There used to be a time when the main public health threat in Nepal was from infectious diseases like malaria, encephalitis, TB and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.
Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, diabetes, renal failure and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, poor health is making Nepalis poorer.
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Also, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on stunting and wasting among children due to malnutrition.
In addition, worsening air pollution has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.
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Nepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by road traffic accidents or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.
A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.
To meet these challenges, Nepal desperately needs affordable and accessible medical care. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.
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A survey last year showed that half of all medical expenditure of Nepalis families is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.
One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a commentary this week, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.
Parts of the scheme are being tried out in Bayalpata Hospital in Achham (which last week won the Global Architecture Festival award in Amsterdam for its design). Insurance reimbursement covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.
Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government can no longer keep passing the buck on providing universal insurance for its citizens.