Health in Nepal

Health care services in Nepal are provided by both the public and private sector and fare poorly by international standards. Disease prevalence is higher in Nepal than it is in other South Asian countries, especially in rural areas.Moreover, the country’s topographical and sociological diversification helps to promote periodic epidemics of infectious diseases, epizootics and natural hazards like floods, forest fires, landslides and earthquakes. Millions of people are at risk of infection and thousands die every year due to communicable diseases, malnutrition and other health-related events which particularly affect the poor living in rural areas. However, Some improvements in health care have been made, most notably significant progress in maternal-child health. For example, Nepal’s Human Development Index (HDI) was 0.458 in 2011^[1] up from 0.291 in 1975.^[2] Other improvements include:^[3]

• Mortality rate during childbirth: From 850 in 100,00 mothers in 1990 to 190 in 2013.^[4]
• Under-five mortality:From 136.9 per 1,000 live births in 1990 to 39.5 in 2015.^[5]
• Infant Mortality: From 97.70 to 29.40 in 20015.^[6]
• Child malnutrition: Stunting 37%, wasting 11% and underweight 30% among child of under five age.^[7]
• Life Expectancy: From 58.5 in 1990 to 68 years in 2012.^[8]
• Human Development Index (HDI): From 0.291 in 1975 to 0.458 in 2011,^[9]

Health care expenditure

In 2002, the government funding for health matters was approximately US$2.30 per person. Approximately 70% of health expenditures came from out-of-pocket contributions. Government allocation for health care was around 5.8% of the budget for 2009.^[15] In 2012, the Nepalese government decided to launch a pilot program on universal health insurance in three districts of the country.^[16]

Health care infrastructure

Health care facilities, hygiene, nutrition and sanitation in Nepal are of poor quality, particularly in the rural areas. Despite that, it is still beyond the means of most Nepalese. Provision of health care services are constrained by inadequate government funding. The poor and excluded have limited access to basic health care due to its high costs and low availability. The demand for health services is further lowered by the lack of health education. Reproductive health care is neglected, putting women at a disadvantage. In its 2009 human development report, UN highlighted a growing social problem in Nepal. Individuals who lack a citizenship are marginalized and are denied access to government welfare benefits.^[17] Traditional beliefs have also been shown to play a significant role in the spread of disease in Nepal.^[18][19]

These problems have led many governmental and nongovernmental organizations (NGOs) to implement communication programs encouraging people to engage in healthy behavior such as family planning, contraceptive use, and spousal communication, safe motherhood practices, and use of skilled birth attendants during delivery and practice of immediate breastfeeding.^[20]

Nutritional status of Nepalese children under 5 years of age^[21]

stagnant 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 mid- and far western regions.though rates of stunting and underweight have decreased and rates of exclusive breastfeeding has increased in past seven years, 41 percent of children under five years of age remain stunted, a rate that increases to 60 percent in the western mountains. There is positive association between household food consumption score and lower prevalence of stunting, underweight and wasting.Children in the food secure household have lowest rates of stunting (33 percent), while children in the food in secure household have rates up to 49 percentage. Maternal education and socioeconomic status have an inverse relationship with childhood stunting. Micro-nutrient deficiencies are widespread, with almost half of pregnant women and children under five, as well as 35 percent of women of reproductive age being anemic. Only 24 percent of children consume iron-rich food, 24 percent of children meet a minimally acceptable diet, and only half of 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 percent) in Nepal.^[22]

Geographical constraints

Much of rural Nepal is located on hilly or mountainous regions. The rugged terrain and the lack of proper infrastructure make it highly inaccessible, limiting the availability of basic health care.^[23] 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.^[24] Most of Nepal's health care facilities are concentrated in urban areas. Rural health facilities often lack adequate funding.^[25]

In 2003, Nepal had ten 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.^[15] In 2000, government funding for health matters was approximately US$2.30 per person, and approximately 70 percent of health expenditures came from out-of-pocket contributions. Government allocations for health were around 5.1 percent of the budget for fiscal year 2004, and foreign donors provided around 30 percent of the total budget for health expenditures.^[2]

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, Nepal has failed to achieve complete decentralization, thus limiting its political, social, and physical potential.^[17]

Health status

Life expectancy

In 2010 with 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 ealth lost through years lived with morbidity and disability^[8]

Diseases

leading disease and to ten cause of death 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%)[11]

HIV/AIDS

Making up 8% of the total estimated population of 40,723, there are about 3,282 children aged up to 14 years are living with HIV in Nepal in 2013, while the adults aged 15 years and above account for 92%. There are 3,385 infections estimated among population aged 50 years and above (8.3%). 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 came down from 2.15 of 2006 to 1.95 for the year 2013 and projected to be 1.86 by 2020.^[26] The epidemic in Nepal is driven by injecting drug users, migrants, sex workers and 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 percent to 34.7 percent 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 percent of migrants returning from Mumbai, India, were infected with HIV, according to the 2006 IBBS among migrants.^[27]

As of 2007, HIV prevalence among female sex workers and their clients was less than 2 percent and 1 percent, respectively, and 3.3 percent 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 percent of the total known HIV infections in Nepal, followed by clients of sex workers (15.5 percent) and IDUs (10.2 percent).^[27]

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 Goals (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 policy and programme management best practices.

Nepal has made significant progress in improving maternal health. Maternal mortality rate was reduced from 748 per 100 000 live birth in 1990^[28] to 190 per 100 000 live birth on 2014. since 1991 to 2013.^[29] Nepal has also made some progress on reducing total fertility rate (TFR), from 5.3 1991^[30] to 2.3 in 2014.^[29]

Despite of other indicator related to maternal health, the health indicator of contraceptive prevalence rate is showing its dereasing trend 2006 (44.2%) and 2011 (43.2%),^[31] and has been attributed to high rates of spousal separation due to migration to other countries for employment (three fourths of youth in rural areas). The use of maternal health services has improved since 1996, with increases in the coverage and number of ANC visits (59% for four ANC visits) in 2014,^[29] rates of institutional deliveries as well as deliveries attended by a SBA (50%).^[29]

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 birth in 2015^[32] from 162 in 1991^[30] according to national data. Global estimates indicate that the rate has reduced by 65% from 128 to 48 per 1000 live births between 1991 and 2013.^[33] 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 at around 22.2 deaths per 1000 Live Birth in 2015 . This compares to a rate of 27.7 in India (2015) and 45.5 in Pakistan (2015).^[32]

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) in 2015 and is one of its challenges going forward.^[32] 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 have 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).^[34]

Child Health programmes in Nepal

The Child Health Division of the Ministry of Health and Population (MOHP), Nepal has launched several child survival interventions, including various operational initiatives, to improve the health of children in Nepal. These include the Expanded Program on Immunization (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 micronutrients supplementation program, vitamin A and deworming campaign, and the Community-Based Management of Acute Malnutrition program.^[29]

Immunization

National immunization program is the priority 1 (P1) program. Since the inception of immunization program to the date it has been an established and successfully public health intervention. Nepal is one of the countries recognized for the well ‐ functioning immunization system with coverage of 97% population equally, successfully to the poor and rich in gender basis of child. New antigen like PCV and MRS has been introduced from 2014. Six districts of Nepal are declared with 99.9% immunization coverage. Nepal has achieved polio free status in 27 March in 2014. Neonatal and maternal tetanus was already eliminated on 2005 and Japanese encephalitis is in control status. Measles case based surveillance is in process to meet the target of elimanation of Measles by 2019.^[29]

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 age 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 community level at all districts in Nepal and it has shown positive results in 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.^[31]

Community-Based Newborn Care Program (CB-NCP)

Nepal Family Health Survey 1996, Nepal Demographic and Health Surveys and World Health Organization estimations over the time have shown that neonatal mortality in Nepal has been decreasing at a slower rate than infant and child mortality. Nepal Demographic and Health Survey 2011 has shown 33 neonatal deaths per 1,000 live births, which accounts for 61 percent of under 5 deaths. The major causes of neonatal death in Nepal are 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 percent of births take place at home (NDHS 2011).^[31]

Therefore, as an urgent step to reduce neonatal mortality, Ministry of Health and Population (MoHP) initiated a new program called ‘Community Based New born Care Package (CB?NCP) based on the National Neonatal Health Strategy 2004.^[31]

National Nutritional Program

The National Nutrition Program under Department of Health Services has laid the vision 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 child bearing 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.^[35]

Malnutrition remains a serious obstacle to child survival, growth and development in Nepal. The most common form of malnutrition is protein energy malnutrition (PEM). The other forms of malnutrition are iodine, iron and vitamin A deficiency. Each type of malnutrition wrecks its own particular havoc on the human body, and to make matters worse, they often appear in combination. Even moderately acute and severely acute malnourished children are more likely to die from common childhood illness than those adequately nourished. In addition, malnutrition constitutes a serious threat especially to young child survival 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, feeding behaviour and poor care and practices leading to an intergenerational cycle of malnutrition.^[36]

An analysis of the causes of stunting in Nepal reveals that around half is rooted in poor maternal nutrition and half in poor infant and young child nutrition. Around a quarter of babies are born 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. The survey also showed that 29 percent of the children are underweight and 11 percent of the children below 5 years are wasted.^[29]

In order to address the under nutrition problem in young children, 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 like Child Nutrition Grant, Micronutrient powder (MNP) distribution to young children (6 to 23 months) and food distribution in the food insecure areas.^[29]

Infant and Young Child Feeding program

UNICEF and WHO recommend 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.^[37]

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.^[37]

References

External links

• The State of the World's Midwifery - Nepal Country Profile