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Have non-communicable diseases become the major health problem in Nepal? – a call for local evidence

[PHP Nepal Vol 2 Issue 5 May 2012] | In the past few years, Nepali newspapers have been presenting alarming headlines on the rising burden of non-communicable diseases (NCDs) in Nepal. These diseases, in particular cardiovascular diseases, chronic obstructive pulmonary diseases, cancers, and diabetes, reportedly are responsible for 60% of all deaths globally, and over 40% of all deaths in Nepal. National and international health experts have expressed their concerns over the increasing number of NCD patients, and the Ministry of Health and Population has taken initial steps towards the prevention and control of NCDs.

More recently, policy makers even opined to revise the 1991 National Health Policy to be primarily oriented on NCDs, as "communicable diseases […] are no longer a small issue as in the past".

Where does this recent interest in NCDs come from? Most of this is sparked by a World Bank study towards the burden of NCDs in South Asia. A policy brief based on this study (NCDs Policy Brief – Nepal) was published in February 2011 stating that, "NCDs already impose the largest health burden in Nepal" as 60% of the total disease burden in Nepal would be due to NCDs leaving 40% for communicable diseases (CDs). The World Bank therefore recommended to "finalize a national NCD policy", and among others to "retool the health work force for NCD prevention and control".

However, the 60/40 paradigm proposed by the World Bank comes with two important caveats. First, the definition used for NCDs is broad, and includes injuries and neuropsychiatric conditions, which are responsible for 12% and 11% of the overall disease burden respectively. NCDs in the strict sense therefore contribute 38% of the national disease burden. CDs are also broadly defined; 28% of the overall disease burden is due to infectious diseases (particularly respiratory infections, diarrhoea, and tuberculosis), and the remaining 12% due to non-infectious CDs, such as nutritional deficiencies. Second, and more important, all data presented here and in the World Bank report, originate from the World Health Organization's "Mortality and Burden of Disease Estimates for WHO Member States in 2004". For all NCDs, and for most CDs, levels of evidence were reported to be low, indicating that country-specific information was totally or partially lacking. The presented estimates were therefore largely based on regional interpolations. Although Nepal may be similar to India and other South Asian countries in various aspects, its health status is not identical to that of its neighbors. These estimates should thus be interpreted with caution.

However, does this mean that NCDs should not be a matter of concern? Definitely not. As in many low and middle income countries, Nepal is faced with an ageing population, a growing urbanization rate, and an expanding middle class. A survey on NCD risk factors (WHO, SOLID Nepal & MOHP, 2003) revealed that 33% of the population consumes tobacco products, and that 59% of males and 26% of females are current alcohol consumers. On average, fruits are consumed only two to three days per week, and only 26% of males and less than 10% of females report to be physically inactive. These factors predispose the population to a growing burden of NCDs, which should be dealt with in the most appropriate way. However, while people are still suffering from the diseases of the past, a dramatic shift towards NCD control and prevention may not be the best option. Furthermore, the not insignificant burden due to injuries and neuropsychiatric conditions should deserve appropriate attention given their proportion of the NCD toll.

As Nepal is faced with a multitude of health problems, communicable and non-communicable, public health policy making is indeed a challenging task. However, it should be clear that this challenge would benefit greatly from more local, high quality and up-to-date information. Further strengthening of the health surveillance capacity should therefore be encouraged, and more resources should be made available for national public health data systems and surveys. Thus, the generated information can form the sound basis of a truly effective and sustainable National Health Policy, and will allow for the monitoring of the progress of the population's health.

Brecht Devleesschauwer is a Doctoral Researcher at Faculty of Veterinary Medicine, Ghent University, Belgium.

Prof. Dr. Jeevan Bahadur Sherchand is a Director of Research Department at Institute of Medicine, Tribhuvan University Kathmandu, Nepal.

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