|
 
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| PERSPECTIVE |
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| Year : 2016 | Volume
: 5
| Issue : 1 | Page : 40-43 |
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Strengthening policy and governance to address the growing burden of diabetes in Nepal
Senendra Raj Upreti1, Guna Raj Lohani1, Akjemal Magtymova2, Lonim Prasai Dixit2
1 Ministry of Health, Kathmandu, Nepal
2 World Health Organization County Office for Nepal, Kathmandu, Nepal
| Date of Web Publication | 18-May-2017 |
Correspondence Address:
Lonim Prasai Dixit
WHO Country Office for Nepal, UN House, Pulchowk, Kathmandu
Nepal
  | Check |
DOI: 10.4103/2224-3151.206551 PMID: 28604396 
Diabetes poses a major challenge to Nepal’s health-care system. Deaths due to noncommunicable diseases (NCDs) have increased from 51% of all deaths in the country in 2010 to 60% in 2014. In 2014, diabetes and other essential NCDs accounted for 46% of the total deaths and 22% of premature deaths in the country. As diabetes is common in adults of working age, the impact will further impoverish individuals and families in Nepal, where out-of-pocket expenditure for health remains high. To halt the rise in diabetes and obesity, the government of Nepal will have to adopt a public health approach that balances individual and population-level interventions. Awareness, early diagnosis and prevention are key to management and control of diabetes. To date, there has been no nationwide robust programme for diabetes prevention in the country and services are inaccessible to much of the Nepalese population. However, under the NCD Multisectoral Action Plan (2014–2020), there will be phase-wise implementation of the World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings. The NCD PEN brings opportunities to strengthen the health workforce, diagnostics, medicines and supplies, the health information system, and research and surveillance and to reduce inequity in diabetes care in Nepal.
Keywords: diabetes, low-income countries, primary health-care system, universal health coverage, WHO PEN package
How to cite this article:
Upreti SR, Lohani GR, Magtymova A, Dixit LP. Strengthening policy and governance to address the growing burden of diabetes in Nepal. WHO South-East Asia J Public Health 2016;5:40-3 |
How to cite this URL:
Upreti SR, Lohani GR, Magtymova A, Dixit LP. Strengthening policy and governance to address the growing burden of diabetes in Nepal. WHO South-East Asia J Public Health [serial online] 2016 [cited 2021 Mar 7];5:40-3. Available from: http://www.who-seajph.org/text.asp?2016/5/1/40/206551 |
| Background | |  |
The World Health Organization (WHO) recognizes diabetes as one of the four high-burden noncommunicable diseases (NCDs). The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030.[1] In 2012, an estimated 1.5 million deaths were attributed to diabetes worldwide and more than 80% of these deaths occurred in low-and middle-income countries.[2]
Diabetes is an emerging public-health epidemic in the WHO South-East Asia Region. The International Diabetes Federation (IDF) estimates that 72 million adults in Bangladesh, India, Nepal and Sri Lanka were living with diabetes in 2013 and, by 2035, the equivalent number is projected to exceed 123 million. These numbers equate with comparative prevalences of 8.1% and 9.4% in 2013 and 2035, respectively.[3] A systematic review of data from Bangladesh, India, Maldives, Nepal, Pakistan and Sri Lanka noted that the rate of increase is greater than previously observed in high-income countries, underscoring the need for rapid, low-cost solutions.[4]
Diabetes and other NCDs therefore pose a major challenge to Nepal’s health-care system; the proportion of deaths attributable to all NCDs has increased from 51% in 2010 to 60% in 2014.[5],[6] The WHO NCD Country profiles 2014 reports that cardiovascular disease was responsible for 22% of all deaths in Nepal, followed by chronic respiratory disease (13%), cancer (8%) and diabetes (3%); together, these four NCDs accounted for 22% of all premature deaths in Nepal.[6]
Diabetes is one of the major causes of premature deaths and disability, and people with diabetes are at increased risk of dying from cardiovascular disease.[7] Exposure to diabetes-related risk factors, and limited access to early diagnosis and management of diabetes, is not only associated with micro-and macrovascular complications but also leads to catastrophic health expenditure. As diabetes is prevalent in adults of working age, it threatens to further impoverish individuals, families and the community as a whole, in a country where out-of-pocket expenditure for health remains high.[8]
| Disease Burden and Diabetes Risk Factors | | |
The global prevalence of diabetes in 2014 was estimated to be 9% among adults aged 18 years and above, and for obesity more than 50%.[9] WHO estimates that there will be 1 328 000 cases of diabetes in Nepal by 2030. According to the 2011–2012 annual report of the department of health services, 84% of the total number of outpatient visits and 90% of the total number of inpatients discharged in Nepal were attributed to NCDs.[10]
There are few national representative studies on diabetes morbidity and mortality in Nepal. Most of the publications are hospital-based cross-sectional studies and some are conducted within a confined geographical area. The Non communicable disease risk factors: STEPS survey Nepal, 2013 reported the national prevalence of diabetes, based on plasma venous blood glucose ≥126 mg/dL and including those on medication, was 3.6% (men 4.6%, women 2.7%). More than 50% of men and women with diabetes were not on medication and 89% of the respondents had never measured their blood glucose.[11] These figures are alarming and give an indication of the access to care, utilization of health-care services and level of awareness in the country. The IDF reports the prevalence of diabetes in Nepal was 4.6% among adults aged 20–79 years in 2014.[12] The study reported that 700 000 cases of diabetes and 14 778 deaths among these age groups were due to diabetes.[12] Studies in Nepal also report that the prevalence of diabetes is increasing in urban areas compared to rural areas in the country.[13],[14],[15] In a study conducted in the capital, the prevalence of diabetes was reported to be 26% and a higher proportion of diabetes was reported in males (27.1%) than females (24.8%>).[16] Other studies have also reported a higher proportion of type 2 diabetes among males compared with females.[17],[18]
The risk factors for type 2 diabetes are common to those for other NCDs. The Nepal STEPS survey reports an increase in risk factors for diabetes such as tobacco use, alcohol consumption, unhealthy diet and lack of physical activity.[11] Nearly one in every two men aged 15–69 years use tobacco (smoke or smokeless) and 99% of the Nepalese population do not meet the recommendation of consuming five servings of fruit and vegetables on a daily basis. Another concern is the high level of salt consumption and increase in unhealthy diets that are high in trans fat and sugar. Risk factors, such as tobacco use, alcohol consumption and raised blood pressure, blood glucose, total cholesterol and triglycerides were more prevalent among men than women, while obesity and low high-density lipoprotein were prevalent among women. Only 0.4% of the populations surveyed were free from NCD risk factors. These lifestyle-related risk factors contribute to increase in blood glucose, blood pressure, blood lipids, overweight and obesity.[11] According to The world health report 2002, the four behavioural risk factors – tobacco, alcohol, diet and physical activity – and four metabolic risk factors – raised blood pressure, blood glucose, blood cholesterol and overweight/ obesity – account for 22% of the NCDs including diabetes.[19]
| Health Workforce and Service Delivery: Challenges and Gaps | | |
People with diabetes need access to appropriate medicines and a wide range of health-care services in the course of their disease. Early diagnosis and management are key to prevention and control of diabetes. There are wide variations in the availability of diabetes care services, and their availability and utilization across different socioeconomic and geographical population groups, indicating the challenge of access and equity. Diabetes services are mainly centred in urban areas and are inaccessible to many Nepalese people. There are no government health-financing schemes for diabetes care and none of the services are funded or subsidized by the government. All services such as diagnosis, treatment, medications and laboratory tests are funded by individuals and households out of pocket. There is also a lack of awareness of diabetes and its complications among the general population. There is no nationwide robust programme for diabetes prevention in the country. Some nongovernmental organizations support occasional mass media awareness activities and screening camps and organize national events to commemorate World Diabetes Day and World Sight Day.
Diabetes services in Nepal are provided by the public and private sectors through different levels of health workforce. The availability of diabetes care services and quality of care are not structured and uniform in the country. Appropriate referrals and consultations are not commonly practised. In the absence of national guidelines for diabetes care, service providers use a range of different guidelines. The categories of health workforce providing diabetes care are endocrinologists, ophthalmologists, primary care physicians, ophthalmic assistants and dietitians. The available health workforce in the country is inadequate and not uniformly distributed. The report of the assessment of diabetic retinopathy and diabetic management system in Nepal, 2015, reveals that one endocrinologist is available for 1 000 000 population and one ophthalmologist for 200 000 population (unpublished data). Although the National Academy of Medical Sciences has started a specialization course (Doctor of Medicine in Endocrinology), it is evident that the current health workforce is inadequate to address the growing burden of diabetes and its complications.
The report also highlights lack of diabetes services at the primary health-care level. The majority of the services are clustered in urban areas and are provided by nongovernmental organizations and the private sector. At the public hospitals, services for diabetes and diabetic retinopathy are only available at zonal, regional and tertiary-level health-care centres, which are accessible to only 30% of the population. Diagnostic facilities have improved over the years. However, many of the laboratory facilities are mainly centred in the capital city and there are limited numbers of laboratories providing quality services.
Early diagnosis and referral services are not available at all levels of health-care services, owing to lack of resources such as trained health professionals, NCD-related drugs and diagnostics, which limits access to diabetes care. In such circumstances, diabetes is often diagnosed late and requires care at tertiary level.
The lack of awareness, inadequate services for diabetes management, including early detection, the cost of services, and the country’s topography are barriers to diabetes care.
| Policies and Programmes: The Way Forward | | |
A multisectoral response is essential to attainment of the WHO target[20] and Sustainable Development Goals[21] to reduce premature mortality due to NCDs by 25% by 2025 and 30% by 2030, respectively. The cost of lifelong diabetes care and loss of productivity negatively impacts the economic growth of individuals and the nation as a whole, and undermines human development. If no action is taken, the World Economic Forum estimates the burden of NCDs including diabetes will cost US$ 30 trillion globally, over the 20-year period 2010 to 2030.[22]
At policy, programme and institutional level, with the exception of the WHO Framework Convention on Tobacco Control,[23] NCDs were practically non-existent in Nepal’s general health policies and programmes. The Nepal Health Sector Plan (NHSP) I (2004-2009) did not prioritize NCDs.[24] However, they were included in NHSP II (2010–2015).[25] The focus has been mainly on management of NCDs at tertiary care level and no information on NCD drugs was included on the Ministry of Health and Population national list of essential medicines, 2011.
However, over the years, NCDs in Nepal have received high-level political commitment. As a follow-up on the Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases,[26] to which Nepal is a signatory, the Government of Nepal has developed the national Multisectoral Action Plan for the Prevention and Control of Non Communicable Diseases (2014–2020).[27] The Nepal National Health Policy 2014 calls for a people-centred approach to quality health services that are more effective and accountable to the citizens.[28] Health is placed central to overall development, building partnerships and establishing multisectoral collaboration. NCDs, including diabetes, are reflected in the National Health Policy 2014,[28] Nepal Health Sector Strategy (NHSS) III (2015-2020),[29] and universal health coverage plans. The basic health service package of NHSS III has incorporated diabetes screening, counselling and laboratory services at all levels of health care.[29]
One of the objectives of the Multisectoral Action Plan for the Prevention and Control of Non Communicable Diseases (2014-2020) is to strengthen and orient health systems to address the prevention and control of NCDs and underlying social determinants, through people-centred primary health care and universal health coverage.[27] Early and appropriate treatments and access to services, particularly primary care, will avoid devastating, irreversible complications of diabetes. In line with the South-East Asia Regional NCD targets, Nepal has also adopted the 10 targets to be achieved by 2025, which include a 25% relative reduction in overall mortality from the four major NCDs.[20] The third action area of the Action Plan[27] is on health-systems strengthening for early detection and management of NCDs and their risk factors. Actions under this area aim to strengthen health systems, particularly the primary health-care system, by implementing the WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings. [30] PEN is an essential package of cost-effective interventions with high impact, including those for early detection and management of type 2 diabetes, which are feasible for application in resource-poor settings. The package will be introduced in the first two years and then expanded to other districts in the country. In this process, diagnostic services will be made available in primary health-care settings.
The government of Nepal therefore has an opportunity to strengthen health-care services via primary health-care facilities, by implementing the essential package of NCD interventions. Phased implementation and escalation of coverage of PEN in all 75 districts[30] brings opportunities to strengthen the health workforce, diagnostics, medicines and supplies, the health information system, research and surveillance and reduce inequity in diabetes care in Nepal. To strengthen the roll-out of PEN in Nepal, we recommend revision of the free essential medicines list of the Ministry of Health and Population, to cover essential drugs for management of NCDs.
The growing burden of diabetes in the country can be addressed through a whole-of-society and whole-of-government approach. WHO aims to stimulate and support the adoption of effective policy and strategic measures for the prevention and control of diabetes and its complications in Nepal.
Source of Support: Nil.
Conflict of Interest: None declared.
Authorship: SRU contributed to the conceptualization and prepared the first draft; GRL contributed to the conceptualization and further inputs in the draft; AM contributed to the conceptualization and prepared the first draft; LPD prepared the first draft and addressed the reviewer’s comments. All authors contributed to the inputs of the final submitted draft.
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