Public Health Status and challenges of Nepal Prepared by Sagar Prasad Ghimire MPH, Institute of Medicine, Nepal

China

Nepal’s Population Pyramid 2003

Basic Information AREA: 1,47,181 Sq.Km HIGHEST MOUNTAIN: Mount Everest POPULATION: 24.6 million REGION: 5 ZONE: 14 DISTRICT: 75

Major Indicators CBR (per 1000 population) 33.1 CDR (per 1000 population) 9.6 TFR 4.1 IMR (per 1000 live birth) 64.4 U5MR (per 1000 live birth) 91.2 Life expectency 59.7 years Mean age at marriage 21.9 (M),19.5 (F) MMR (per 100000 live birth) 539* PGR 2.24 Literacy Rate 54.1 Urban Population 14.2 % (Source: Census, 2001* NDHS 1996)

Diseases status Ten Leading Outpatient Diseases, 2003/04 (dominated by infectious diseases) Skin Diseases Diarrhea Diseases Acute Respiratory Infection Intestinal Worms Pyrexia Gastritis Ear Infection Chronic Bronchitis Abdominal Pain Sore Eye and Complaints Top Reasons for Hospitalization, 2003/04 Spontaneous Delivery Diarrhea and Gastroenteritis Pneumonia Typhoid Other Chronic Obstructive Pulmonary Unsuspected Acute Lower Respiratory Injury of unspecified body region Unspecified Abortion Single Delivery by Caesarean Section Fever of Unknown Origin

Some related facts: proportion of HH, who have access to safe drinking water:79.9% (92.3% urban and 78.1% rural) Proportion of HH with any type of toilets was 33.2% but the proportion with safe toilets was only 29.4% 39.8% of them had at least one ANC check-up during their last pregnancy About 13% of deliveries took place under the guidance of medically trained persons (a Survey by CBS-Nepal 2000)

Health Service Coverage Fact Sheet 2001/2002 2002/2003 2003/2004 EXPANDED PROGRAMME ON IMMUNIZATION BCG Coverage 94 % 97 % 96 % DPT-3 Coverage 80 % 86 % 90 % Polio-3 Coverage 84 % Measles Coverage 76 % 85 % Nutrition Growth Monitoring Coverage as % of <3 Children New Visits 41 % 51 % 55 % Proportion of Malnourished Children (Weight/Age) 16 % 14 % 12 %

Health Service Coverage Fact Sheet contd. 2001/2002 2002/2003 2003/2004 ACUTE RESPIRATORY INFECTION Reported Incidence of ARI/1,000 <5 Children New Visits 229 289 344 Annual Reported Incidence of Pneumonia (Mild+Severe)/1,000 among <5 Children New Visits 97 113 131 DIARRHOEAL DISEASES Diarrhoeal Deaths/1,000 117 200 222 0.04 0.05 Case Fatality Rate/1,000 0.22 0.20 0.25

Health Service Coverage Fact Sheet contd. 2001/2002 2002/2003 2003/2004 SAFE MOTHERHOOD Antenatal First Visits as % of Expected Pregnancies 43 % 53 % 66 % ANC Four Visits among 1st Visit 37.8 % 36.8 % 43.6 % Average No. of ANC Visits per Pregnant Woman 1.9 1.8 2.1 Deliveries Conducted by Health Workers as % of Expected Pregnancies 7.9 % 16.1 % 18.3 % Deliveries Conducted by TBAs as % of Expected Pregnancies 7.1 % 8.4 % 11.3 % PNC First Visits as % of Expected Pregnancies 14.4 % 18.1 % 28.3 %

Health Service Coverage Fact Sheet contd. 2001/2002 2002/2003 2003/2004 FAMILY PLANNING Contraceptive Prevalence Rate (adjusted) 37.4 % 37.8 % 40.2 % MALARIA CONTROL PROGRAMME Blood Slide Examination Rate per 100 Malarious Area Population 0.6 % 0.8 % Slide Positivity Rate (SPR) 9.2 % 8.1 % 4.3 % LEPROSY CONTROL PROGRAMME New Case Detection Rate/10,000 5.73 3.24 2.84 Prevalence Rate/10,000 4.41 3.04 2.41

Health Service Coverage Fact Sheet contd. 2001/2002 2002/2003 2003/2004 TUBERCULOSIS CONTROL PROGRAMME Case Detection Rate 70 % 71 % Treatment Success Rate on DOTS 89 % 90 % 88 % Sputum Convertion Rate 84 % 85 % 86 % DOTS Coverage (Population) 95 % 96 % Health Services Coverage Fact Sheet: Source: Annual Report, Department of Health Services (2003/2004)

Cumulative HIV/AIDS Situation of Nepal As of October 31, 2005 Condition Male Female Total   New Cases in October 2005 HIV Positives (Including AIDS) 4042 1522 5564 99 AIDS (out of total HIV) 671 258 929 22 Death 273 (10*) * In oct 2005

Structural Health Organogram of Nepal

Health Problems Major health concerns New and re-emerging conditions Maternal Health Malnutrition / anemia New and re-emerging conditions Sexually Transmitted Infections HIV Vector-borne diseases Malaria Kala-azar Japanese Encephalitis Infectious diseases Acute respiratory Infection Tuberculosis Diarrhea

Why is Health Delivery System Failing? Insecurity and conflict Lack of human resources (high vacancy rates in rural locations) Lack of supplies and equipment at rural facilities Lack of sufficient infrastructure inputs Mismanagement of ‘poor funds’ and subsidies Mistrust and fear of government services Poor perceived quality of care and provider behavior Supply and demand centralized Inaccessibility

Health Financing WHO target is US$12 (NRs.850) public spending per person Nepal official spending only US$3.10 (NRs.220) per person Development Budget 7.28% earmarked for health (9th Plan); only 3.8% received Escalation of conflict reducing budget for military spending Donors Provide for majority of current health budget Consider health a ‘safe’ and necessary sector Will continue to pursue even in conflict

Public Health Challenges Resource Gap current 30 % : How to fulfill ?, Issue of Debate. Privatization of health services: increase quality in urban areas but challenging for remote and far people. Epidemiological transition: Still facing huge burden of communicable disease(Diarrhoea, ARI) with newly emerging Non-communicable disease along with some new concentrated epidemic (HIV/AIDS) Internal conflict: Negative impact on overall social development (Death, Violence, Handicapped, Disabled, migration, Rape) WTO, Membership: Lacking preparation and capacity to promote national interest. Human Resource for health: Urban centered highly skilled manpower Globalization: Commercialization (Safe Delivery kit, ORS, FP devices) Privatization (Quality increase but accessibility and affordability) Introduction of user’s fee in public health facilities: Affordability for poor people

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