The Nepal NCDI Poverty Commission officially launched its National Report on 26 March 2018 in Kathmandu.
Executive Summary of Report
The burden of noncommunicable diseases and injuries (NCDIs) in terms of disability and death in Nepal has more than doubled over the past 25 years. In 2015, 51% of all death and disability (DALYs) were caused by NCDs and 14% were caused by injuries. Approximately half of this burden of disease actually occurs during childhood and early productive years (under the age of 40), and virtually all NCDIs cause death at an earlier age in Nepal than higher-income countries. Although global targets in NCDs largely focus on four major diseases (cardiovascular disease, type 2 diabetes, chronic respiratory diseases, and cancers), 60% of death and disability from NCDIs in Nepal are due to other conditions, such as non-ischemic cardiac conditions, infection-related cancers, musculoskeletal disorders, mental health conditions, neurological disorders, and injuries (particularly as a result of natural disasters).
Some of these conditions disproportionately affect poorer segments of the Nepali population, such as ischemic and hypertensive heart disease, COPD, hemorrhagic and ischemic stroke, asthma, hearing loss, rheumatic heart disease, congenital heart disease, cirrhosis due to HBV, and peptic ulcer disease. Households in lower income quintiles have higher prevalence of respiratory diseases and asthma, gastrointestinal conditions, musculoskeletal conditions, and heart-related conditions. Many of these conditions are more likely linked to untreated infectious diseases, living conditions associated with poverty, and poor access to health services. Injuries, gastrointestinal conditions, and heart-related diseases cause the most impoverishment among NCDIs across the population, and at an individual household level, cancers, injuries, heart-related conditions, and kidney/liver diseases are severely impoverishing. Patient voices and narratives have been documented to faithfully capture the human experience of these conditions (visit http:// www.voicesofncdipoverty.org).
Despite inclusion of NCDIs in basic health services and high reported availability of NCDI services at public facilities, availability of key medications and readiness of NCD services remain very limited, and availability of trained human resources is a particular challenge. Although the government allocates 11% of expenditures to health, 48% of total health expenditure in Nepal comes from out of pocket. Thirty-three percent of this out-of-pocket spending is on NCDIs. The government allocates only 6.4% of health spending to NCDIs. Considering the burden and distribution of NCDIs in Nepal, this commission selected 25 NCDI disease conditions on which to increase health sector interventions. These conditions, which build on the existing goals in the Nepal health system, include asthma, chronic obstructive pulmonary disease, hypertensive heart disease and stroke, rheumatic heart disease, diabetes (type 1 and 2), breast and cervical cancer, childhood leukemias/ lymphomas, major depressive disorder, epilepsy, sickle cell disease, cirrhosis, motor vehicle road injuries and other injuries. The commission has identified 23 potential cost-effective interventions to be introduced and/or incrementally intensified within the health sector to establish Universal Health Coverage for these priority NCDI conditions by 2030. These interventions, if implemented to a realistic target coverage, are projected to avert at least 9,680 premature deaths every year by the year 2030. Furthermore, these interventions will lead to larger benefits by averting morbidity and DALYs given the emphasis on interventions for severe conditions affecting those at younger ages. These interventions would cost roughly 22% of total health expenditure, or 1.4% of current GDP, roughly $8.76 per capita, which although high, may be reasonable in consideration of the vast burden of disease comprised collectively by these conditions.
In addition to consideration of these interventions, the commission also identified several areas to strengthen governance, health system strengthening, and monitoring of this expanded set of priority NCDIs. Specific approaches include strengthening the availability and readiness of essential health services and consideration of structured capacity building program for health service providers; promoting care packages, such as the Package of Essential Noncommunicable Disease (PEN) interventions for primary health care; increasing the availability of specialty services and personnel; expanding progressive vertical programs providing free-care for disease specific areas (as has been done for cardiac surgery and dialysis); decentralizing and task shifting services for improved access in remote areas; and expanding basic health coverage for NCDIs to avoid impoverishing out-of-pocket costs. Monitoring of the response can be strengthened by expanding existing household data collection (i.e., STEPs, DHS, MICS) to include more diverse NCDI conditions as well as socioeconomic stratifiers, strengthening civil registration and vital statistics system to improve cause of death reporting mechanism such as obtaining information from community verbal autopsy programs, establishing disease registries to capture NCDIs at the community level, and expanding health facility surveys to include key areas such as in NCDs, mental health, and injury related services (i.e., surgery, rehabilitation, and palliative care). The establishment of a specific directorate for NCDIs within the federal and provincial Ministries of Health, as well as a high-level multi-sectoral task force, would provide greater governance and accountability to lead and track progress on NCDIs in Nepal. Finally, given the clear health and economic burden of the vast category of NCDIs, increased resources for NCDIs should be strongly considered, including a possible target of 20% of government expenditure on health towards these conditions. Progressive taxation on tobacco, alcohol, and sugary beverages, as well as other revenue streams, should be explored to both generate revenue and discourage use of key NCDI risk factors. In summary, this report provides a critical analysis of NCDIs in Nepal; and recommends realistic interventions to address an expanded set of prioritized NCDI conditions. Our recommendations specifically consider challenges pertinent to the poorest population and also pay attention to the unique differences in the diseases and risk factors that impact them. In the current context of national health system reform, we are confident that the recommendations of this report will provide valuable guidance for framing new policies and programs on NCDIs in Nepal.