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Health in Nepal

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Health care services in Nepal are provided by both public and private sectors and are generally regarded as failing to meet international standards. Prevalence of disease is significantly higher in Nepal than in other South Asian countries, especially in rural areas.[1][2] Moreover, the country’s topographical and sociological diversity results in periodic epidemics of infectious diseases, epizootics and natural hazards such as floods, forest fires, landslides, and earthquakes.[2] A large section of the population, particularly those living in rural poverty, are at risk of infection and mortality by communicable diseases, malnutrition and other health-related events.[2] Nevertheless, some improvements in health care can be witnessed; most notably, there has been significant improvement in the field of maternal health. These improvements include:[3]

  • Human Development Index (HDI) increased to 0.458 in 2011[4] from 0.291 in 1975.[5][6]
  • Mortality rate during childbirth deceased from 850 out of 100,00 mothers in 1990 to 190 out of 100,000 mothers in 2013.[7]
  • Mortality under the age of five decreased from 61.5 per 1,000 live births in 2005 to 31.4 per 1,000 live births in 2018.[8]
  • Infant Mortality decreased from 97.70 in 1990 to 29.40 in 2015.[9]
  • Child malnutrition: Stunting 37%, wasting 11%, and underweight 30% among children under the age of five.[10]
  • Life Expectancy rose from 66 years in 2005 to 71.5 years in 2018.[11][12]
Population growth 1.74[13]
Life expectancy 71.5 [14]
Fertility 2.18[15]
Infant mortality 29.40[16]
Total expenditure on health per capita (Intl $, 2014) 137[17]
Total expenditure on health as % of GDP (2014) 5.8[17]

Health care expenditure

In 2002, government funding for healthcare was approximately USD $2.30 per person. Approximately 70% of health expenditure came from out-of-pocket contributions. Government allocation for health care was approximately 5.8% of the budget in 2009.[18] In 2012, the Nepalese government launched a pilot program for universal health insurance in five districts of the country.[19]

As of 2014, Nepal's total expenditure on health per capita was USD $127.[20]

Health care infrastructure

Health care services, hygiene, nutrition, and sanitation in Nepal are of very poor quality and fail to reach a large proportion of the population, particularly in rural areas.[21] The poor have limited access to basic health care due to high costs, low availability, lack of health education and conflicting traditional beliefs.[22] Reproductive health care is limited and disadvantages women. The United Nation's 2009 human development report highlighted a growing social concern in Nepal in the form of individuals without citizenship being marginalized, and denied access to government welfare benefits.[23][24][25]

These problems have led many governmental and non-governmental organizations (NGOs) to implement communication programs encouraging people to engage in healthy behavior such as family planning, contraceptive use, spousal communication and safe motherhood practices, such as the use of skilled birth attendants during delivery and immediate breastfeeding.[26]

Micro-nutrient deficiencies are widespread, with almost half of pregnant women and children under five, as well as 35% of women of reproductive age, being anaemic. Only 24% of children consume iron-rich food, 24% of children meet a minimally acceptable diet, and only half of the pregnant women take recommended iron supplementation during pregnancy. A contributing factor to deteriorating nutrition is high diarrhoeal disease morbidity, exacerbated by the lack of access to proper sanitation and the common practice of open defecation (44%) in Nepal.[27]

Nutrition of children under 5 years[28]

Periods of stagnant economic growth and political instability have contributed to acute food shortages and high rates of malnutrition, mostly affecting vulnerable women and children in the hills and mountains of the mid and far western regions. Despite the rate of individuals with stunted growth and the number of cases of underweight individuals having decreased, alongside an increase of exclusive breastfeeding in the past seven years, 41% of children under the age of five still suffer from stunted growth, a rate that increases to 60% in the western mountains. A report from DHS 2016, has shown that in Nepal, 36% of children are stunted (below -2 standard deviation), 12% are severely stunted (below -3 standard deviation), 27% of children under 5 are underweight, and 5% are severely underweight. Variation in the percentage of stunted and underweight children under 5 can be compared between urban and rural regions of Nepal, with rural areas being more affected (40% stunted and 31% underweight) than urban areas (32% stunted and 23% underweight). There is positive association between household food consumption scores and lower prevalence of stunting, underweight and wasting. Children in a secure food household have the lowest rates of stunting (33%), while children in an insecure food household have the highest rates (49%). Similarly, maternal education has an inverse relationship with childhood stunting. In addition, underweight and stunting issues are also inversely correlated to their equity possessions. Children in the lowest wealth quintile are more stunted (49%) and underweight (33%) than children in the highest quintile (17% stunted and 12% underweight).[29]

The nutritional status of children in Nepal has improved over the last two decades. Decreasing trends of children having stunted growth and being underweight have been observed since 2001. The percentage of stunted children in Nepal was 14% between 2001 and 2006, 16% between 2006 and 2011, and 12% between 2011 and 2016.[29] A similar trend can also observed for underweight children. These trends demonstrate progress towards the achievement of the Millennium Development Goal (MDG) target. However, there is still a long way to go to meet the SDG target of reducing stunting to 31% and underweight to 25% among children under 5 by 2017 (National Planning Commission 2015).[citation needed]

Micro-nutrient deficiencies are widespread, with almost half of pregnant women and children under five, as well as 35% of women of reproductive age, being anaemic. Only 24% of children consume iron-rich food, 24% of children meet a minimally acceptable diet, and only half of the pregnant women take recommended iron supplementation during pregnancy. A contributing factor to deteriorating nutrition is high diarrheal disease morbidity, exacerbated by the lack of access to proper sanitation and the common practice of open defecation (44%) in Nepal.[27]

Urban areas Rural areas Overall
Stunted 27% 42% 41%
Wasted 8% 11% 11%
Underweight 17% 30% 29%

Geographical constraints

Much of rural Nepal is located on hilly or mountainous regions. Nepal's rugged terrain and the lack of properly enabling infrastructure make it highly inaccessible, limiting the availability of basic health care in many rural mountain areas.[30] In many villages, the only mode of transportation is by foot. This results in a delay of treatment, which can be detrimental to patients in need of immediate medical attention.[31] Most of Nepal's health care facilities are concentrated in urban areas. Rural health facilities often lack adequate funding.[32]

In 2003, Nepal had 10 health centers, 83 hospitals, 700 health posts, and 3,158 "sub-health posts," which serve villages. In addition, there were 1,259 physicians, one for every 18,400 persons.[18] In 2000, government funding for health matters was approximately USD $2.30 per person and approximately 70% of health expenditure came from contributions. Government allocations for health were around 5.1% of the budget for the 2004 fiscal year, and foreign donors provided around 30% of the total budget for health expenditure.[5]

Political influences

Nepal’s health care issues are largely attributed to its political power and resources being mostly centered in its capital, Kathmandu, resulting in the social exclusion of other parts of Nepal. The restoration of democracy in 1990 has allowed the strengthening of local institutions. The 1999 Local Self Governance Act aimed to include devolution of basic services such as health, drinking water, and rural infrastructure but the program has not provided notable public health improvements. Due to a lack of political will,[33] Nepal has failed to achieve complete decentralisation, thus limiting its political, social and physical potential.[23]

Health status

Life expectancy

In 2010, the average Nepalese lived to 65.8 years. According to the latest WHO data published in 2012, life expectancy in Nepal is 68. Life Expectancy at birth for both sexes increased by 6 years over the year 2010 and 2012. In 2012, healthy expectancy in both sexes was 9 year(s) lower than overall life expectancy at birth. This lost healthy life expectancy represents 9 equivalent year(s) of full health lost through years lived with morbidity and disability[11]

Diseases

According to WHO data, the nine leading causes of morbidity (illness) and mortality (death) in Nepal are:

  1. COPD (9.2%)
  2. Ischaemic Heart Disease (9.2%)
  3. Lower respiratory infection (7%)
  4. Diarrhoeal disease (3.3%)
  5. Self harm (3%)
  6. Tuberculosis (3%)
  7. Diabetes (2.8%)
  8. Road injury (2.7%)
  9. Preterm birth (2.5%)[14]

HIV/AIDS

Main article: HIV/AIDS in Nepal

Making up approximately 8.1% of the total estimated population of 40,723, there were about 3,282 children aged 14 years or younger living with HIV in Nepal in 2013. There are 3,385 infections estimated among the population aged 50 years and above (8.3% of the total population). By sex, males account for two‐thirds (66%) of the infections and the remaining, more than one‐third (34%) of infections are in females, out of which around 92.2% are in the reproductive age group of 15‐49 years. The male to female sex ratio of total infection decreased from 2.15 in 2006 to 1.95 in 2013 and is projected to be 1.86 by 2020.[34] The epidemic in Nepal is driven by injecting drug users, migrants, sex workers & their clients and MSM. Results from the 2007 Integrated Bio-Behavioral Surveillance Study (IBBS) among IDUs in Kathmandu, Pokhara, and East and West Terai indicate that the highest prevalence rates have been found among urban IDUs, 6.8% to 34.7% of whom are HIV-positive, depending on location. In terms of absolute numbers, Nepal's 1.5 million to 2 million labor migrants account for the majority of Nepal’s HIV-positive population. In one subgroup, 2.8% of migrants returning from Mumbai, India, were infected with HIV, according to the 2006 IBBS among migrants.[35]

As of 2007, HIV prevalence among female sex workers and their clients was less than 2% and 1%, respectively, and 3.3% among urban-based MSM. HIV infections are more common among men than women, as well as in urban areas and the far western region of Nepal, where migrant labor is more common. Labor migrants make up 41% of the total known HIV infections in Nepal, followed by clients of sex workers (15.5 percent) and IDUs (10.2 percent).[35]

Maternal health

Nepal has made significant progress in improving the health of women and children and is on track in 2013 to achieve Millennium Development Goal (MDGs) #4 (to reduce child mortality) and #5A (to reduce maternal mortality). This review provided an opportunity for the MoHP and other stakeholders in Nepal to synthesize and document how these improvements were made, focusing on effective policy and program management practices.

Nepal has made significant progress in improving maternal health. Maternal mortality rate was reduced from 748 per 100,000 live births in 1990[36] to 190 per 100,000 live births on 2014. Nepal also has made some progress on reducing total fertility rate (TFR), from 5.3 in 1991[37] to 2.3 in 2014.[38]: 241 

Despite other indicators related to maternal health, the indicator of contraceptive prevalence rate is showing a decreasing trend: 2006 (44.2%) and 2011 (43.2%),[39] and has been attributed to high rates of spousal separation due to migration to other countries for employment (3/4 of youth in rural areas). The use of maternal health services has improved (increased) since 1996, with increases in the coverage and number of ANC visits (60% for at least four antenatal visits) in 2014,[38]: 242  rates of institutional deliveries as well as deliveries attended by a skilled birth attendant (56%).[38]: 242 

Child health

Nepal is also on track to achieve MDG 4, having attained a rate of 35.8 under 5 child deaths per 1000 live births in 2015,[40] down from 162 in 1991[37] according to national data. Global estimates indicate that the rate has been reduced by 65% from 128 to 48 per 1000 live births between 1991 and 2013.[41] Nepal has successfully improved coverage of effective interventions to prevent or treat the most important causes of child mortality through a variety of community-based and national campaign approaches. These include high coverage of semiannual vitamin A supplementation and deworming; CB-IMCI; high rates of full child immunization; and moderate coverage of exclusive breastfeeding of children under 6 months. However, in the past few years, the NMR has remained stagnant with it being stated at around 22.2 deaths per 1000 live births in 2015. This compares to a rate of 27.7 in India (2015) and 45.5 in Pakistan (2015).[40]

The NMR is a serious concern in Nepal, accounting for 76% of the infant mortality rate (IMR) and 58% of the under 5 mortality rate (U5MR) as of 2015, and is one of its challenges going forward.[40] Typically, a history of conflict negatively affects health indicators. However, Nepal made progress in most health indicators despite its decade-long armed conflict. Attempts to understand this has provided a number of possible explanations including the fact that in most instances the former rebels did not purposely disrupt delivery of health services; pressure was applied on health workers to attend clinics and provide services in rebel base areas; the conflict created an environment for improved coordination among key actors; and Nepal’s public health system adopted approaches that targeted disadvantaged groups and remote areas, particularly community-based approaches for basic service delivery with a functional community support system through female community health volunteers (FCHVs), women’s groups and Health Facility Operational Management Committees (HFOMCs).[42]

Child health programmes

The Nepalese Child Health Division of the Ministry of Health and Population (MOHP), has launched several child survival interventions, including various operational initiatives, to improve the health of children in Nepal. These include the Expanded Program on Immunisation (EPI), the Community-Based Integrated Management of Childhood Illnesses (CB-IMCI) program, the Community-Based Newborn Care Program (CB-NCP), the Infant and Young Child Feeding program, a micro-nutrients supplementation program, vitamin A and deworming campaign, and the Community-Based Management of Acute Malnutrition program.[38]: 29 

Immunization

The National Immunisation Program is a priority 1 (P1) program in Nepal. Since the inception of the program, it has been universally established and successfully implemented. Immunisation services can be obtained for free from EPI clinics in hospitals, other health centers, mobile and outreach clinics, non-governmental organizations and private clinics. The government has provided all vaccines and immunization-related logistics without any cost to hospitals, private institutions, and nursing homes. Nepal has since gained recognition for the success of the program, in relation to its successful coverage of 97% population equally, regardless of wealth, gender and age. However, despite the widespread success of the National Immunisation Program, inequities still exist. Nevertheless, the trends in last past 15 years have shown promising positive changes indicating possibilities of achieving complete immunization coverage.[43] Two more vaccines were introduced between 2014 and 2015 – the inactivated poliomyelitis vaccine (IPV) and the pneumococcal conjugate vaccine (PCV). Six districts of Nepal are declared with 99.9% immunization coverage. Nepal achieved polio-free status on 27 March 2014. Neonatal and maternal tetanus was already eliminated in 2005 and Japanese encephalitis is in a controlled state. Nepal is also on track to meet the target of the elimination of measles by 2019.[38]: i, ⁠8  One percent of children in Nepal have not yet received any of the vaccine coverage.

Community-Based Integrated Management of Childhood Illnesses (CB-IMCI)

The Community-Based Integrated Management of Childhood Illness (CB-IMCI) program is an integrated package that addresses the management of diseases such as pneumonia, diarrhea, malaria, and measles, as well as malnutrition, among children aged 2 months to 5 years. It also includes management of infection, Jaundice, Hyperthermia and counseling on breastfeeding for young infants less than 2 months of age. CB-IMCI program has been implemented up to the community level in all the districts of Nepal and it has shown positive results in the management of childhood illnesses. Over the past decade, Nepal has had success in reducing under-five mortality, largely due to the implementation of the CB-IMCI program. Initially, the Control of Diarrheal Diseases (CDD) Program began in 1982; and the Control of Acute Respiratory Infections (ARI) Program was initiated in 1987. The CDD and ARI programs were merged into the CB-IMCI program in 1998.[39]

Community-Based Newborn Care Program (CB-NCP)

The Nepal Family Health Survey 1996, Nepal Demographic and Health Surveys, and World Health Organization estimations over time have shown that neonatal mortality in Nepal has been decreasing at a slower rate than infant and child mortality. The Nepal Demographic and Health Survey 2011 has shown 33 neonatal deaths per 1,000 live births, which accounts for 61% of under 5 deaths. The major causes of neonatal death in Nepal are an infection, birth asphyxia, preterm birth, and hypothermia. Given Nepal’s existing health service indicators, it becomes clear that strategies to address neonatal mortality in Nepal must consider the fact that 72% of births take place at home (NDHS 2011).[39]

Therefore, as an urgent step to reduce neonatal mortality, Ministry of Health and Population (MoHP) initiated a new program called 'Community-Based Newborn Care Package' (CB-NCP) based on the 2004 National Neonatal Health Strategy.[39]

National Nutritional Program

The National Nutrition Program under the Department of Health Services has set it's ultimate goal as “all Nepali people living with adequate nutrition, food safety and food security for adequate physical, mental and social growth and equitable human capital development and survival” with the mission to improve the overall nutritional status of children, women of childbearing age, pregnant women, and all ages through the control of general malnutrition and the prevention and control of micronutrient deficiency disorders having a broader inter and intra sectoral collaboration and coordination, partnership among different stakeholders and high level of awareness and cooperation of population in general.[44]

Malnutrition remains a serious obstacle to child survival, growth, and development in Nepal. The most common form of malnutrition is protein-energy malnutrition (PEM). Other common forms of malnutrition are iodine, iron, and vitamin A deficiency. These deficiencies often appear together in many cases. Moderately acute and severely acutely malnourished children are more likely to die from common childhood illness than those adequately nourished. In addition, malnutrition constitutes a serious threat to young children and is associated with about one-third of child mortality. Major causes of PEM in Nepal is low birth weight of below 2.5 kg due to poor maternal nutrition, inadequate dietary intake, frequent infections, household food insecurity, poor feeding behaviour and poor care & practices leading to an intergenerational cycle of malnutrition.[45]

An analysis of the causes of stunted growth in Nepal reveals that around half is rooted in poor maternal nutrition, and the other half in poor infant and young child nutrition. Around a quarter of babies are born with a low birth weight. As per the findings of Nepal Demographic and Health Survey (NDHS, 2011), 41 percent of children below 5 years of age are stunted. A survey by NDHS and NMICS also showed that 30% of the children are underweight and 11% of children below 5 years are wasted.[38]: 241 

In order to address under-nutrition problems in young children, the Government of Nepal (GoN) has implemented:

a) Infant and Young Child Feeding (IYCF)
b) Control of Protein Energy Malnutrition (PEM)
c) Control of Iodine Deficiency Disorder (IDD)
d) Control of Vitamin A Deficiency (VAD)
e) Control of Iron Deficiency Anaemia (IDA)
f) Deworming of children aged 1 to 5 years and vitamin A capsule distribution
g) Community Management of Acute Malnutrition (CMAM)
h) Hospital-based nutrition management and rehabilitation

The hospital-based nutrition management and rehabilitation program treats severe malnourished children at Out-patient Therapeutic Program (OTP) centres in Health Facilities. As per requirement, the package is linked with the other nutrition programs such as the Child Nutrition Grant, Micronutrient powder (MNP) distribution to young children (6 to 23 months)[38]: 22, ⁠24  and food distribution in the food insecure areas[citation needed].

Infant and Young Child Feeding program

UNICEF and WHO recommended that children be exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life (WHO/UNICEF, 2002). The nutrition program under the 2004 National Nutrition Policy and Strategy promotes exclusive breastfeeding through the age of 6 months and, thereafter, the introduction of semisolid or solid foods along with continued breast milk until the child is at least age 2. Introducing breast milk substitutes to infants before age 6 months can contribute to breastfeeding failure. Substitutes, such as formula, other kinds of milk and porridge are often watered down and provide too few calories. Furthermore, possible contamination of these substitutes exposes the infant to the risk of illness. Nepal’s Breast Milk Substitute Act (2049) of 1992 promotes and protects breastfeeding and regulates the unauthorized or unsolicited sale and distribution of breast milk substitutes.[46]

After six months, a child requires adequate complementary foods for normal growth. Lack of appropriate complementary feeding may lead to malnutrition and frequent illnesses, which in turn may lead to death. However, even with complementary feeding, the child should continue to be breastfed for two years or more.[46]

Road Traffic Accidents in Nepal

Road traffic injuries are one of the global health burdens, an eighth leading cause of death worldwide. Globally, approximately 1.25 million lives are cut short every year because of a road traffic injuries. Ranging from 20 to 50 million people become victims of non-fatal injuries, with many acquiring a disability for the rest of the life as a result of their injury. [47] In Nepal, a road traffic accident rank eighth among killer causes of disability-adjusted life years and also eighth among premature cause of death after Non-Communicable Diseases and Communicable Diseases. [48]

A substantial problem of road traffic accident with fatalities occurs mainly on highways caused by bus crashes in Nepal. Due to the country's geography, bus accidents mostly happen in the hilly region and along the long-distance route causing 31 percent of fatalities and serious injuries every year. [49] Accidents involving motorcycles, micro-buses, cars etc highly prevail in the capital city, Kathmandu compared to other cities and lowland areas. The number of Road Traffic Accidents in the capital city was (53.5±14.1) of the number for the entire country.[50] People between 15 to 40 ages are the most affected group followed by those above 50 years and majorities were male making 73 percent of disability-adjusted life years. The number of registered vehicles in Bagmati Zone was 129,557, a 29.6 percent of the whole nation in fiscal year 2017/2018.[51] [50]

The table below shows the trend of fatality per 10000 vehicles between 2005 and 2013.

Year Accidents Fatalities Total Vehicles Fatality per 10000

vehicles

2005-6 3894 825 536443 15.38
2006-7 4546 953 625179 15.24
2007-8 6821 1131 710917 15.91
2008-9 8353 1356 813487 16.67
2009-10 11747 1734 1015271 17.08
2010-11 140131 1689 1175824 14.36
2011-12 14291 1837 1342927 13.68
2112-13 13582 1816 1545988 11.75

source: Traffic Accidents Record, Traffic Directorate, Nepal Police, 2013.[51]

Mental Health

In terms of the network of mental health facilities, there are 18 outpatient mental health facilities, 3 day treatment facilities, and 17 community-based psychiatric inpatient units available in the country. The majority of the mental health service users are treated in outpatient facilities. Thirty-seven percent of patients are female. The patients admitted to mental hospitals belong primarily to the following two diagnostic groups: Schizophrenia, schizotypal and delusional disorders (34%) and Mood [affective] disorders (21%). On average, patients spend 18.85 days in mental hospitals. All of the patients spent less than one year in the mental hospital during the year of assessment.

Two percent of the training for medical doctors is devoted to mental health, and the same percentage is provided for nurses. One Non Government Organization is running a community mental health service in 7 of the 75 districts in the country. In other districts, community mental health services are not available, as mental health services are not yet integrated into the general health service system.

Even though Nepal's mental health policy was formulated in 1996, there is no mental health legislation as yet. In terms of financing, less than one percent (0.17%) of health care expenditures by the government are directed towards mental health. There is no human right review body to inspect mental health facilities and impose sanctions on those facilities that persistently violate patients' rights.[52]

See also

References

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