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The Nepal NCDI Poverty Commission An Equity Initiative to Address Noncommunicable Diseases and Injuries National Report – 2018 THETHE NEPAL NEPAL NEPAL NCDINCDI ReframingReframingReframing Noncommunicable Noncommunicable Noncommunicable Diseases Diseases Diseases POVERTYPOVERTY and andInjuries Injuriesand for the Injuriesfor Poorestthe Poorest forBillion theBillion Poorest Billion CommissionCommission ACRONYMS & ABBREVIATIONS AHW: Auxiliary Health Worker MPI: Multidimensional Poverty Index ANM: Auxiliary Nurse Midwife NCD: Noncommunicable Diseases ASI: Assistant Sub-Inspector of police NCDI: Noncommunicable Disease and Injuries ASRH: Adolescent and Sexual and Reproductive Health NHFS: Nepal Health Facility Survey BAC: Blood Alcohol Content NLSS: National Living Standards Surveys CAPD: Continuous Ambulatory Peritoneal Dialysis OOP: Out of Pocket CBS: Central Bureau of Statistics OPHI: Oxford Poverty and Human Development Initiative CHU: Community Health Unit ORCs: Outreach Clinics DALY: Disability Adjusted Life Years PEN: Package of Essential DDA: Department of Drug Noncommunicable Diseases Administration PHC: Primary Health Care DH: District Hospital PHCC: Primary Health Care Center DMARDs: Disease-Modifying Agents Used in Rheumatic Disorders PHCRD: Primacy Health Care Revitalization Division EHCS: Essential Health Care Services PL: Poverty Line EPI: Expanded Program for Immunization PMTCT: Prevention of Mother to Child Transmission FHCP: Free Health Care Policy PoP: Plaster of Paris FHD: Family Health Division SES: Socio-economic Status FP: Family Planning SHP: Sub-Health Post GBD: Global Burden of Disease SLTHP: Second Long-Term Health GBV: Gender Based Violence Plan GoN: Government of Nepal SN: Staff Nurse HA: Health Assistant STS: Service Tracking Survey HIV: Human Immunodeficiency VDC: Village Development Virus Committee HOTC: Human Organ Transplant VIA: Visual inspection with acetic Center acid HP: Health Post WHO: World Health Organization HRH: Human Resource for Health YLD: Years Lived with Disability MDGP: Doctor of Medicine in YLL: Years of Life Lost General Practice MoH: Ministry of Health The Nepal NCDI Poverty Commission: National Report-2018 1 LIST OF NATIONAL COMMISSION MEMBERS COMMISSION CO-CHAIRS Dr. Bhagawan Koirala Dr. Senendra Upreti Manmohan Cardiothoracic Former Secretary Vascular and Transplant Ministry of Health and Center Population Institute of Medicine Government of Nepal Coordinator Other Members Dr. Biraj M Karmacharya Dr. Meghnath Dhimal Kathmandu University School of MedicalSciences Nepal Health Research Council Core Team Members & Group Coordinators Mr. Shiva Raj Mishra Nepal Development Society Dr. Shiva Raj Adhikari (Commissioner) Dr. Natalia Oli Tribhuvan University Kathmandu Medical College Dr. Krishna K Aryal (Commissioner) Mr. Achyut Raj Pandey Abt Associates Nepal Health Research Council Dr. SP Kalaunee (Commissioner) Dr. Arpana Kalaunee Possible Health Team Hospital Dadeldhura Dr. Archana Shrestha (Commissioner) Dr. Suresh Mehata Harvard TH Chan School of Public Health Ipas Nepal Dr. Abhinav Vaidya (Commissioner) Mr. Pravin Paudel Kathmandu Medical College HERD International Dr. Abha Shrestha (Research Fellow) Research Assistants Dhulikhel Hospital–Kathmandu University Hospital Amiya Bhatia Commissioners Harvard TH Chan School of Public Health Matthew Coates Dr. Anjani Kumar Jha Harvard Medical School BP Koirala Memorial Cancer Hospital Dr. Bhola Shrestha Advisers Nepal Ministry of Health Dr. Gene Bukhman Dr. Khem B Karki Harvard Medical School Nepal Health Research Council Dr. Neil Gupta Dr. Dinesh Neupane Partners In Health Nepal Development Society Dr. Dan Schwarz Mr. Vijay Kumar Pandey Possible Health Nepalese Media Dr. Arjun Karki Grande International Hospital Dr. Rajendra Koju Kathmandu University School of Medical Sciences Dr. Saroj Prasad Ojha Tribhuvan University Dr. Bhaskar Raj Pant Grande International Hospital Mr. Anant Raut Possible Health Dr. Sanjib Kumar Sharma BP Koirala Institute of Health Sciences Dr. Deewakar Sharma Shahid Gangalal National Heart Centre 2 The Nepal NCDI Poverty Commission: National Report-2018 TABLE OF CONTENTS Acronyms & Abbreviations 1 List of National Commission members 2 List of Tables 5 List of Figures 6 Foreword 7 Executive Summary 8 The Nepal NCDI Poverty Commission 11 1.0 Background 12 1.1 Introduction and Background of NCDIs in Nepal 12 1.2 Objectives of the Nepal NCDI Poverty Commission 14 1.3 Methodology 15 2.0 Situation Analysis of NCDIs and Socioeconomic Status in Nepal 16 2.1 Distribution of Poverty in Nepal 16 2.2 Burden of Diseases in Nepal 19 2.3 Risk Factor Profile for NCDI in Nepal 23 2.4 Relationship of NCDI burden with Socio-economic Status 24 2.4.1 Literature Review 24 2.4.2 Rates of NCDI Disease Burden by Poverty Level (GBD) 26 2.4.3 Household Burden of Disease by Consumption Quintile 27 2.5 NCDI Health Sector Services in Nepal 29 2.5.1 National Health Facilities and Human resources 29 2.5.2 The Current NCD Basic Services (free of cost) Provided at the Lowest Levels: 29 2.5.3 Current Availability of NCDI Services in Nepal 31 2.5.4 Specialty NCDI Services in Nepal 33 2.6 Economic Impact of NCDIs on Households 34 2.6.1 Household Cost of NCDIs 34 2.6.2 Impoverishment Impact of NCDIs 35 3.0 Priority Setting for NCDI Pathways 36 3.1 Expansion of Priority NCDI Conditions 36 3.2 Selected Interventions for Expanded NCDI Health Sector Capacity 38 3.3 Integration of Proposed Interventions in New Federalist Structure 42 The Nepal NCDI Poverty Commission: National Report-2018 3 3.4 Affordability and Fiscal Space for Proposed Interventions 44 3.4.1 Health Expenditure on NCDI 44 3.4.2 Opportunities for Expanding Fiscal Space for NCDI Services 45 4.0 Conclusions and Summary 48 4.1 Key Findings 48 4.2 Key Recommendations 51 5.0 References 54 List of Appendices (with link to access and download) 56 4 The Nepal NCDI Poverty Commission: National Report-2018 LIST OF TABLES Table 1: Frequency of total published studies, relevant published studies, and published studies with socioeconomic disaggregation within each NCDI disease category. (Source: Nepal NCDI Poverty Commission) 24 Table 2: The current NCD services standards in Nepal at various levels of the health system basic services (free of cost) provided at the lowest levels. (Source: NHSS) 30 Table 3: Availability Availability of Essential Components of Care for Diabetes, Cardiovascular Disease, and Chronic Respiratory Disease at District Hospitals and Primary Health Care Centers (Source: Nepal Service Provision Assessment) 31 Table 4: Selected priority NCDI conditions for expansion of services and interventions (Source: Nepal NCDI Poverty Commission) 37 Table 5: Cost effectiveness, financial risk protection, and equity scores for selected health sector interventions for expanded NCDI services in Nepal. Baseline and target coverage estimates as well as incremental cost of introduction and scale up are shown. (Source: Nepal NCDI Poverty Commission) 40 Table 6: Break down of out of pocket payments in Nepal 45 Table 7: Revenue collected from excise duty in NPR (2014/15) 46 Table 8: Scenario analysis for projected change in tobacco consumption, number and percent of people discontinuing tobacco use, years of life saved, and government revenue at various tax rates and price of tobacco 47 The Nepal NCDI Poverty Commission: National Report-2018 5 LIST OF FIGURES Figure 1: Distribution of percent of individuals living in the global “poorest billion” within Nepal. (Source: Oxford Poverty & Health Development Initiative) 17 Figure 2: Multidimensional Poverty Index (MPI) Map by Province (Source: Nepal’s Multidimensional Poverty Inex: Analysis Toward Action 2014, Nepal Planning Commission, Government of Nepal) 17 Figure 3: Distribution of absolute numbers of individuals living in the global “ poorest billion” in Nepal. (Figures are in thousands) (Source: Oxford Poverty & Human Development Initiative) 18 Figure 4: Major causes of burden of disease (Level 1) in Nepal (DALY=Disability Adjusted Life Years) (Source: Global Burden of Disease 2015) 19 Figure 5: Major causes of DALYs by age, Nepal. (DALYs= Disability Adjusted Life Years, in thousands) (Source: Global Burden of Disease, 2015) 20 Figure 6: Years of life lost (YLLs) per death per condition in Nepal (y-axis) versus YLLs per death per condition in high-income countries 20 Figure 7: Percent of NCDI DALYs for each disease (Level 2) category in Nepal (all ages, both sexes, 2015) (Source: Global Burden of Disease, 2015) 21 Figure 8: Individual NCDI conditions (Level 3) with most DALYs per 100,000 populations in Nepal (all ages, both sexes, 2015) (Source: Global Burden of Disease, 2015) 22 Figure 9: Percent of NCDI DALYs attributable to risk factor categories within Global Burden of Disease, 2015 23 Figure 10: Individual NCDI conditions with most DALYs per 100,000 populations in Nepal (all ages, both sexes) modelled for rate within population in global poorest billion (“poor”) and population not in global poorest billion (“Non-Poor”) (Source: Global Burden of Disease 2015 and Oxford Poverty & Human Development Initiative) 27 Figure 11: Household prevalence of chronic illnesses, by quintile (Source: NLSS, 2010) (NB- “Rheumatic” indicates musculoskeletal illness, typically arthritis) 28 Figure 12: Average household annual cost of treatment for various chronic diseases by consumption quintile (Source: NHLSS Year 2011) 34 Figure 13: Comparison of prevalence of NCD and injury conditions with their impact on poverty 35 Figure 14: Organization of proposed
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