Nepal Monitor: The National Online Journal

Nepal's general health policies give a low priority to Non-communicable diseases (NCDs). However, a national NCD policy and strategy has been drafted and awaits government review and adoption. In addition, a national policy and framework for injury and violence prevention is being considered. The Framework Convention on Tobacco Control (FCTC) was adopted. On this theme, a Smoking (Prohibition and Control) Act had been drafted in 2001, but has not yet been approved.

Tobacco control efforts point in right direction but have not yet yielded major results. The Ministry of Finance has set a tax on tobacco products. There is also a partial ban on tobacco advertising (applicable to electronic media only). Smoking has been banned in major public places. Anti-tobacco programs are implemented by a tobacco control cell within the Ministry of Health and Population (MoHP) and the National Health Education Information and Communication Center (NHEICC). The Ministry of Education also includes in the school curriculum elements on the ill-effects of tobacco consumption. Finally, the Nepal Health Research Council recently conducted a training program in alcohol and tobacco control.

Several other NCD-related programs are ongoing or under preparation. An NCD awareness program is under preparation for implementation in three districts. Screening camps for the detection of breast and cervical cancer, hypertension, and diabetes have been held in three districts. The National Institute for Injury Prevention is playing a major role in assisting the government in its injury prevention program. Implementation of the World Health Organization (WHO)'s Global Strategy on Diet, Physical Activity and Health has also been started.

SURVEILLANCE
Gradually, Nepal has set up the building blocks of a national surveillance system. In 2004, using WHO STEPS methods, behavior risk factor surveys were conducted in Kathmandu and then in 2006, nationally. Two cancer registries have been established, and a National Injury Surveillance Format is under development. Medical records are being analyzed to better understand the causes of violent deaths and to facilitate an evidence-based injury prevention policy. Health information systems are being developed for health, logistics, and fiscal management.

HEALTH SERVICE DELIVERY AND HUMAN RESOURCES
The MoHP has developed a decentralized system with sub-health posts, health posts, and primary health care centers. However, little effort at the primary health care level for prevention and control of NCDs and their risk factors has been made. In addition, delivery of curative health services are rather poorly developed (2 hospital beds per 10,000 populations). The main focus has been on NCD management through specialty hospitals at the tertiary level. Specialty tertiary care centers for NCDs include: Shahid Gangala National Heart Center, the B.P. Koirala Memorial Cancer Hospital, the charitable Bhaktapur Cancer Hospital, the Suresh Wagle Memorial Cancer Center at Tribhvan University Teaching Hospital, and the Mental Hospital at Lagankhel (Lalipur). The latter is the only facility that provides mental health services. Overall, NCDs accounted for 82% of outpatient department cases and 88% of inpatient morbidity in the public sector.

Through great efforts, Nepal has been working with external development partners to implement its national health strategy. The Nepal Health Sector Program Implementation Plan 2004-2010 relied on a sector-wide approach. It aimed to implement the Second Long Term Health Plan, particularly with the objective to extend access to essential services. Through the program, since 2008, such services are made available to the public at several facilities free of charge. The package - which includes tobacco- and alcohol-related services does not specifically refer to other NCDs. Page 3 NCDs Policy Brief: Nepal February 2011

Several training programs on NCDs have been conducted but these remain at small-scale. These include continuing medical education and training among health workers and trainees in: NCD data management and analysis and developing policy briefs; alcohol and tobacco control; mental health and rehabilitation management; highway injuries; and oral health care. However, like the other South Asian countries, Nepal's work force is inadequate. Nepal has only 2.1 physicians, 2.2 nurses, 2.4 midwives, and 0.1 pharmacists per 10,000 population and these providers are skewed towards urban areas.

A National Essential Medicines List has been developed but information on NCD-related drugs is not available.

FINANCE
The proportion of the government budget allocated to NCD-related activities for FY2009-10 is negligible, at 0.7%. Taxation of tobacco and alcohol products constitutes the main funding source for NCD activities. NCD spending is mainly on tobacco control, nutrition, and cancer programs.

PPOOLLIICCYY OOPPTTIIOONNSS FFOORR NNEEPPAALL
The World Bank's recent publication: Capitalizing on the Demographic Transition: Tackling Non-communicable Diseases in South Asia (2010) introduces a policy framework for identifying NCD-related policy options. The options below follow this framework.

FINALIZE NATIONAL NCD POLICY
The draft NCD policy gives the bases for building strategies, plans and action. At this stage, the government could engage widely with stakeholders before finalizing the draft and adopting it.

STRENGTHEN TOBACCO CONTROL POLICIES
To better control tobacco, Nepal could expand and built upon its current efforts. The broad framework outlined in the FCTC can serve as useful reference. Reducing consumption will likely require a specific focus on taxation.

CREATE A NATIONAL NCD SURVEILLANCE SYSTEM
The current elements of the surveillance system could be complemented by specific focuses on risk factors, including tobacco (especially among women), alcohol use, and injuries. Public and private institutions with surveillance experience should be tapped for capacity development and technical assistance.

RETOOL THE HEATH WORK FORCE FOR NCD PREVENTION AND CONTROL
Efforts should focus on the two objectives: to increase the size and the skill level for NCDs among health professionals. Concomitantly, the health infrastructure for primary care will need to be equipped with basic diagnostic and management capacity. However, these efforts will not reach the poor, if specific financing strategies for access to services and medications are not in place.

DEVELOP EVALUATION CAPACITY AND SYSTEM: As the national NCD policy is adopted and policies developed, evaluation plans will be need to fine tune and redirect efforts and resources.

TAKE AN ACTIVE ROLE IN REGIONAL COLLABORATION
Regional collaboration can be very effective for preventing and controlling NCDs. Several promising areas for regional cooperation have been identified. Actively participating in regional collaboration on NCDs prevention and control would be beneficial. Activities include:
Expanding and harmonizing tobacco advertising band to reduce demand
Increasing and harmonizing tobacco taxation to reduce consumption
Page 4 NCDs Policy Brief: Nepal February 2011

Harmonizing tobacco taxes and strengthening anti-smuggling measures
Standardizing and mandating food labeling policy to improve knowledge and awareness of food composition
Collaborating on group purchasing of essential medications to increase their access and affordability
Establishing a regional health technology assessment institution to improve the
comparative effectiveness of interventions for NCDs and other conditions
Using regional education and training capacity to complement the national needs for human resources in order to improve both staffing and skill levels
Establishing a regional network of surveillance and burden assessment to improve national capacity through knowledge sharing and experience exchange

To see the complete document, go here.
For the full report, "Capitalizing on the Demographic Transition: Tackling Non-communicable Diseases in South Asia (Feb 2011)"

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