Changing prioritiesIt is high time that both infectious and chronic diseases were integrated into Nepal’s primary health care system
Earlier this year, the World Health Organisation (WHO) released a global report which stated that non-communicable diseases (NCDs) account for 38 million deaths, or more than two-thirds of all deaths worldwide. It was previously assumed that only rich people were prone to NCDs, but paradoxically, it has now become a leading cause of deaths in resource-constrained countries. The WHO report mentions that more than three-quarters of the 38 million deaths occurred in low and middle-income countries. Due to this epidemiological transition, there is a triple burden of communicable, re-emerging and non-communicable diseases in many developing countries. This shift has highlighted the need to bring in policies toaddress NCDs along with other infectious diseases.
Nepal lacks data on the magnitude and burden of NCDs. The 2013 STEPS survey, the second national level survey, indicated that tobacco use, alcohol consumption, inadequate daily intake of fruits and vegetables, low physical activity, obesity and high blood pressure were the major risk factors of NCDs in Nepal. And that almost all (99.6 percent) of the population had at least one of these risk factors. Further, a 2012 World Bank report stated that almost 60 percent of the total deaths in Nepal were due to NCDs, whereas it was only 45 percent in 2000. These studies show the increasing burden of NCDs on the country.
On the contrary, the importance of such problems was only realised in 2010 after the national policy documents of Nepal Health Sector Support Programme-2 added components of community-based mental health services and health education and behavioural change communication in the Essential Health Care Services package. Even though the NCDs were highlighted in these policy documents, less than one percent of the national health budget is allocated to NCDs. But this might be due to the limited budget the health sector receives, which is designed to address communicable diseases, vaccine preventable diseases, maternal and child health, tuberculosis and HIV/AIDS to achieve the Millennium Development Goals (MDGs).
The health care priorities of resource-constrained countries are mostly influenced by the international context. Unfortunately, the MDGs do not include the components of NCDs. They might only figure in the global health priorities in the next decade after epidemiological transition. For instance, the third goal of the Post-2015 Development Agenda of the UN ensures a healthy life and promotes well-being and has set targets like reducing premature mortality from NCDs by one-third by 2030 and halving deaths and injuries from road traffic accidents by 2020. Similarly, the first global target of NCDs demands a reduction in the deaths caused by cardiovascular disease, diabetes, cancer and chronic respiratory diseases by 25 percent by 2025.
Nepal, being a signatory to the 25x25 target (reducing premature mortality from NCDs by 25 percent by 2025) and Sustainable Development Goals, has committed itself to achieving these targets in the future despite many barriers. The major challenge is to divert the priority towards NCDs beyond the fact that a majority of the deliveries are conducted by unskilled or semi-skilled birth attendants, and that one in 20 children dies before his or her fifth birthday.
The next barrier is our vital structurally weak registration system. For instance, the recently revised Health Management Information System tools have not incorporated NCD indicators which would be crucial for monitoring the progress of NCD interventions in the future. Third, we do not have separate divisions or sections at the Department of Health Services that are responsible for NCDs. Not surprisingly, Nepal’s primary health care system does not address the issues related to NCDs in peripheral health institutions besides providing health education and counselling.
Although, the government has decided to include medicines against NCDs in the list of essential drugs that are supplied free of cost; this is not enough. More specifically, we do not have trained and qualified health workers who can address NCD-related health problems in peripheral health institutions. Thus, it is high time our health system was redesigned to address the issue.
First, we need to redesign our structure and distribution of health workers. They should be trained to manage cases at the community level and be distributed on the basis of population density rather than sanctioned posts. The second step is to ensure adequate and uninterrupted supply of essential drugs and equipment for diagnosis and treatment of NCDs. Furthermore, early diagnosis and treatment reduces the future cost of illness. However, these interventions will work only if there is an effective referral mechanism which needs to be strengthened.
Majority of the Nepalis cannot afford the expensive medicines required to treat NCDs. Hence, the government needs to reduce taxes and duties on essential drugs and equipment. This is crucial because a majority of health care expenditure is out-of-pocket, and subsidies will enable patients to get services from the private sector without having to sell their fixed assets in the course of treatment. On its part, the Nepali government has discouraged the risk factors by increasing taxes on alcohol, tobacco products and junk food and by imposing fines for consuming tobacco or alcohol in public places. The government needs to introduce separate funds so that revenues generated from taxes and fines can be utilised to subsidise NCD interventions.
It is high time that both infectious and chronic diseases were integrated into Nepal’s primary health care system despite its limited resources. This requires a strong political commitment to taxation and subsidies, appropriate training of health workers, supply of necessary medicines and equipment and an effective referral system.
Khanal is a student of public health at the University of Melbourne, Australia