Journal of Nepal Medical Association 2018-06-02T12:15:26+00:00 Dr. Angel Magar Open Journal Systems <p>Journal of Nepal Medical Association is an internationally peer reviewed, MedLine/PubMed indexed,&nbsp;a general medical journal of Nepal Medical Association. JNMA is the first and oldest medical journal from Nepal since 1963 AD. JNMA is available at <a href="">PubMed</a>, <a href=";query&quot;%3A%7B&quot;filtered&quot;%3A%7B&quot;filter&quot;%3A%7B&quot;bool&quot;%3A%7B&quot;must&quot;%3A%5B%7B&quot;term&quot;%3A%7B&quot;index.issn.exact&quot;%3A&quot;1815-672X&quot;%7D%7D%2C%7B&quot;term&quot;%3A%7B&quot;_type&quot;%3A&quot;article&quot;%7D%7D%5D%7D%7D%2C&quot;query&quot;%3A%7B&quot;match_all&quot;%3A%7B%7D%7D%7D%7D%2C&quot;from&quot;%3A0%2C&quot;size&quot;%3A100%7D">DOAJ</a>, <a href=";btnG=&amp;hl=en&amp;as_sdt=0%2C5">Google Scholar,</a>&nbsp;Index Copernicus, EBSCO, EMBASE and other repositories.&nbsp;</p> <p>The JNMA abide by:<br>1. International Committee of Medical Journal Editors for Uniform Requirements for Manuscripts Submitted to Biomedical Journals<br>2. World Association of Medical Editors for best editorial practice<br>3. Council of Science Editors for best editorial practice<br>3. Committee on Publication Ethics for practising good publication ethics</p> <p>&nbsp;JNMA is included and associated with</p> <p><a href=""><img src="" alt="Member of OASPA" height="75"></a>&nbsp;,<img src="" alt="Search JNMA article in DOAJ">&nbsp;,&nbsp;&nbsp;<a href=";as_epq=&amp;as_oq=&amp;as_eq=&amp;as_occt=any&amp;as_sauthors=&amp;as_publication=jnma&amp;as_ylo=&amp;as_yhi=&amp;hl=en&amp;as_sdt=0%2C5"><img src="" alt="Search JNMA article in Google Scholar" height="75"></a>,<img src="" alt="Member of OASPA" width="121" height="75">,<img src="" alt="" height="75">,</p> <h1><a href=";Full=journal%20of%20nepal%20medical%20association" target="_blank" rel="noopener">Science Citation Index</a></h1> Peritoneal Dialysis or Haemodialysis for Kidney Failure? 2018-05-31T20:57:12+00:00 Badri Man Shrestha 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Prevalence of Internet Addiction and Associated Psychological Co-morbidities among College Students in Bhutan 2018-05-31T21:15:33+00:00 Karma Tenzin Thinley Dorji Mongal S Gurung Dorji Pelzom Sandip Tamang Umesh Pradhan Gampo Dorji <p>Introduction: Globally 3.5 billion people have access to internet and most of them are young adults and adolescents. In South Asia, Bhutan has the highest proportion of population with internet access at 37% in 2016. Many studies in Asia have reported significantly high level of internet addiction among college going students. In this light, this study was designed to estimate the prevalence of internet addiction and other co-morbidities. <br>Methods: This cross sectional study included 823 first year and final year students aged 18-24 from six colleges in Bhutan. A self-administered questionnaire consisting of three parts was utilized for data collection. The data was entered and validated in Epidata and analyzed using STATA/IC 14. <br>Results: The prevalence of moderate and severe internet addiction was 282 (34.3%) and 10 (1%) respectively. Positive correlations between internet addiction and psychological well-being (r= 0.331 95% CI: 0.269, 0.390), between Internet Addiction score and years of internet usage (r=0.104 95% CI: 0.036, 0.171), age and years of using internet (r= 0.8 95% CI: 0.012, 0.148) were observed. The commonest mode of internet use was martphone 714 (86.8%). The use of computer laboratory (aPR 0.80, 95%CI: 0.66, 0.96) and internet use for news and educational purposes (aPR 0.76, 95%CI: 0.64, 0.9) showed protective effects. <br>Conclusions: The prevalence of internet addiction is high among the college going students in Bhutan. This warrants timely interventions to address the problems of internet addiction.</p> 2018-05-03T14:31:46+00:00 ##submission.copyrightStatement## Periodontal Health Status and Pregnancy Outcomes: A Survey in Medical Doctors 2018-06-02T12:13:03+00:00 Sujaya Gupta Barsha Shrestha Neha Gupta Anik Tuladhar Sushil KC Bhageshwar Dhami <p>Introduction: Periodontal disease and caries are the most common causes of tooth loss worldwide. Studies have demonstrated strong association between periodontitis and adverse pregnancy outcomes. Medical doctors, who are the primary healthcare providers, seldom advise women to seek dental care during pregnancy. This study was undertaken to explore the knowledge, attitudes and behaviours of medical doctors towards oral health and to identify the barriers of prenatal periodontal healthcare in their practices and its possible implications on pregnancy outcomes.<br>Methods: Total 377 doctors filled the questionnaire. The data collected through personal contacts, social networking, emails, online forms and networking at conferences were analysed using Statistical Package for the Social Sciences 20 software program and presented in tables, charts and diagrams.<br>Results: Out of 263 (69.8%) male and 114 (30.2%) female doctors enrolled in the study, only 52 (13.8%) had received education or training on oral care during pregnancy. Among them 299 (79.3%) agreed that there is possible link between health of teeth-gums and pregnancy. Approximately 105 (27.9%) encountered patients with oral/periodontal problem every week but only 108 (28.6%) “always” advised their patient for regular dental check-ups. Similarly, 358 (95%) agreed that there is need for universal guidelines however, 133 (35.3%) thought there was insufficient time to advice patients on oral health during check-ups.<br>Conclusions: An adequate referral system to oral healthcare providers and biannual check-ups is recommended for both general patient as well as pregnant women for preventing adverse situations related to oral and specifically periodontal diseases.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Accuracy of Frozen Section with Histopathological Report in an Institute 2018-05-31T20:57:12+00:00 Purbesh Adhikari Paricha Upadhyaya Smriti Karki Chandra Shekhar Agrawal Shyam Thapa Chhetri Ajay Agrawal <p><span style="margin: 0px; color: black; line-height: 107%; font-family: 'Times New Roman','serif'; font-size: 12pt;">Introduction: Frozen section helps in rapid intra-operative diagnosis. It is commonly used during surgical procedures to detect malignancy so that modifications of surgery can be decided at the time of surgery on the table. Frozen section is also performed for evaluation of surgical margins and detection of lymph node metastasis. In addition it is applied for detection of unknown pathological processes.The objective of this study was to assess the accuracy of frozen section diagnosis in comparison to gold standard histopathological diagnosis and to find concordance and discordance rate of frozen section with histopathological report.<br>Methods: This was a cross sectional study of 41 frozen section samples done in the department of pathology of BP Koirala Institute of Health Sciences from September 2014 to August 2015. All frozen section samples with their permanent tissue samples sent for final histopathological evaluation were included in the study.<br>Results: The overall accuracy of frozen section diagnosis was 97%. The sensitivity was 94%, specificity was 87%, positive predictive value was 90% and negative predictive value was 93%. The concordance rate was 90.2% and the discordance rate was 9.8%.<br>Conclusions: The results of frozen section varied in different organ systems and the common cause of discrepancy in our study were the gross sampling error and the interpretational error. </span></p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Knowledge and Awareness Regarding Dental Implants among Patients Attending a Tertiary Care Center 2018-05-31T20:57:12+00:00 Anjana Maharjan Sagun Regmi Reshu Agrawal Sagtani <p>Introduction: Loss of natural teeth is a debilitating and irreversible process, which leads to functional, cosmetic and psychological morbidities. Dental implant serves as one of the options of tooth replacement, which are stronger, functionally effective and more durable. However, public awareness regarding it has been found to be low in Asian countries. This study was designed to know the status of knowledge and awareness of dental implant.<br>Methods: Seventy nine patients visiting dental department of Patan Academy of Health Sciences were included in this study through non-probability sampling. Data on knowledge and awareness regarding dental implants were collected through a survey after ethical approval from Institutional Review committee of Patan Academy of Health Sciences. Data entry was done in Epidata and analyzed with the help of Statistical Package of Social Sciences version 20.<br>Results: Total 33 (41.8%) of study populations choose dental implant as alternative for replacing teeth, 22 (30.4%) choose fixed dental prosthesis. 36 (45.6%) and 32 (40.5%) of population stated that long treatment time and high cost respectively as the disadvantages of dental implants. Only 12 (15.2%) were aware that dental implants are anchored in jaw bone. The source of information about dental implants was dentists for 48 (60.8%) of the patients followed by friends, media and medical doctors. <br>Conclusions: Within the limitations of this study, we conclude that awareness of patients attending tertiary care center of Kathmandu valley is low. Hence, there is a need of organizing dental education programs to create awareness about dental implants.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Relationship of Body Mass Index with Dental Caries among Children Attending Pediatric Dental Department in an Institute 2018-05-31T20:57:12+00:00 Parajeeta Dikshit Senchhema Limbu Rosina Bhattarai <p>Introduction: Oral health, the mirror of general well being, is altered by many mediators like infection, chronic inflammation, and genetic predisposition. The present dietary pattern among children is contributing to childhood overweight as well as increasing the risk for developing dental caries. The food habits contributing to dental caries as well as obesity are similar. Undernutrition has also shown to be associated with the dental caries. The study was conducted to investigate the relationship of body mass index to dental caries.<br>Methods: A cross sectional clinical study was conducted on 7 to 12 year old children, studying in public schools, visiting the Department of Pediatric Dentistry for a routine dental check up. The study evaluated the nutritional status by calculating the body mass index using the formula BMI= Weight (kg)/Height2 (m2). Then their Body Mass Index and correlated with the Dental caries status using WHO criteria for decayed, missing and filled teeth index. Data analysis was done by SPSS 20 software program.<br>Results: Total of 251 children between 7 to 12 years were evaluated. The mean age of the participants was 9.12 years. No statistically significant result was found on comparing the nutritional status to dental caries (P=0.43). A statistically significant difference though was found on comparing dental caries status among gender (P=0.021) as well different age groups (P=0.031).<br>Conclusions: The study showed the presence of more normal and underweight children but there was no statistically significant association between body mass index and decayed, missing and filled teeth index.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Feto-maternal Outcomes of Emergency Caesarean Section following Residential Posting at Dhading District Hospital 2018-05-31T20:57:12+00:00 Pramod Kattel <p>Introduction: Caesarean section is a commonly performed major obstetric surgery to deliver baby under certain indications which may be maternal or fetal. If performed timely, it is helpful to save the life of mother and fetus and if not, it increases both maternal and fetal risks. <br>Methods: A hospital based descriptive cross-sectional study was conducted at Dhading district hospital from 17th October 2016 to 17th October 2017. Total of 41 patients undergoing emergency caesarean section meeting the selection criteria were included. <br>Results: The incidence of emergency caesarean section was 41 (5.5%). Most common indication for caesarean delivery was fetal distress in 12 (29.3%) followed by failed induction and cephalopelvic disproportion each accounting 6 (14.6%) cases. The least common causes being chorioamnionitis and cord prolapse in 1 (2.4%). Regarding perinatal outcomes, 33 (80.5%) babies delivered were of normal weight. Low Apgar score (&lt;7) at one minute was noted in 8 (19.5%) cases. Neonatal resuscitation in the form of oxygen supplementation was required in 2 (4.9%) cases whereas bag and mask ventilation was required in 5 (12.2%) cases. Referral for neonatal intensive care unit admission was done in 6 (14.6%) cases. There were three neonatal deaths.<br>Conclusions: Residential posting was fruitful to decrease feto-maternal morbidities and mortalities. Even to minimize the delay of treatment, government should provide adequate equipments and skilled man-power to run neonatal intensive care unit. </p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Length of Stay of Psychiatric Admissions in a Tertiary Care Hospital 2018-05-31T20:57:12+00:00 Madhur Basnet Nidesh Sapkota Suren Limbu Dharanidhar Baral <p>Introduction: The length of stay among psychiatric in-patients is usually longer than that of others. In-patient management is costly and longer length of stay can lead to catastrophic costs. We conducted this study to explore about the length of stay of psychiatric admissions and factors affecting it.<br>Methods: We collected the data of all the patients admitted to the psychiatric ward of B. P. Koirala Institute of Health Sciences from 1st January 2007 to 31st December 2016 from the database of the medical records section after ethical approval. The sociodemographic and clinical variables were analyzed using SPSS 20.0 version. Length of stay more than 3 weeks was considered as long stay. Bivariate and multivariable logistic regression analyses were conducted to identify factors associated with length of stay.<br>Results: There were 3687 admissions during the study period. The average length of stay was 19.36 (±13.14) days. On logistic regression, the factors associated with shorter length of stay were: male gender (aOR= 0.79, 95%CI: 0.68-0.93), being self employed (aOR= 0.17, 95%CI: 0.12-0.22), homemakers (aOR= 0.18, 95%CI: 0.14-0.24), farmers (aOR= 0.20, 95%CI: 0.15-0.27) and students (aOR= 0.23, 95%CI:0.17-0.32). Similarly, factors associated with longer length of stay were: being from other Eastern Terai districts(aOR=1.37, 95%CI: 1.11-1.70), other Eastern Hill districts (aOR= 1.68; 95%CI: 1.29-2.20), diagnosis of schizophrenia and related disorders (aOR=4.01, 95%CI: 1.34-12.0), having medical co-morbidity (aOR= 3.47; 95%CI: 2.49-4.84) and being readmitted (aOR= 1.23, 95%CI: 1.03-1.47).<br>Conclusions: There was significant association of length of stay with gender, age, address, occupation, diagnosis and readmission</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Awareness of Infection Control among Dental Students and Interns 2018-05-31T20:57:12+00:00 Barsha Ghimire Suresh Chandra <p class="p1">&nbsp;</p> <p class="p2"><span class="s2"><strong>Introduction: </strong></span>Disease transmission can occur through direct contact, blood, oral fluids, or other secretions and indirect contact with contaminated instruments, operatory equipment, or objects. Prevention of cross contamination helps in reducing the infection. The level of education of the students, and their knowledge about the infection control directly relates to the patient care. The current study aims to determine the level of knowledge and infection control procedures among dental students in a clihnical practice.</p> <p class="p2"><span class="s2"><strong>Methods: </strong></span>This was a cross-sectional study with a self-administered questionnaire comprised of 18 open and close-ended questions related to infection control and prevention. Answers of the questions were analysed by SPSS version 20.</p> <p class="p3"><strong>Results: </strong>Among the students included, 53 (36.8%) participants were intern, 31 (21.5%) from fifth year, 31 (21.5) from fourth year and 29 (20.1) were third year. Performance satisfaction shows that the students were fairly satisfied with their performance. When students were asked to rate the implementation of infection control policy in their clinical practice 1 (0.7%) were very good, 74 (51.4%) were fair, 44 (30.6%) were good are while 25 (17.4%) were poor to implement infection control policy in their practice.</p> <p class="p4"><strong>Conclusions: </strong>The level of knowledge and practice of infection control measures was poor among dental students. The attitude towards infections control measures was positive, but a greater compliance was needed. Formal class and examination may help improve knowledge and clinical practices.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Blood Component Separation Service: A New Experience in an Institution 2018-05-31T20:57:13+00:00 Santosh Upadhyaya Kafle Gaurav Kattel Tanchona Nembang Smriti Karki <p>Introduction: Blood component separation facility began dispatching its blood component units from 21st April 2013 at the new blood component separation service complex at B.P. Koirala Institute of Health Sciences. With the supply of blood components being finite and with the added recognition of a high rate of inappropriate use of blood component services around the world, there is a need to monitor these services. Our study was conducted to identify blood component utilization pattern in institute and to know about different blood components demand for future preparedness. <br>Methods: This retrospective study was conducted at B.P. Koirala Institue of Helath Sciences, Dharan, Nepal for blood component dispatched from 21st April, 2013- 12th February, 2014. Blood components requisitions from all clinical department were reviewed regarding the specific component requested, blood group and socio-demographic profile.<br>Results: Among 3054 transfusion units dispatched, 1552 were males, 1498 females and 4 unspecified. Likewise, 1722 were pack cell volume, 808 platelet rich plasma, 523 fresh frozen plasma and 1 cryoprecipitate disptached respectively with majority of A positive blood group demanded from Neonatal and Paediatric Intensive Care Unit ward for Packed Cell Volume was 201 and Fresh Frozen Plasma was 300 followed by emergency ward for Platelet Rich Plasma. About 197 (6.45%) requistions forms lacked the details of requesting department, while some even reveal multiple demands.</p> <p>Conclusions: Packed Cell Volume of A positive blood group being the predominant blood component requested from Neonatal Intensive Care Unit/Pediatrics Intensive Care Unit ward at the institute making most requests.&nbsp;</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Knowledge, Awareness, and Attitude Regarding Dental Implants among Dental Interns 2018-06-02T12:15:26+00:00 Arati Sharma Bidhan Shrestha Bijay Kumar Chaudhari Pramita Suwal Raj Kumar Singh <p class="p2"><span class="s2"><strong>I</strong></span><span class="s3"><strong>ntroduction: </strong></span>Implant therapy is an elective dental procedure of dental rehabilitative treatment. Objective of this study was to assess the knowledge, awareness, and attitude of dental interns of Nepal toward dental implants and to see associations of the responses with gender and geographic location of dental college.</p> <p class="p2"><span class="s3"><strong>Methods: </strong></span>It was conducted from June 2016 to June 2017 after taking ethical clearance and approval from the research committee. The sample included the interns who were present at the time of the survey. Data collection was done through a cross-sectional questionnaire survey, during clinical postings of the interns at all the dental colleges of Nepal, supervised and monitored by the investigators themselves; coded and entered in Microsoft Excel 2013 and statistical analysis was done by SPSS.</p> <p class="p2"><span class="s3"><strong>Results: </strong></span>A majority of the interns said they are moderately well informed about dental implants 141 (50.36%); main advantage of dental implants is they are conservative 164 (58.6%); most important factor for implant success is case selection 143 (51.07%); the longevity of dental implants is 10-20yrs, 162 (57.85%), 188 (67.14%) agreed that they were not provided with sufficient information and 191 (68.21%) stated that they need more information; 180 (64.3%) felt the difficulty encountered while placing implants is average and 229 (81.78%) stated that they need more hygiene care than natural teeth.&nbsp;</p> <p class="p3"><span class="s3"><strong>Conclusions: </strong></span>A majority of interns have knowledge regarding dental implants, but the percentage of those who gave unsatisfactory answers is also large. They have a positive attitude towards gaining more information through various means.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Prevalence of Different Types of Apical Root Canal Morphology and their Treatment Recommendations in an Institute 2018-05-31T20:57:13+00:00 Sushmita Shrestha Smriti Karki Navin Agrawal Mannu Vikram Vimmi Singh Ashish Shrestha <p class="p1">&nbsp;</p> <p class="p2"><span class="s2"><strong>Introduction: </strong></span>Canals can be of different shapes in cross section including round canals, oval canals, long oval canals or ribbon shaped canals. Recesses of nonround canals may not be included in the round preparation created by rotary instruments and thus they remain unprepared. The aim of this study included determination of shape and taper of the apical root canal based on diameter at different levels.</p> <p class="p3"><span class="s2"><strong>Methods: </strong></span>This was a cross sectional study which used convenient sampling technique to determine the sample size. Seventy extracted teeth were sectioned horizontally at one, two and three millimeter from the apex using the diamond disc which was observed under trinocular research microscope for the determination of diameter of root canal under 10x magnification.</p> <p class="p3"><span class="s2"><strong>Results: </strong></span>The most common canal configuration was oval. The taper of the canals was 25% in mesial root and 20% in distal in bucco-lingual orientation and 14% in mesial root and 15% in distal in mesio-distal orientation.</p> <p class="p4"><span class="s2"><strong>Conclusions: </strong></span>The most prevalent canal configuration in this study was non round, however, most of the rotary instruments tend to prepare root canals into round shape making their use questionable. The taper of the root canals was found to be higher in our study than what most of the shaping instruments have to offer. So it would be advisable to consider this fact while selecting instruments and preparing these non-round canals as far as the Nepalese subpopulation is considered.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Air due to Glue: Spontaneous Pneumothorax in a Young Adult with Glue Sniffing 2018-05-31T20:57:13+00:00 Deebya Raj Mishra Narendra Bhatta Bidesh Bista Puru Koirala Ramhari Ghimire <p class="p2">Solvent abuse, as inhalant specially, in the form of low cost adhesives like dendrite is common in low income countries among children and the teens. This habit is often a stepping stone to harder drugs. The neurological and neuropsychological effects of solvent abuse are well explored. But the respiratory effects are often overlooked. In this report, we present a case of a 19 year old gentleman, with regular history of sniffing of commercial “glue” compounds. This patient presented with right sided chest pain and chest x-ray showed a right sided pneumothorax. The pulmonary barotrauma, possibly due to increased intra-alveolar pressure, during the sniffing process can lead to alveolar rupture and in turn, pneumothorax. In the absence of other risk factors for Pneumothorax, the link between inhalant abuse and respiratory complications has to be explored in patients with history of such abuse.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Perforation Peritonitis at High Altitude 2018-05-31T20:57:13+00:00 Bhawana Amatya Paleswan Joshi Lakhey Prativa Pandey <p class="p2">Trekkers going to high altitude can suffer from several ailments both during and after their treks. Gastro-intestinal symptoms including nausea, vomiting, and abdominal pain are common in high altitude areas of Nepal due to acute mountain sickness or due to a gastro-intestinal illness. Occasionally, complications of common conditions manifest at high altitude and delay in diagnosis could be catastrophic for the patient presenting with these symptoms. We present two rare cases of duodenal and gastric perforations in trekkers who were evacuated from the Everest trekking region. Both of them had to undergo emergency laparotomy and repair of the perforation using modified Graham’s patch in the first case and distal gastrectomy that included the perforated site, followed by two-layer end-to-side gastrojejunostomy and two-layer side-to-side jejunostomy in the second case. Perforation peritonitis at high-altitude, though rare, can be life threatening. Timely evacuation from high altitude, proper diagnosis and prompt treatment are essential</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Giant Ovarian Mucinous Cystadenoma Complicating Term Pregnancy 2018-05-31T20:57:13+00:00 Sangeeta Kaushal Mishra Manoj Yadav Sripad J Walavalkar <p class="p1">&nbsp;</p> <p class="p2">Huge ovarian cyst are found in less than 1% of all ovarian cyst in pregnancy and are associated with poor feto-maternal outcome. A 28 years old G2P1 with history of normal vaginal delivery 3 years back was referred from local health post with complains of intermittent pain abdomen at 29 weeks. Her scan showed huge ovarian cyst of 18.9×17.6 cm with multiple thick septation. Woman was conservatively managed till term and elective surgery was planned however she presented in labour with breech presentation at 39 weeks and 4days. Emergency lower segment caesarian section along with left sided salpingo–oophorectomy was done along with delivery of 2.5 kg healthy female baby. Histopathology was suggestive of mucinous cystadenoma of ovary. Although antepartum removal of ovarian cyst has been recommended to ensure good pregnancy outcome, expectant management and timed intervention can be adopted for pregnancy with huge ovarian cysts.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement## Nepal Health Insurance Bill: Possible Challenges and Way Forwards 2018-05-31T20:57:13+00:00 Nirmal Kandel <p class="p1">Nepal has one of the highest proportions of out of pocket expenditures on health and one quarter of the people is living below poverty line. In recent time, there is some increase of the health budget but country still relies on development partners. The endorsement of the national health insurance bill has enabled government to establish the national health insurance scheme through development of adequate policies, strategies and mechanisms for implementation at national and federal level. The scheme has many challenges to address on governance and leadership, financing, information, health services, workforce, and essential medicines and technologies. Therefore, it is imperative to establish a robust mechanism like a “tree”, which has strong roots of building blocks of health systems, which produces fruits that ensure improved responsiveness, efficiency and equity and financial protection. It is necessary to learn and apply from the experiences of other countries while implementing the national health insurance scheme.</p> 2018-04-30T00:00:00+00:00 ##submission.copyrightStatement##