immunizations are available free of cost at the local health centres. Health, Population and Environment - 10 207

Notes • Adolescence is the period of life when a child develops into an adult. It is the period of rapid physical, mental and emotional changes in life. According to WHO, adolescence is the stage of life which ranges from 10 to 19 years of age. • The diseases which are transmitted through sexual intercourse are STDs. There are more than 20 STDs including HIV, Hepatitis B, gonorrhea, syphilis, Chanchroid, Chlamydia and Trichomoniasis. • The full form of AIDS is Acquired Immune Deficiency Syndrome. It is caused by RNA retrovirus HIV (Human Immunodeficiency Virus). • HIV and AIDS do not have similar meaning. HIV is the name of the virus and AIDS is the final stage of HIV infection. There is no AIDS immediately after the entry of the virus in the body. • The causative agent of syphilis is a microorganism called Treponema Pallidum. • A chancre is a small non-itchy, painless granule like appearance developed at delicate areas like lips, breasts, or genital areas as the first symptom of syphilis. • Safe motherhood is the process of protecting a mother from complicated pregnancy, childbirth and recovery. • The international conference held in 1990 in the capital city of Egypt, “Cairo Conference”, reported that 5,00,000 women died due to complicated pregnancy and delivery in the world every year. • Trained birth assistance refers to the help and care given by trained health personnel to a mother during childbirth. • Maternal and child health (MCH) care is defined as the process of promoting health of pregnant, neonate and breastfeeding mother as well as children below five years. • A newborn baby is called an infant. The baby has a normal weight of about three kilograms and normal height of about 50 centimeters. • Immunization is the process of increasing the immunity power against germs by administering the related immunizing vaccination. 208 Health, Population and Environment - 10

Exercise A. Give very short answers to the following questions. 1. What is adolescence? 2. What are the major changes seen during adolescence? 3. Give an example of sexually transmitted disease. 4. Write the full form of HIV and AIDS. 5. When was HIV first recognized in the world? 6. What is myalgia? 7. What is Treponema pallidum? 8. What is a chancre? 9. What does the suffix '-rrhoea' denotes in medical language? 10. Write any one major symptom of gonorrhea. 11. When was the Cairo Conference held? 12. Write the full form of TBA. 13. What does a postnatal mother mean? 14. What do you mean by 'Golden 1000 Days' in the context of health promotion in Nepal? 15. How is dengue transmitted? B. Give short answers to the following questions. 1. What do you mean by reproductive health education? What is its significance in our life? Describe briefly. 2. How is HIV transferred? Explain the ways HIV is transmitted from a host to a healthy person. 3. Write a paragraph describing the signs and symptoms of HIV/AIDS. 4. Give a short introduction to syphilis with its symptoms in three progressive stages. 5. List any five measures to prevent oneself from syphilis and gonorrhea. 6. What is chancroid? Give a brief introduction to it. 7. Define safe motherhood. What are the international efforts made for strengthening the status of safe motherhood? Describe in brief. Health, Population and Environment - 10 209

C. Give long answers to the following questions. 1. Explain any five major considerations for safe motherhood. 2. How should we take care of the postnatal mother? Describe any five techniques. 3. What is immunization schedule? Why is it important? Give an introduction to the diseases and name of immunizations provided to the infants in Nepal. 4. What are the risky conditions of pregnancy? Explain. 5. Explain the methods and considerations for taking care of an infant. 6. \"Unsafe sex may result in transmission of venereal diseases.\" Justify this statement with examples. 7. What is abortion? What are the conditions of illegal abortion in Nepal? Explain. 8. Explain the characteristics and types of food that should be provided to a baby up to two years of age. 9. What are the causes of HIV/AIDS transmission in Nepal? Explain in detail. 10. Define safe motherhood. Elaborate the responsibilities of family members for the protection of mother's health. 210 Health, Population and Environment - 10

C o ns u mers ' 9 Health and C o mm u n i t y H ealt h Contents 9.1 Concept of Community Health 9.1.1 Introduction to Community Health 9.1.2 Importance of Community Health 9.1.3 Scope of Community Health 9.2 Health Service Providing Agencies and Their Functions 9.3 Provisions of Health Services in Nepal 9.4 Voluntary Health Agencies in Nepal 9.5 Major Policies and Programmes of Health Sector in Nepal 9.5.1 Policies of Health Sector in Nepal 9.5.2 Major Programmes of Health Sector in Nepal 9.6 Bad Habits, Its Effects and Measures for Prevention 9.7 Tobacco, Smoking and Drugs (Effects and Measures for Prevention) 9.7.1 Tobacco and Smoking 976.2 Drugs Health, Population and Environment - 10 211

9.1 Concept of Community Health Consumers’ health means the state of health determined and affected by the use of goods and services available in the market. According to the consumer protection Act 2054, \" a consumer is a person or institution who consumes or uses the services and goods available in the market.\" The status of our health is dynamic. There are frequent ups and downs. Goods and services which we consume in our daily life play an important role in our well-being. The trend of consumption plays an important role in determining our health level. Consumption of goods and services available in the market include the health services and medicines as well. We purchase such things from the health centres. In this context, the hospitals and health centres are also regarded as a kind of market. There are several things in our community which are being used by people as consumers. Therefore, community health is closely related to consumers’ health. 9.1.1 Introduction to Community Health The status of health can be evaluated in different ways. Personal health, family health, consumers’ health and community health are some of the approaches of studying the statuses of human health. Our health is affected and determined by the surroundings, environment, social practices and health services available in the community. There are various types of diseases which affect individuals or groups of individuals in different ways. Some diseases can be controlled by personal effort, but some of them, basically those which are communicable and can become all epidemic, need community effort to be controlled. There is a need of public participation or the involvement of a whole society. Therefore, community health is synonymously known as public health, community medicine, or social medicine. Community health is defined as a science and art of developing a balanced integration of curative, promotive, preventive and rehabilitative health services to make a community healthy by promoting environmental and personal health of a community 212 Health, Population and Environment - 10

through organized community effort. The concept of community health has been adopted by many countries. World Health Organization (WHO) has given the concept of primary health care, which has been adopted by Nepal, too. Primary health care gives emphasis to providing basic and necessary health services to all the people living in all corners of the world. That’s why primary health care is also considered as an objective of community health. In the past, the community health program was understood as a program of sanitation of public places and cure of the diseases in the community. But these days it is considered in a broad sense and it includes curative, promotive, preventive, as well as rehabilitative health services. Community health gives focus to the participation of the community in preventing diseases in the community. 9.1.2 Importance of Community Health Community health is of great importance for us. Various community health problems are prevented and controlled through the help of community health measures. The importance of community health is explained in the following points: a) Production of healthy manpower Healthy manpower is an important Importance of Community Health infrastructure for the development of a nation. We need efficient 1 Production of healthy manpower human resource to carry out any 2 Availability of health services down to sort of work for a country. Efficiency grassroots level 3 Promotion of social services cannot be expected from unhealthy 4 Development of healthy environment 5 Development of preventive, promotive, manpower. Community health is curative and rehabilitative health important for the production of behaviour of people healthy and efficient manpower as they go to the grassroots level1 to provide health services, encourage people to keep the environment clean, fight against various diseases in the community and make people healthy. b) Availability of health services down to grassroots level Community health possesses a concept of providing health services to all the people of the world, wherever they are living. People living in remote and rural areas suffer from even minor health problems. Even diarrhea in rural areas of Nepal has been a fatal disease due to lack of simple health 1 Grassroots level: basic or local level, the level to the common citizen Health, Population and Environment - 10 213

awareness and services. Community health is important to tackle such problems as it aims at providing health services and facilities down to the grassroots level of the community, including very poor people who cannot afford expensive health services. c) Promotion of social services Society is made up of people. Public participation in the community is promoted by community health for the promotion of overall health status of the whole society. Such practices increase the involvement of people to serve others. It also enhances the sense of humanity and social service as diseases are considered as a common problem of all the people in a community. d) Development of healthy environment Community health gives focus to environmental health, too. There are many people living in a common environment. This common environment must be healthy for the sound health of people living there. There is an integrated and unified effort for sanitation, control of pollution, and other environmental hazards. Therefore, community health concept is very important for the development of a healthy environment. e) Development of preventive, promotive, curative and rehabilitative health behavior of the people Community health is a balanced integration of various aspects of health services and awareness in the community. It is important to modify the health behavior to promote health and efficiency of people through their own effort. 9.1.3 Scope of Community Health Community health is primarily concerned with the common issues of people's health in a community. The scope of community health includes the following factors: a) Inspection of essential goods supplied in community Essential goods mean those goods and materials which are linked with the healthy survival of the people. Food, milk, drinking water are some examples of essential goods. Due to rapid population growth in the town areas, it has been very difficult to find natural safe drinking water. People depend upon a community-based water supply system. If it becomes polluted, there is risk of epidemic and endemic diseases. Similarly, dairy distributes milk to majority of the people. It should be monitored regularly to prevent diseases in the community. 214 Health, Population and Environment - 10

b) Prevention and control of communicable diseases and epidemics Communicable diseases have host-specific causative agents. They transfer from people to people through vectors. Sometimes they take the form of epidemics and cause immense loss of lives. Many communicable diseases, which are no longer a community problem in the developed countries, are still prevailing in our country. Community health also puts emphasis on the prevention and control of communicable diseases. c) Environmental health and sanitation Environment is the surrounding where we live. It is our responsibility to keep our environment clean. Sometimes we need combined efforts to tackle the environmental problems in the community. In such cases, community health can play a vital role in resolving such problems. For example, we can construct drainage, system, sewerage, community parks and gardens by working together with the community members. Community sanitation is not possible with the effort of a single individual. Community effort is needed with the participation of many people from the community. d) Immunization Immunization is the process of preventing fatal communicable diseases with the administration of vaccinations. It requires skilled health workers, medical instruments and vaccination antigens. It is possible with community effort. Mass immunization programmes help in lowering the immunization cost and increasing the coverage of the beneficiaries. There is an immunization schedule made by Government of Nepal to make it available and accessible for the people living even in the remote and rural areas. The schedule includes immunization against tuberculosis, poliomyelitis, hepatitis, diphtheria, measles, whooping cough and tetanus. e) Prevention of malnutrition There are two kinds of malnutrition. They are overnutrition and undernutrition. Overnutrition is the excess of nutrients that cause abnormality in human health. It is rarely found in the town areas of Nepal. Problems of undernutrition is comparatively more common in the remote and rural society of Nepal. It may be lack of knowledge, awareness and less availability of food materials. Community health also aims to reduce the problem of malnutrition through awareness, campaigns and provision of nutritious food supply to children. Health, Population and Environment - 10 215

f) Safety, risk management and first aid Accidents and sudden health problems may occur at any time at home, in the yard, road, playground, kitchen or any other place. There may be unexpected health risks due to natural calamities like an earthquake, flood and landslide. Potential risks should be identified earlier as far as possible to minimize the adverse effects of the risks. Where there is concern of such unexpected health problems, safety and first aid are vital. The provision and management of effective safety and first aid are possible through community health processes. We can manage such a provision with combined and planned effort of the community members. g) Health education Health education is essential to tackle several superstitious beliefs, wrong health practices and traditional unhealthy lifestyles. Community health aims to make people aware of the scientific bases of human health and environment. There should be formal health education courses, informal health education programmes and regular health awareness campaigns in the community to raise the health status of the people. h) Control of tobacco, drug abuse and alcoholism Tobacco, drugs and alcohol are the root causes of a number of health problems of the people. They do not show direct causation of diseases but produce a long-run inevitable progression of the underlying causes of chronic diseases. Therefore, community health also plays a vital role in controlling such harmful abuses among the people. 9.2 Health Service Providing Agencies and Their Functions Introduction Health services are those services which are utilized to promote the health status as well as to solve health problems. Nepal is ranked as a developing country, and it obviously has many types of health problems. The health sector is badly affected by the poor economic condition of Nepal. The economy of Nepal depends upon the funds and aid given by other countries. The main problem of the health sector in Nepal is the practice of traditional and unscientific systems. Modern medicine is not accessible to all people. They depend upon the traditional healers like the Dhami and Jhakri, though, in different developmental plans of Nepal, the health sector has received in high priority. Health services can be categorized into preventive, prormotive, curative and rehabilitative services in Nepal. 216 Health, Population and Environment - 10

i. Preventive health services ii. Promotive health services iii. Curative health services iv. Rehabilitative health services a) Preventive health services It is wise to prevent diseases than to attempt for their cure after onset. It protects us from loss of energy and strength. Morbidity is the condition of being diseased. This category of health services aim to reduce the rate of morbidity among people. Preventive health services are the set of healthcare provided to healthy people for the prevention of susceptible diseases. Preventive health services are designed for all people at all age groups. It primarily includes the following health services in Nepal: i. National Immunization Programme ii. Nutrition iii. Diarrhoea and Respiratory Disease Control Programme iv. Leprosy Control Programme v. HIV/AIDS and STDS Control Programme vi. Health Education vii. Health Awareness and Sanitation Programme viii. National TB Control Programme b) Promotive health services The status of peoples' health is always dynamic. It is never static. Promotive health services can be defined as the set of services provided to people for the further betterment of health status. Promotive health services basically include the following services. i. Health Education and Awareness ii. Nutrition and Balanced Diet iii. Environmental Sanitation Programme iv. Maternal and Child Health Care (MCHC) v. Vitamin A Distribution Project Health, Population and Environment - 10 217

c) Curative health services Curative health services are the set of health services used for diagnosis and treatment of diseases. In spite of personal, family and community healthcare provided to people, diseases may get manifested at different modes and forms. When immune power of a diseased person cannot fight against the germs, they are to be treated with medicines. Before starting the treatment against any diseases, it is very important to know the real information of causative agents. The process of identifying the underlying cause and causative agents of disease is called diagnosis. There may require laboratory tests, microscopic observation and general evaluation of the patients' symptoms to diagnose a disease properly. On the basis of diagnostic information, a medical practician decides the useful methods of treatment and medicines. It is very important in controlling epidemic, endemic and pandemic diseases. d) Rehabilitative health services Literally, the term 'rehabilitation' means 'the action of restoring someone to healthy and normal life through medication, treatment or therapy after recovering from an illness. In other words, rehabilitation means the assistance provided to regain the health-functions that have been lost or diminished due to disease. Sometimes, a patient may require several weeks or months duration to restore the initial strengths and abilities. Rehabilitative health services may include the assistance to adjustment at home, counselling service, education and awareness regarding the precautions and care during the post-recovery period. 9.3 Provisions of Health Services in Nepal Provision of health services to its citizens is one of the basic responsibilities of government of every country. Basic health services are regarded as the basic components of human right. In order to develop a system of convenient distribution of health services and facilities to people, Government of Nepal has adopted a hierarchical distribution channel of health service centres. It consists of the service centres at central, regional, zonal, district, electoral constituency, ilaka, village, community and ward levels. a) Central Level Ministry of the Health and Population (MoHP) plays a leading role of regulating the health sector and delivering health services to the people of Nepal. Regulatory function has been carried out mainly by 218 Health, Population and Environment - 10

divisions within the Ministry of Health (MoH) and through central level professional and institutional councils, such as, Nepal Medical Council. Besides these, Department of Drug Administration also functions as a regulatory body for production and supply of medicines and other health products. The other two departments of the MoH, namely Department of Health Services and Department of Ayurveda, manage delivery of the health services at the central level. There are some hospitals under the direct monitoring and supervision of MoHP. They are highly equipped with their specialized services and medical excellencies. Some of the hospitals under the central level of health service distribution in Nepal are: i. Bir Hospital, Kathmandu ii. Kanti Childrens' Hospital, Maharajganj, Kathmandu iii. Martyr Shukraraj Tropical and Infectious Hospital, Teku, Kathmandu iv. Mental Hospital, Lagankhel, Kathmandu v. Indrarajyalaxmi Maternity Hospital, Thapathali, Kathmandu vi. Martyr Gangalal National Heart Centre, Bansbari, Kathmandu vii. BP Koirala Cancer Hospital, Chitwan viii. BP Koirala Institute of Health and Sciences, Dharan ix. Patan Hospital, Patan x. Karnali Academy of Health Science etc. b) Province Level Province level of health service is primarily governed by the province health directorate office established in each province. They serve as a monitoring and supervising unit for province, district, village and community based service centres. Major responsibilities and tasks of the regional directorates are: i. To conduct periodic supervision and monitoring at all health institutions in the province. ii. To determine requirement of manpower for health institutions in the province. iii. To ensure supply of drugs, equipment, instruments and other materials at different health institutions. iv. To ensure effective implementation of public health programs. Health, Population and Environment - 10 219

v. To manage the immediate solution of problems arising from natural disasters and epidemics in the province at different levels. vi. To foster coordination with external development partners for effective delivery of resources and health. vii. To systematically maintain data, statements and information regarding health services in the province, update and publish them as required. viii. To identify gaps in health service delivery in the province and seek for solution. c) District Level District health office and district hospitals are the major bodies working as the leading health service centres at district level. There are sixty District Health Offices and fifteen District Public Health Offices in Nepal till 2074 BS. Health service centres take the following major responsibilities in district level. i. To conduct supervision and monitoring at all health institutions in the district. ii. To determine requirement of manpower for health institutions in the district. iii. To ensure effective implementation of public health programs at district level. iv. To address the problems arising from natural disasters and epidemics in the district. v. To plan and implement them for effective delivery of health services. vi. To maintain data, statements and information regarding health services in the district, update and publish them as required. vii. To run OPD, IPD (Outdoor Patient Department and Indoor Patient Department), and Emergency Health services to patients as per the requirements. viii. To run reliable and extended laboratory with X-RAY, ultrasound and other necessary diagnostic test facilities. d) Electoral Constituency Level Electoral Area is the political division of land with one elected member in the parliament. The elected member from an area focuses primarily 220 Health, Population and Environment - 10

in his/her area with developmental plans and strategies. There are 165 electoral areas in Nepal at present according to the Constitution of Nepal, 2072 BS. There is provision of at least one primary health centre (PHC) in each electoral area. There are altogether 208 PHC in Nepal. There is IPD service available in each PHC with at least one MBBS Doctor and three beds for the patients. Major functions of PHC are given below: i. To provide MCH (Maternal and Child Health) care service. ii. To conduct immunization programmes. iii. To control communicable diseases, epidemics and infectious diseases like diarrhoea and flu. iv. To conduct awareness and educational programmes regarding nutrition and preventive health. v. To plan and implement them for effective delivery of public health services. vi. To manage provision for first aid and emergency services. vii. To run OPD, IPD (Outdoor Patient Department and Indoor Patient Department) and Emergency Health services to patients as per the requirements. viii. To receive referred patients from lower service centers and to refer complicated cases. There are two main departments in hospitals: indoor patient department (IPD) and outdoor patient department (OPD). OPD and IPD have different provisions of treating with patients. Difference between OPD and IPD is as below: Difference between OPD and IPD OPD IPD Patients from outside admit first in this Patients are admitted after referral. department. Many patients visit OPD in a day. Limited numbers of patients are there in IPD. There are no (zero) beds in OPD. There are bed facilities in IPD. Patient with high-risk complications are Patients with any level of risk visit OPD. admitted in IPD. Health, Population and Environment - 10 221

Patients get diagnosis and suggestions Patients can get diagnosis, suggestions from the experts in OPD. as well as the expert’s direct supervision and care in IPD. There is instant monitoring of the There is routine check-up and repeated patient from medical personnel. monitoring of the patient from the medical personnel. e) Ilaka Level An Ilaka is a unique division of district with the communities with common concerns, issues and resources. There are at least six Ilakas in a district. There is at least a health post in an Ilaka. Health posts are headed by an HA (Health Assistant). There are 1559 health posts in Nepal at present. Major functions of a health post are: i. To provide MCH (Maternal and Child Health) care services to the grassroots level. ii. To conduct immunization programmes. iii. To conduct school health programmes at schools in Ilaka. iv. To provide general health check-up services to people. v. To assist couple for birth control and birth spacing through different contraceptive methods and devices. vi. To manage provision for first aid and emergency services. vii. To manage preventive and promotive health services. f) Village Level Villages are the basic constituents of Ilakas and districts. There is at least a sub health post in a village. Sub health posts are headed by CMA (Certified Medical Assistant). There are 2247 sub health posts in Nepal at present. Major functions of a sub health post are: i. To conduct health awareness programmes to the villagers. ii. To educate people the methods of preventing communicable and infectious diseases. iii. To provide MCH (Maternal and Child Health) Care services to the grassroots level. ii. To conduct immunization programmes. v. To assist couple for birth control and birth spacing through different contraceptive methods and devices. vi. To manage provision for first aid and emergency referral services. 222 Health, Population and Environment - 10

Difference between health posts and health centres Health Post Health Center Health posts are headed by Health Health center is headed by an MBBS medical Assistants officer There are comparatively less health There are comparatively more health personnel (7 in Terai region, 6 in personnel (at least 12) mountain and hill regions) Only outdoor service is available Both outdoor and indoor services are available Laboratory is not available Laboratory is available with a lab technician It is comparatively a lower level It is comparatively a higher level health service health service provider provider Comparatively more in number. Comparatively less in number. 9.4 Voluntary Health Agencies in Nepal a) Nepal Reds Cross Society Nepal Red Cross Society was established in 1963 AD (2020 BS), after one hundred years of establishment of International Red Cross Society (i.e. in 1863 AD). Nepal Red Cross Society was formally recognized by the international Committee of Red Cross Society on October 1, 1964. Jean Henry Dunant was the founder of International Red Cross Society (ICRC). He was born on May 8, 1828 AD. The founder president of Nepal Red Cross Society was Princep Shah from the then royal family. Nepal Red Cross Society has been carrying out the following activities: i. Service oriented activities: Nepal Red Cross Society is involved actively in service-oriented activities. Rescue of victims of natural disasters like flood, landslide, earthquake, storms, etc. and other fatal events like fire, accidents, etc. It also serves them in rehabilitation and re-settlement. ii. Health service activities: Health service activities like vaccination, nutrition, family planning, blood donation and transfusing play active roles during the epidemics to prevent lives with health service activities. iii. Development activities: It helps in community development program. Its major functions in community development programs are drinking water supply program, sanitation, literacy program, awareness programs, etc. Health, Population and Environment - 10 223

iv. Organizational development activities: Nepal Red Cross Society performs many organizational development activities like workshops, trainings, seminars, exhibitions, etc. It has extended branch offices in all the districts of nation. Junior Red Cross Circles are formed among school students. The society also expands its general members, life-time members, special members, honorary members, etc. who can contribute for the development of the organization. b) Nepal Paropakar Association Nepal Paropakar Association was established on Aswin 10, 2004 BS. Before its establishment, it had made history in charity of people. Its formal establishment with the name “Nepal Paropakar Association” was an amendment of “Paropakar Volunteers Group” which was established in 2003 BS. Initiation of the group was a product of self-motivated movement of some youths in Dayabirsingh Kansakar serving victims of cholera, which broke out in Kathmandu valley in 1994 BS causing a big loss of lives. Mr. Dayabirsingh Kansakar initiated and handled the movement of charity2 with his friends and volunteers. It has a central office in Vimsensthan, Kathmandu. The association is contributing people by providing the following services: • It distributes free medicines for poor, helpless and orphans through charitable dispensary. • It provides health services to people in different parts of the country through primary health depot and donation department. • The association had established Paropakar Orphanage3 in 2010 BS in Kathmandu. Now, it is providing secondary level education to orphans and general people at Paropakar Adarsha Secondary School. • It started Indra Rajya Maternity Hospital from 2016 BS. • It is providing ambulance service for people. • The association is involved in social charitable works of public concerns. 2 Charity : kindness towards people shown with provision of money, medicine, food, and other supports 3 Orphanage : house where the orphans are kept 224 Health, Population and Environment - 10

c) Family Planning Association of Nepal (FPAN) FPAN was established in Nepal in 2016 BS. Later on in 2026 BS, it received full registration from IPPF (International Planned Parenthood Federation). In the beginning, it worked mainly for family planning to control undesired births. But, these days it works broadly in various fields of reproductive health of Nepali people. Some of the major objectives of FPAN are listed below: i. To help couples plan the number of children to have in their family ii. To assist in protecting and promoting MCH (Maternal and Child Health) iii. To counsel and help couples to have children in case of infertility and sterility iv. To conduct family planning clinics in different places v. To encourage public participation in family planning activities and awareness programs d) Nepal Heart Foundation Heart diseases have been a global problem in the recent days. Change in lifestyle, less physical exercises, unhealthy and fatty food habits, use of harmful preservatives in readymade food stuffs, etc have been the main causes behind this problem. Nepal is also encountering increasing heart diseases in the recent days. In this context, Nepal Heart Foundation was established in 2045 BS. It’s central office is in Kathmandu. It has extended the branches in many districts. Nepal Heart Foundation is working for diagnosis, treatment, prevention, and control of different heart diseases like hypertension (i.e. high blood pressure), hypotension (i.e. low blood pressure), high cholesterol, coronary heart diseases, valve diseases, heart attack, etc. It contributed for establishment of Martyr Gangalal Heart Center. It conducts awareness program for healthy lifestyle and healthy food habits to prevent heart diseases. It helps in the treatment of heart diseases and open heart surgery for poor people. It has started National rheumatic fever and heart disease prevention and control program from 2064 BS in Nepal. Except the above-mentioned different organizations, there are many other national and international organizations working for promotion of Health, Population and Environment - 10 225

health in Nepal. WHO, UNICEF4 , FAO5, UNFPA, Rotary Club, Lions Club, Jaycees, etc. are some examples of international non-governmental organizations. Many local and national organizations are registered in respective district offices to run various health programs in their districts. e) Nepal Anti-tuberculosis association Nepal Anti-tuberculosis Association was established in 2010 BS by 10 social workers. Its central office is in Kalimati, Kathmandu. This organization works against tuberculosis disease in Nepal. It is a non- government organization with service motive. It is a non-profit making voluntary organization. Some of the main projects and programs started to control tuberculosis are described in short below: Tuberculosis Control Project: This project was started in 2022 BS with tripartite agreement between WHO, Nepal Government, and UNICEF. This project works throughout the country. Nepal Anti tuberculosis Association is assisting this project. This project has main objectives of case finding or identification of tuberculosis disease in patients, distribution of medicines, vaccination (BCG) against tuberculosis, etc. GermanNepalTuberculosisProject(GENETUP):NepalAnti-tuberculosis Association has started GENETUP to fight against tuberculosis in Nepal. This project includes the objectives similar to Tuberculosis Control Project. Besides, it focuses upon DOTS program, which have been very effective for treatment of tuberculosis disease; because, in this program patients of tuberculosis take medicine regularly under direct supervision and observation of medical personnel. Tuberculosis is caused due to a strong bacteria (Tuberculosis Bacilli), and one needs regular intake of medicine for a long period of time to control this disease. In addition to these programs and projects, National Tuberculosis Center is established recently. This is also working for the victims of tuberculosis in Nepal. Some of the main objectives of Nepal Anti-Tuberculosis Association are given below: i. To carry out study and research works in different parts of Nepal to find out status of tuberculosis disease among Nepali people 4 UNICEF : United Nations Children’s Fund(Previously: United Nations International Children’s Emergency Fund) 5 FAO : Food and Agricultural Organization 226 Health, Population and Environment - 10

ii. To make people aware about preventive measures of tuberculosis iii. To provide preventive, promotive, curative, and rehabilitative health services for the victims of tuberculosis iv. To coordinate with government and INGO’s for anti-tuberculosis activities v. To help national organizations by providing assistance to fight against tuberculosis Main activities adopted by this organization in Nepal to control tuberculosis disease are: i. Dissemination of information and knowledge about TB disease, its causes, mode of communication, etc. ii. Organizing different workshops, seminars, and trainings to share and exchange ideas and experiences with others iii. School based TB prevention health education program to penetrate through wide range of human population iv. Conducting community based health education program v. Diagnosis and treatment of tuberculosis patients vi. BCG vaccination program for the children f) Nepal Cancer Relief Society (NCRS) Nepal Cancer Relief Society (NCRS) is a non-profit community-based nationwide social organization founded on Bhadra 21, 2039 B.S with the aim of fighting against the spread of cancer in Nepal. The organization has now established its branches in 40 districts of Nepal and has been mobilizing more than 10,000 volunteers nationwide. NCRS is a pioneer organization for tobacco control in Nepal. NCRS works in both cancer prevention and its cure. Tobacco control is the major preventive activity done by NCRS because it is a sole preventable risk factor for several types of cancer. 9.5 Major Policies and Programmes of Health Sector in Nepal 9.5.1 Policies of Health Sector in Nepal In ancient times, health was regarded as a matter of personal concern. Improvement of overall health is not possible without the participation of all people living in a certain area. Local and central governments must make appropriate health plans and policies to implement them in an effective way. These days, health services are regarded as an indispensable part of fundamental human rights. Health, Population and Environment - 10 227

In Nepal, formal health plans and policies were first brought in the Fifth Five-Year Plan (1975-80). The government launched Health Service Policy in 2048 BS, with the slogan “Health for all by 2000” and other commitments at international forums. There have been some remarkable and important achievements like extension of health posts and sub-health posts in the rural areas, establishment of primary health centres, family planning programs, maternal child health care programs, etc. in Nepal after the formulation of health plans and policies. 15th plan (2076/77-2080/81) also includes very important health policies for the promotion of health status of Nepal. The table given below reflects some health data of Nepal with the achievements and targets of the recent plan of Nepal. Health Achievements and Targets in Different Plans of Nepal SN Health Indicators Figures at Figures at the end of Target of 15th the end of 14th plan: plan: 13th plan achievement: target: (76/77-80/81) 1 Infant Mortality Rate (per 1000) 23 21: 20 14 2 Child Mortality Rate. 38 39: 30 24 3 Total Fertility Rate. 2.3 2.3: 2.1 2.1 4 Maternal mortality rate. 258 239: 145 99 5 Family planning user % 49.6 NA: 60 NA 6 Modern Contraceptive user’s NA 43: NA 53 %. 7 TBA %. 50 52: 70 79 8 Life expectancy (Years). 69 69.7: 72 76 Source: NPC(National Planning Commission), 2073, 2076 BS. Due to political instability and the insurgency in Nepal, the health sector was also adversely affected. A three-year interim plan started 2064 BS. The plan includes the following main objectives: i. Gradual change with promotion of health posts into primary health centres and sub-health posts into health posts on the basis of population density and demand of health services will be made. ii. Basic health services will be made available as a fundamental human right. iii. Emphasis will be given to promoting the health status of socially and economically disadvantaged and marginalized groups of people. Such 228 Health, Population and Environment - 10

groups include women, indigenous (adibasi-janajati), marginalized and suppressed (dalits), elderly people, etc. iv. Provision for management of free beds in government and private hospitals for poor and marginalized people will be made. v. Priority will be given to health infrastructure like buildings, skilled manpower, provision of basic services and medication, etc. vi. Preventive, promotive, curative and rehabilitative health services will be expanded throughout the nation. vii. Health activities will be conducted with focus on continuation of primary health care and its extension to remote rural areas. viii. Sexual and reproductive health including reproductive health education, awareness for safe motherhood, treatment of prolapsed uterus, will be managed to improve maternal health. ix. Gynaecologists will be appointed in district hospitals. x. Urban health program and elderly people health program will be initiated. xi. Assistance to non-governmental organizations will be continued for national health movements like nationwide eye camp service, family planning camps, etc. xii. Programs will be initiated for expansion of alternative health services like Aurvedic medicine, homeopathic medicine, natural therapy, yoga, etc. 9.5.2 Major Programmes of Health Sector in Nepal Programmes in health sectors are designed to implement national health policies effectively. Health programmes help in practical and real execution of health plans to the grassroots level of people. The programmes are mainly categorized into the following three categories. a) Health Service Programmes The services like safe motherhood, family planning service, child health service, venereal diseases and HIV/AIDS control service, malaria and kalazaar control services, natural disaster-rescue service etc. are included in these programmes. b) Public-Private Partnership Programmes In this category of health service, health programmes are designed to promote public health through the combined efforts of public sector and Health, Population and Environment - 10 229

private sectors. It encourages public participation and involvement of the beneficiaries and other stakeholders in decision-making. It is a newer concept that is growing nowadays in every field of public concerns like health and education sectors. c) Special Health Service Programmes Health services provided to suppressed, marginalized, orphans, helpless, victims of conflict and war, and victims of natural disasters. There are social security and health insurance programmes for health security of general citizen. Some of the major programmes in health sector in Nepal are discussed below. • Expanded Programme of Immunization (EPI) • Community-based Integrated Management of Childhood Illness (CB- IMCI) • Family Planning and MCH (Maternal Child Health) Care • HIV/AIDS Control Programme • Vitamin A deficiency and Blindness Control Project • Malaria Control Programme • National Health Education Information and Communication Center (NHEICC) a) Expanded Programme of Immunization (EPI): Immunization is the process of preventing communicable diseases with the help of early administration of antigens of the disease germs. The specific antigens administered make our body able to recognize the causative agents of disease and activate the immune system for the destruction of the germs. In order to prevent fatal communicable diseases like tuberculosis, tetanus, measles, whooping cough and poliomyelitis, the government has launched the extended immunization programme from the year 2034 BS. It was later expanded to the whole nation in 2045 BS. The major objectives of the Expanded Programme of Immunization are: i. To protect children from infectious communicable diseases like diphtheria, measles, tetanus, whooping cough, tuberculosis and poliomyelitis. ii. To make immunization accessible for all children at the grassroots level. 230 Health, Population and Environment - 10

iii. To prevent pregnant women from tetanus iv. To tackle sudden outbreaks of epidemic and endemic diseases In order to achieve the goals mentioned above, the expanded programme encompasses the following strategies: Major Strategies of Expanded Programme of Immunization i. Increasing awareness on immunization and diseases through the process of education ii. Motivating people for optimum participation in the immunization programme iii. Using skilled manpower in immunization to make it effective against the target diseases iv. Organizing TT vaccination programs in schools and the community against from tetanus. v. Providing pregnant women with TT vaccination to protect the mother and fetus from tetanus b) Community-based Integrated Management of Childhood Illness (CB-IMCI): This program, IMCI, is basically designed to tackle major childhood killer diseases like pneumonia, diarrhea, malaria, measles and malnutrition. The core objectives of the CBIMNCI programme is to reduce the morbidity, mortality and disability among newborns, infants and children aged under-five and to improve the nutritional status of children. This programme was first piloted in Mahottari district and was extended to the community level nationwide. The Ministry of Health initiated this programme in 2054 BS with the help of WHO and UNICEF. CBIMCI included the strategies for improving knowledge and case management skills of health service providers, strengthening the overall health system and improving community and household level care practices. CB-IMCI plays a role in contributing to the survival, healthy growth and development of under-five years old children of Nepal. This programme also aims to improve newborn and child survival and their healthy growth and development. The major objectives of CB-IMCI are: • To reduce neonatal morbidity and mortality by promoting essential Health, Population and Environment - 10 231

newborn care services. • To reduce neonatal morbidity and mortality by managing major causes of illness. • To reduce morbidity and mortality by managing major causes of illness among children under five years. In order to achieve the above-mentioned objectives, it has adopted the following strategies: i. Rapid expansion, phase-wise implementation and onsite coaching ii. Strengthen the provision and quality integrated neonatal and child health services at the community and health facility levels iii. Strengthen management of logistics supply iv. Research and innovation for program improvement v. Strengthen home and community-based practices and promote community participation vi. Promotion of birth preparedness plan vii. Promotion of essential newborn care practices and postnatal care to mothers and newborns vii. Identification and management of non-breathing babies at birth viii. Identification and management of preterm and low birth weight babies ix. Management of sepsis among young infants (0-59 days) including diarrhea x. Behavior change communications for healthy pregnancy, safe delivery, healthy newborn and U5 children xi. Improved knowledge related to essential newborn care, nutrition and care of sick children xii. Timely referral of sick children c) Family Planning and MCH (Maternal and Child Health) Care: T h e Family Planning Association of Nepal was formed in 1959 A.D. with the objective of generating awareness on the need for a family planning program at a national level. In 1968, Family Planning, Maternal and Child Health Board was established under the Ministry of Health. The activities of this project included antenatal services, prenatal services, childhood immunization projects, preschool children services, and provision of contraceptives to married couples. New considerations of family planning 232 Health, Population and Environment - 10

programs include the presence of health aid to conduct intensive home visits for follow-up purposes. It also includes the integration of family planning services with other health services. The current plan aims to reduce the Infant Mortality Rate by stressing childhood immunization and rehydration therapy, and to accelerate sterilization programs. Nevertheless, a successful family planning program must be a way of life, where community participation is of utmost importance. Family planning and MCH Care services are delivered from sub-health posts and health posts in rural areas. The services are distributed from hospitals and primary health centres in town areas in Nepal. Private clinics, hospitals and health service providing centres are gradually increasing their services in both rural and town areas in Nepal. The major objectives of Family Planning and MCH Care are: i. To provide periodic health examination services for infants and mothers ii. To provide nutritious foods for children iii. To provide health education to the infants and mothers iv. To make effective provisions for pregnant and delivering mother v. To provide care to the postnatal mother vi. To assist people in deciding a proper family size vii. To make the family happy through the process of health education, health services and family planning services Programs and Strategies of Family Planning and MCH Care i. Counseling married couple regarding contraceptive measures and family planning ii. Providing family planning services for those couple who do not want more children iii. Counseling breastfeeding mothers regarding their health concerns and child's health iv. Providinghealtheducationforthepreventionandcontrolofcommunicable diseases v. Conducting health awareness programs regarding highly infectious diseases like measles, poliomyelitis, diarrhoea, pneumonia, etc. vi. Providing health awareness regarding nutrition and a healthy lifestyle Health, Population and Environment - 10 233

d) HIV/AIDS Control Programme: AIDS was first clinically observed in 1981 in the United States. HIV/AIDS has become a chronic fatal disease in many areas of the world. Human Immuno-eficiency Virus Infection and Acquired Immune Deficiency Syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the Human Immunodeficiency Virus (HIV). Since Nepal's first cases of HIV/AIDS were reported in 1988, the disease has primarily been transmitted by injecting drug use and unprotected sex. Available data indicate that there has been rapid increment in the number of new infections in Nepal. The infection rates of HIV/AIDS in Nepal among the adult population has become a threat to the Nepalese health system. The prevalence rate masks a concentrated epidemic among at-risk populations, such as female sex workers (FSWs), injecting drug users (IDUs), and migrants. Cultural factors have also been shown to play a significant role in the spread of HIV and AIDS in Nepal. The Government of Nepal's National Center for AIDS & STD Control (NCASC) is playing leading role in the prevention and control of HIV/AIDS in Nepal. Major programs against HIV/AIDS in Nepal are: i. To examine blood for finding out the prevalence of HIV/AIDS and other STIs ii. To develop public awareness through formal and non-formal educational process iii. To formulate plans and policies related to HIV/AIDS and STIs iv. To work for rehabilitation of HIV / AIDS victims v. To facilitate HIV / AIDS victims for their life-supportive programs vi. To facilitate programs like HIV / AIDS awareness campaigns and proper use of condom vii. To plan and recommend the inclusion of HIV / AIDS education in the curriculum of national mainstream education e) Vitamin A deficiency and Blindness Control Project : Vitamin A is a group of nutritional organic compounds that includes retinol, retinal, retinoic acid etc. Vitamin A is important for growth, development, maintenance of the immune system and good vision. Vitamin A deficiency, along with several other nutritional disorders, has been a long-standing, major public health problem in Nepal. Deficiency causes xerophthalmia, 234 Health, Population and Environment - 10

or dryness of the eye, and nutritional blindness and also increases the risk of morbidity and mortality. A large proportion of the population, especially children and women, are deprived of modern health services. The Government of Nepal, committed to health for all by the year 2000, had implemented health service-related activities to overcome problems of malnutrition and vitamin A deficiency. In Nepal, an estimated 500 000 people out of a population of 20 million are at risk of total or partial blindness due to vitamin A deficiency, with millions more affected by less severe forms of the disorder. Over the last decade, the government has been committed to raising the levels of awareness in health and nutritional improvement among the rural people and has implemented public health-related measures to tackle problems of vitamin A deficiency. Short-term measures have involved curative activities such as distribution of vitamin A capsules and oral rehydration therapy to treat diarrhoeal episodes in children. Long-term measures have focused on educational and agricultural interventions to enhance production, distribution and consumption of vitamin A-rich vegetables and fruits. f) Malaria Control Programme: Malaria is an infectious disease caused by a parasite: it is spread by the bite of an infected mosquito. People are affected by malaria when the parasite enters the blood. The parasite causes a deadly infection, which kills many people each year. The parasite that causes malaria is a protozoan called 'Plasmodium'. It is carried by mosquitoes. Therefore, prevalence of malaria is more in those places where there are more prevalence of mosquitoes. Despite several challenges like lack of education and poverty, Nepal has made significant progress, achieving and exceeding the malaria targets in the recent years. Based on the evaluation of its National Malaria Control Programme in 2010, Nepal has adopted a long-term Malaria Elimination Strategy 2011–2026 with the vision of a malaria-free Nepal by 2026. The current preventive and control measures should be strengthened to sustain the achievements made so far with improved community involvement. The malaria control programme is currently under execution in 65 districts of Nepal. Ten districts in the mountain region are declared malaria-free districts. Thirteen districts in the Terai region face severe problems of malaria. The malaria control programme, with the assistance from the government, is distributing anti-mosquito nets, mosquito-killing agents to the people free of cost. Some programmes under execution for controlling malaria in Nepal are: Health, Population and Environment - 10 235

i. Identification of malaria in the community ii. Provision of free treatment for the victims of malaria iii. Provision of anti-mosquito agents and net iv. Immunize target victims against malaria v. To conduct awareness programs for the prevention and control of malaria g) National Health Education Information and Communication Center (NHEICC): National Health Education, Information and Communication Center (NHEICC) was established under the Ministry of Health and population in 2051 BS. It is responsible for planning, implementing, monitoring and evaluating awareness raising,information,education and communication program related to health programs and services. NHEICC works under the Ministry of Health and Population(MoHP). The general objective of NHEICC is to raise the health awareness of the people as a means to promote improved health status. Its other major objectives are: i. To increase knowledge, improve skills and promote the desired behavior change on Essential Health Care Services (EHCS) and beyond ii. To create a demand for quality EHCS among all castes and ethnic groups, and disadvantaged and hard to reach populations iii. To advocate for the required resources (human and financial) and capacity development for effective communication programs and interventions to achieve the NHSP (Nepal Health Sector Programme) goals iv. To increase access to new information and technology on health programs v. To raise awareness among the public on communicable and non- communicable diseases and to encourage all to seek preventive measures vi. To intensify and strengthen action against tobacco use, both smoked and smokeless, excessive use of alcohol, unhealthy diets and physical inactivity vii. To mitigate public panic and respond to communication needs during emergency situations. viii. To promote environment health, hygiene and sanitation. 236 Health, Population and Environment - 10

9.6 Bad Habits, Its Effects and Measures for Prevention A habit is a routine of behavior that is repeated regularly and tends to occur subconsciously. In other words, a habit is a more or less a fixed way of thinking, or feeling acquired through previous repetition of a mental experience. A bad habit is a negative behavior pattern. Common examples include the habits of taking junk food, gambling, sticking with electronic gadgets, sex abuse, etc. a) Bad food habit Food is essential for healthy survival. Food is the source of nutrients required for our body. But food becomes the source of harmful components if we have bad food habit. The habit of taking junk food, street food, stale food, spicy food and food containing harmful chemicals damages our health. Therefore, we should avoid such bad habits. b) Gambling Gambling is the activity of playing a game for betting on an uncertain outcome. Gambling does not include bona-fide business transactions valid under the law. There are certain games which are famous in gambling. Some of them can make the players (gamblers) addicted to the games. Many people have lost their property in gambling and have become bankrupt overnight. When a person develops a habit of participating in gambling, s/he loses the capacity to analyse the adverse outcomes. Instead, s/he gets in gambling despite the loss of property. Playing cards, dice etc. are some examples of gambling in Nepal. We must remain far from such bad habits. c) Prolonged engagement with electronic gadgets Electronic gadgets mean the Electronic Gadgets electronic machines like the mobile phone, television set, electronic gaming devices, i- pads, computers and laptops. It is good to use them for knowledge or for getting essential and genuine information. There are many disadvantages of using them in wrong ways. Sticking to Health, Population and Environment - 10 237

the Internet for prolonged time makes people physically inactive. Non communicable diseases like diabetes, cardiovascular diseases, eye problems, spinal cord disorders are common disadvantages related to our health caused by the habit of using them in a wrong way. Besides, prolonged engagement in social networks spoil the precious time that can be utilized for productive works, research and study. Incidents of cyber crimes and social problems are also found to be the adverse effects of using mobile and internet in a wrong way. Therefore, we must be conscious regarding our ways of using these modern achievements of information and communication technology. d) Sex abuse Sexual abuse is usually undesired sexual behavior by one person upon another. The offender is referred to as a sexual abuser. The term also covers any behavior by an adult or older adolescent towards a child to involve in any form of sexual activity. It also means the habit of being involved in sex with multiple partners. Such habits are against our moral and social norms. They may cause transmission of several venereal diseases like HIV/AIDS, gonorrhea and syphilis. e) Alcoholism Alcohol is a chemical compound, which is formed by the decomposition of organic matters. Its main constituent is ‘ethanol’, which generates abnormal brain waves and creates a feeling of different sensations. If alcohol intake is excessive, the person may die due to poisoning or intoxication. If alcohol intake becomes frequent for a certain time, a habit develops, which develops a desire to take it again and again. Such condition is known as alcoholism. Alcoholism has been a common problem of Nepal, persisting equally in the rural, urban, underdeveloped and developed areas. There are various types of alcohol in the market. Alcohol is widely sold openly in the markets of Nepal. It is easily available, and there is no strict restriction on alcoholic use. The extent of alcoholic production, transaction and tax collection is so high that policy makers refuse taking effective actions against alcoholism in Nepal. It has been a burning social problem in Nepalese society. Some laws on controlling alcoholism have been initiated by the government to regulate its transaction within legal parameters. 238 Health, Population and Environment - 10

Causes of alcohol intake Alcohol is a familiar drink in most parts of the world from ancient time. In some ethnic groups, alcohol has an indispensable role in their cultural and religious practices. Even in the holy book of the Hindus–Rigbeda, alcohol (Somaras) has been described as an energetic drink extracted from a specific climber plant called ‘Somalata’. Some of the causes of alcohol intake are: i. Alcohol is used for entertainment and recreational purpose during feasts and festivals. ii. Alcohol has some religious and cultural support. iii. It is commonly used to be relieved from tiredness and muscle ache by those persons who involve in hard physical labor. iv. Some think that it makes the digestion easy. v. People take alcohol under pressure and requests from friends and relatives. vi. Some are attracted by advertisements. vii. Worldwide tradition of welcoming and entertaining guests with alcohol. viii. Wrong belief that alcohol reduces tension and mental stress. Effects of alcoholism Immediate or short-term effects i. Alcohol acts as a stimulant. It increases uncontrolled physical and verbal activities. ii. Alcohol acts as a depressant on some people. Under such effect, the physical and verbal activities decrease. iii. A person vomits if the intake is excessive. iv. Body becomes imbalanced and passive. In the case of excessive intake, unconsciousness may occur. v. Causes impaired, blurred, or double vision due to imbalanced movement of the eye muscle. vi. Loss of short-term memory. Long-term effects Physical effects i. Alcoholism decreases the performance of the body systems. ii. Liver is affected severely, leading to liver damage or cirrhosis. iii. It causes infertility. Health, Population and Environment - 10 239

iv. Digestive system is affected adversely. v. Symptoms of ageing start earlier. Mental effects i. Thinking capacity and creativity decrease. ii. Loss of memory is experienced. Social effects i. The drunkard loses social prestige. ii. Social relationships are disturbed. Prevention and control of alcoholism Alcoholism has been a problem all over the nation. In urban areas, there is a trend of alcohol intake among all groups of people, from children to elderly people. It is widely available in our markets, and everybody can purchase desired brands of alcohol easily. Following measures can be adopted for prevention and control of alcoholism: i. Awareness program should be conducted. ii. Proper knowledge and information about alcohol and alcoholism should be included in formal and non-formal educational programs. iii. The cultural and religious norms promoting alcoholism should be discouraged. iv. Alcohol should be banned in public places v. Strict laws and rules should be made to manage the production and distribution of alcoholic substances. vi. There should be the initiation of an organized effort for rehabilitation of drunkards. People should remain far from friends who drink regularly. vii. Utilization of free time in recreational and creative activities can help avoid alcoholism. 9.7 Tobacco, Smoking and Drugs (Effects and Measures for Prevention) 9.7.1 Tobacco and Smoking Introduction Tobacco is an agricultural product processed from a herb of the genus Nicotiana containing a toxin called nicotine that produces an euphoric effect in the human 240 Health, Population and Environment - 10

brain if taken. Besides nicotine, there are tar and other chemical substances which give a remarkable sensation if taken. It is taken in many ways. Chewing tobacco, cigarette, bidi, etc. are common forms of tobacco intake. Tobacco gums are also manufactured in the form of chewing gum, which is helpful for those who want to give up tobacco. Tobacco is a major cause of diseases all over the world. About five million people die in the world every year due to tobacco-borne diseases. It is estimated that the number reached 10 million in the year 2020. It has been proved that the chance of heart diseases, brain strokes, asthma, and lung cancer are 3, 1.5, 1.5 and 12 times more respectively in tobacco users than others. It lowers the body temperature and reduces temperature difference between the environment and body. Due to the fall in difference in temperature, the user feels virtual warmth, which leads people to tobacco abuse. Tobacco contains more than 4,000 poisonous substances, in it. Among them, 43 substances including nicotine and tar, are carcinogenic (i.e., causing cancer). Causes of tobacco intake There are many causes behind the habit of tobacco intake. People start tobacco intake primarily in late childhood and adolescent period. Some of the main causes of tobacco intake are listed below: i. Imitation of tobacco intake among peer groups ii. Request and pressure in friends’ circle iii. Imitation of senior members in the family and community iv. To satisfy the curiosity of taste and become habituated v. To have the wrong notion that it reduces tension and gives pleasure vi. To have a desire to be mature and an adult vii. To adopt the habit as a fashion viii. To feel warm in cold season Health, Population and Environment - 10 241

Effects of tobacco intake Immediate or short-term effects i. Vertigo and nausea among beginners ii. Feeling of intoxicated sensation with change in brain waves, which the abusers term as “pleasure” iii. Sudden fall in body temperature iv. Increase in pulse rate v. Irritation in respiratory track Long-term effects i. Teeth, skin, nails, fingers and palm turn yellowish ii. Asthma, cough, cancers and heart diseases iii. High chance of heart attack and brain stroke iv. Low function of nervous system; gradual damage of optic nerve causing blurred vision and progressive blindness v. Still births or miscarriage in women vi. Increased level of nicotine, causing desire of regular and continued nicotine intake Control of tobacco intake i. Management of proper health education including the knowledge about tobacco ii. Awareness program in village and town areas especially focused on adolescents iii. Declaration of smoking-free zones in public places iv. Restriction on advertisements in public media and public places v. Encouraging people to have healthy personal habits vi. If the abusers want to give up this habit, the following methods can be adopted • Have a strong commitment to give up tobacco and stop the habit abruptly. • If not possible, start declined doses with reduced frequency. • Initiate soft forms of tobacco like tobacco gums and other soft alternatives like clove, pepper, etc. • Increase involvement in creative, recreational and entertaining activities. 242 Health, Population and Environment - 10

9.7.2 Drugs In general, a drug is a chemical substance that can alter the physiological process of body systems. Drugs are used as a medicine or used in a medicine. The meaning of drugs is not confined to its general meaning if drugs are abused. Besides this, other non-medicinal addictive substances are also consumed nowadays. Some of the drugs and substances used commonly by drug addicts are: Tidigesic, Norgesic, diazepam, ibuprofen, opium, morphine, heroin, cocaine, cannabis, etc. The world Health Organization defines drug as “any chemical entity or mixture of entities, other than those required for the maintenance of normal health, the administration of which alters the biological function and possible structure.” Drug abuse kills life A drug addict becomes addicted after crossing certain stages. The stages are drug use, drug misuse and drug abuse. The necessary intake of a drug as prescribed by a medical practitioner, is called drug use. Sometimes, drugs use is essential for continuation of survival. If a person takes drug in an inappropriate way for any purpose without the prescription of medical personnel, it is called drug misuse. The deliberate use of an illegal drug or of too much of a prescribed drug is called drug abuse. When a drug user practises its abuse repeatedly, that may result in drug addiction. Drug addiction is the condition when an individual experiences a repeated psycho-physiological need to take a habit- forming drug for compulsive satisfaction or intoxication. The intoxication produced by the drugs is termed as euphoria. Drug addiction has become a worldwide psychosocial problem today. Health, Population and Environment - 10 243

Causes of drugs addiction i. Most of the addicts learn to take drug from friends. ii. Drug abuse is taken wrongly as a solution to frustrations in life. iii. Drug addiction is promoted by religon. Some Hindus take drugs to appease Lord Shiva. iv. Abusers try to influence others to take drugs. v. Due to curiosity about drug intake among adolescents. Effects of drug intake i. Reduction of smooth body functions ii. Reduction in motor coordination iii. Change in body homeostasis: elevated blood pressure and heartbeat iv. Loss of appetite v. Headache, sweating, nausea, dizziness vi. Increases vulnerability of needle based communicable diseases, like HIV/ AIDS, hepatitis B, hepatitis C, etc. vii. Loss of memory and comprehension viii. Loss of social behavior: imbalance in social relationships, inclination to social crimes, etc. Prevention and Control of Drug Abuse i. Management of proper health education including knowledge and information about drugs in school and higher education. ii. Public awareness programs against drug abuse by government and non- government organizations. iii. Enforcement of strict laws and acts to monitor and control illicit drug abuse. iv. Management of recreational and rehabilitation centres. v. Family workshops and family counseling on drug abuse. vi. Participation of vulnerable groups (children and adolescents) in anti drug abuse movement. vii. Have good harmony and peace in families. viii. Provision of strict punishment and fine against illicit drug distributors and producers. 244 Health, Population and Environment - 10

Notes • Consumers’ health means the state of health determined and affected by the use of goods and services available in the market. • A consumer is a person or institution who consumes or uses the services and goods available in the market. • Communityhealthisdefinedasascienceandartofdevelopingabalanced integration of curative, promotive, preventive and rehabilitative health services to make a community healthy by promoting environmental and personal health of a community through organized community effort. • Preventive health services are the set of healthcare provided to healthy people for the prevention of susceptible diseases. • Promotive health services are the set of healthcare provided to healthy people for further improvement of their health status. • Curative health services are the set of health services used for diagnosis and treatment of diseases. • Nepal government has adopted a hierarchical distribution channel of health service centres. It consists of the service centres at central, province, district, electoral constituency, ilaka, village, community and ward levels. • Public-Private Partnership Programmes are the set of health programmes which are designed to promote public health through the combined efforts of public sector and private sectors. It encourages public participation and involvement of the beneficiaries and other stakeholders in decision-making. • The core objectives of the CBIMNCI (Community-based Integrated Management of Childhood Illness) programme is to reduce the morbidity, mortality and disability among newborns, infants and children aged under-five and to improve the nutritional status of children. • Family planning and MCH services are delivered from sub-health posts and health posts in rural areas. The services are distributed from hospitals and primary health centres in the urban areas in Nepal. Health, Population and Environment - 10 245

• Nepal has adopted a long-term Malaria Elimination Strategy 2011–2026 with the vision of a malaria-free Nepal by 2026. • National Health Education, Information and Communication Center (NHEICC) is responsible for planning, implementing, monitoring and evaluating awareness raising,information,education and communication program related to health programs and services. • Alcohol intake becomes frequent for a certain time, a habit develops, which develops a desire to take it again and again. Such condition is known as alcoholism. • The necessary intake of a drug as prescribed by a medical practitioner, is called drug use. • If a person takes drug in an inappropriate way for any purpose without the prescription of medical personnel, it is called drug misuse. • The deliberate use of an illegal drug or of too much of a prescribed drug is called drug abuse. When a drug user practises its abuse repeatedly, that may result in drug addiction. Exercise A. Give very short answers to the following questions. 1. Define consumers' health. 2. When was 'Consumers Protection Act' enforced in Nepal? 3. How many primary health centres were there in 2006 in Nepal? 4. Write the full form of OPD and IPD. 5. How many indoor beds are there in the OPD of a hospital? 6. What was the target of the 15th Plan of Nepal for Infant Mortality Rate? 7. Define alcoholism. 8. Write one reason that triggers people to take alcohol. 246 Health, Population and Environment - 10

9. How many people in the world die due to tobacco-borne diseases every year? 10. What type of program can be conducted by non-governmental organizations to control drug abuse? B. Give short answers to the following questions. 1. Briefly describe the concept of community health. 2. Differentiate between health post and health center. 3. List major five hospitals in Nepal. 4. Write short notes on: a. CB-IMCI b. MCH care c. NEICC 5. What are the health-related objectives of the current developmental plan of Nepal? 6. What are short-term and long-term effects of alcohol? Explain. C. Give long answers to the following questions. 1. Why do people take tobacco? Explain five reasons with reference to your local context. 2. Define drugs, drug abuse, drug misuse and drug abuse. How are they interrelated with each other? Explain. 3. What are common bad habits? How do they affect human life? Explain 4. 'Alcoholism has become a severe social problem in Nepal.' Examine the causes and suggest five effective measures of controlling it in our society. 5. It is not possible to achieve good health through an individual's effort only. Clarify it. 6. There is need of healthy manpower to develop a nation. Explain. 7. \"It is better to prevent diseases than cure them.\" Clarify it with suitable examples. 8. How can you prevent your friends from alcoholism and tobacco use? Explain. 9. Tobacco and tobacco related substances harm human health. Justify. 10. List any five voluntary health agencies of Nepal. Give brief introduction to them. 11. Give detailed introduction to : a. Nepal Paropakar Association b. Nepal Redcross Society Health, Population and Environment - 10 247

Primary Health 10 Care, Risk Awareness and Safety Education Contents 10.1 Methods and Procedures of First Aid 10.1.1 First Aid on the Basis of Time, Place and Nature of Casualty: Things to Be Considered by the First Aid Provider. 10.1.2. First Aid Box 10.1.3. Major Techniques of First Aid 10.2 First Aid in Certain Cases 10.3 Human Health 10.2.1 Balanced Diet 10.3.2 Healthy Environment 10.3.3 Physical Activities 10.2.4 Safer and Healthy Lifestyle 248 Health, Population and Environment - 10

10.1 Methods and Procedures of First Aid ‘Aid’ is the assistance, or help given to somebody in a difficult situation. The difficult situations may result due to an accident, injury or any sort of sudden harm. Therefore, ‘first aid’ should be understood as the first assistance, or help given to a casualty until a medical personnel and service become available. The objectives of first aid are: i. To save the life of the casualty before appropriate medical care becomes available. ii. To manage medical care for the casualty as soon as possible. iii. To manage proper rest and provide consolation to the casualty. First aid can save life in difficult situations. There is a proverb, ‘accidents occur accidentally’, though some accidents occur due to negligence and lack of knowledge of safety education. In any sort of situation, first aid can be a milestone in the minimization of harm and continuation of life. The importance of first aid is can be listed as: i. It helps in reduction of physical and mental harm to the casualty. ii. It helps in quick-management of proper health care to the casualty. iii. The casualty can get psychological comforts. iv. First aid can be the main source of proper information about accidents and probable harms. Availability of medical personnel and services can be made available by two ways: i. By taking the casualty to a medical center ii. By calling an ambulance or doctor to visit the casualty First aid is given by any person near the casualty. There may not be an expert at the time of accident or injury. Therefore, everybody must have the knowledge of first aid. Education about first aid brings knowledge to students about the need to help the wounded, injured, fainted, drowned and other people having similar sudden health problems in different situations. 10.1.1 First Aid on the Basis of Time, Place and Nature of Casualty: Things to Be Considered by the First Aider Methods and procedures of first aid are not the same in different situation. They differ according to time, place and nature of the casualty. Accidents Health, Population and Environment - 10 249

may occur at any time. It is very difficult to provide first aid at night time. Accidents and injuries may happen in remote places as well. Similarly, the intensity of the injury and risks differs according to the nature of the casualty. The first aider should be conscious enough to determine the level and quick steps to be taken with preference. The casualty should be provided with basic and life saving aid like stopping the bleeding, removal of obstructions in the respiratory tract etc. In the towns, we can call an ambulance or any other motor vehicle to take the victim to the nearest health center. In rural areas, we have to manage convenient carrying tool. If the victim is out of danger and recovering with rest, we should let him/her remain calm. It is the first aid aider, who should take the right decision with reference to the time, place and nature of casualty. 10.1.2. First Aid Box A first aid box is also called a first aid kit. It is a small box with essential materials and equipments required for providing first aid. It is generally used among students of schools. It is also kept at police stations, sports clubs, playground, vehicles, fairs, etc. Some of the common materials and devices kept in the first aid box are given below: First Aid primary care guide Rehydration agent Small diary book (e.g. Jeevan Jal) Crepe and woven bandages Thermometer Triangular bandage Thread and rubbers Tincture Iodine Torch light Gauze swabs Scissors Medium dressing Soap and handkerchief Pencil Safety pins Cotton swab Sterile info card Wound closure strips Scalpel Vinyl gloves Syringes Antiseptic wipes (e.g. Dettol) Sterile pieces of cloth Aspirin tablets Paracetamol tablets Micropore tape Ibuprofen tablets 250 Health, Population and Environment - 10