Policy Gaps and Challenges” was successfully held on Oct 11, 2018 at Alfa House Kathmandu. In association with Nepal NCD Alliance, Resource Centre for Primary Health Care (RECPHEC) organized this seminar. The seminar was participated by the key persons and stakeholders working for reducing NCDs in Nepal. The executive summary of the study report is as follow:

EXECUTIVE SUMMARY

1. Introduction
Non-communicable diseases (NCDs) are chronic conditions i.e. cancer, cardiovascular diseases, diabetes mellitus and Chronic Obstructive Pulmonary Diseases (CoPD) associated with modifiable risk factors namely tobacco use, harmful use of alcohol, unhealthy diet physical inactivity and indoor air pollution. Removal of risk factor e.g. tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity and indoor air pollution can reverse the process of development of the NCDs. Major NCDs affect mainly adult populations both rich and poor people and exposure to several years to risk factors leads to manifestations of the disease.

1.1. Global Response to NCDs
Non-Communicable Diseases (NCD) e.g. cardiovascular diseases including stroke, cancer, diabetes mellitus and chronic obstructive pulmonary disease are global public health problems affecting all countries and continents of the world. In view of the emerging global health problem, World Health Organization declared NCDs as global public health problem in March, 2000 and United Nations High Level Meeting in September, 2011 resolution on prevention and control of NCDs and resolution requested member countries to implement policies for control and prevention of NCDs. The main reason behind the increase in NCDs is change in lifestyle of the population with risk factors such as unhealthy diet, less physical activity, consumption of alcohol and use of tobacco, while the risk factor for chronic obstructive pulmonary disease is tobacco smoking and air pollution.

1.2. NCD Situation in Nepal
NCDs have become major public health problem in Nepal. A hospital based study in 1996 showed that the burden of NCDs was 42% in Nepal, while studies carried out in 2010 and afterwards have shown that the burden of NCDs have crossed more than 50%. Among NCD risk factors national level surveys have shown that the one third of Nepalese drink alcohol or use tobacco and diet also seems not healthy. In response to growing problems of NCDs, Government of Nepal has already started some policy actions since 1990s. Main purpose of the study is to review and analyze the policies and strategies implemented by Government of Nepal and other stakeholders to address the problem of NCD and identify the policy gaps and action points if any and also look after the NCD in context of state restructuring in Nepal.

2. Objectives
Review NCD related policies and strategies of Nepal and identify the policy gaps and challenges and policy actions in control and prevention of NCDs

3. Methodology
Desk top review of policies, laws, strategies, guidelines and actions implemented by different sectors of Government of Nepal includingsurvey and study reports.

4. Design of study
This is a retrospective analytical study, based on sectoral multi-sectoral policies and strategies implemented by state and non-state agencies in Nepal and identify gaps in NCD policy and programme.

5. Findings
5.1.1. Sectoral policies and implementation status
5.1.2. NCD Policy,Plans and Programme
NCDs related some health problemsare included in Constitution of Nepal 2072, Nepal Health Sector Programme3 (2016-2020) and Sustainable Development Goals, Nepal (2016-2030). Constitution of Nepal (2072) has included health as a fundamental right of the citizens and in accordance to it, Government of Nepal has to deliver the basic health services to all needy citizens free of cost through municipalities and PEN packagefor prevention and control of NCDs has been designedand integrated with the draft basic health care package.

5.1.2. National NCD Policy and Strategy
NCDs Policy and Strategy- drafted in 2009, but not formulated till date

Health system strengthening policies-Existing health system had difficulty to respond the health needs of the complex diseases such as NCDs during 1990s.So, to respond the increasing problem of major NCDs, Ministry of Health established Oncology Unit at Bir Hospital in 1991, BP Memorial Cancer Hospital in 1996,Shahid Ganga Lal National Heart Center in 2000 and Manmohan Cardiothoracic, Vascular and Transplant Center in 2009 and all these four national centers in public sector are providing high quality services in cancer and cardiovascular diseases. Kanti Children’s Hospital, the only national children’s hospital is also providing diagnosis, surgery and chemotherapy servicesto children. Similarly, Manipal Medical College, BhaktapurCancer Hospital, National Cancer Hospital, Kathmandu Cancer Center and Sushil KoiralaMemorial Cancer Hospital established by NGOs and private health services are also providing cancer services. With all these institutions in NCDs care, hospital system in diagnosis, surgery, chemotherapy, radiotherapy and brachytherapy now significantly strengthened in Nepal. Hospice services are required to non-treatable cancer patients for their comfort and quality of life by providing palliative care and such services are available now within and outside Kathmandu valley and terminally sick cancer patients can utilize hospice services offered by these facilities.

Primary health Care and NCDs-To enhance the capacity and integrate NCD services at primary health care level, Ministry of Health has started implementing the programme essentialfor NCDs (PEN) package and implemented till date in 10 districts. The free health care scheme in 2015 added new drugs and now total free drug list is 70 and some of these drugs are related to NCDs and the NCDs patients now can access these drugsat primary health care level, except drugs for cancer treatment.

5.1.3. Policy for Poor People with NCDs
All the NCDs are catastrophic illnesses, as their immediate treatment cost is very high such as treatment of cancer or need long term treatment such as hypertension or diabetes mellitus or CoPD. If poor people get diseases like NCDs, this can be catastrophic for them and they cannot pay the hospital bills and there is danger of dying of such people without treatment. To avoid such situation Ministry of Health has declared impoverished citizen fund 2015 and from this fund selected diseases of catastrophic hospital bills are included and among them two NCDs are cardiovascular diseases and cancer are included and this fund supports treatment up to 100,000.00 NRs. However, this fund helps poor citizens, who developed renal failure due to NCDs also can receive support for kidney transplant or hemodialysis.

5.1.4. Health promotion
Health promotion is the only efficient and effective approach to reduce the new cases of NCDs. NCDs prevention and promotion programme has several approaches-

a. Vaccination- Piloting of Gardacil vaccine against the human papilloma virus carried out as a pilot study in 2011 in Chitwan and Kaski districts. National Immunization programme is planning to introduce the Gardacil vaccine to prevent cancer of cervix in high school girls. Hepatitis vaccine already included in routine immunization and there is possibility of decrease inhepatic carcinoma in future.

b. Cancer screening- cancer of cervix screening services till FY 2015-16, is available in 64 districts, and 98 doctors and nurses trained in visual inspection and acetic acid cryotherapy treatment.

c. Awareness campaign- awareness campaign during celebration of world tobacco day, world heart day, world diabetes day are intensified

d. Behavioral change communication-anti-tobacco communication strategy 2017 finalized, but there is no communication strategy for life style change, and other risk factors.

e. Nutrition- national nutrition policy and Strategy 2004 exists, but needs revision

f. Community based interventions- all communities have different types of NCDs Risk Factors, and all types’of risk factors are not prevalent in the communities. So, if community based interventions in cooperation with civil society and NGOs, can be implemented, they can be very effective.

g. Yoga and Physical exercise Corner-Yoga and physical exercise corner with some equipment in big offices and business houses is rare to find in Nepal.

5.1.5. Surveillance and research
Nepal has started doing NCD Risk Factor Survey adopting the WHO STEPS survey method and first survey carried out by Ministry of Health in 2008 and second survey carried out by Nepal Health Research Council (NHRC) in 2013 and third survey is also ongoing and it is conducted by NHRC itself and results will be available within 2018.

5.1.6 Sectoral coordination
Ministry of Health created a position of focal point for NCDs and healthy ageing in 2002 and in 2004 nine memberNCD Steering Committee formed, chaired by the chief specialist of the curative division of the Ministry of Health. Recently, the organogram of Ministry of Health Population has changed and the NCDs and Mental Health Section has been placed under the Epidemiology and Disease Control Division of Department of Health Services.

5.1.6. Partnership
Partnership agreements between non-governmental cancer hospitals for service delivery and with other NGOs for health promotion done periodically.

5.1.7. Human resource for health for NCDs Services
Universities and academies have started producing highly trained human resource in health like cardiologist, cardio-thoracic surgeon, oncologists, radiotherapists and diabetes and endocrine specialists.

5.2. Multi-sectoral policies and implementation status
Health sector only cannot control the problems of NCDs and for effective NCDs prevention and control programme other sectors also must contribute positively.

5.2.1 Coordination
In 2012 multi-sectoral coordination and facilitation committee formed under the vice-chair of the National Planning Commission and according to multi-sectoral action plan for prevention and control of NCDs 2015, High Level Multi-sectoral Committee chaired by Chief Secretary of Government of Nepal has been formedand it started functioning.

5.2.2. Tobacco and alcohol tax
Tobacco control act passed by parliament in 2011 and it prohibit use of tobacco in public places and advertisement and alcohol act passed by parliament in 1974 and it prohibits sale of alcohol below 18 years and discourages home brewed alcohol. Budget speech of 2008-09 enforced new rule of separate license for opening a liquor shop in urban areas. Alcohol control policy approved by cabinet in 2017, but it is still not made public.

Ministry of Finance declared one paisa tax in in each stick of 1994 and 25 paisa in 2018. Excise tax levied in alcohol since 2002 and in 2018 additional 10% tax applied by revenue department and per liter tax in alcohol is 100-1100 NRs depending upon the alcohol low or high content. According to tobacco control act 25% of tax money is sent to health tax operating fund.

5.2.3. Tax on sugar item
For the first time the budget of 2018-19 has put excise tax on cocoa mixed chocolate, both imported and local.

5.2.4. Advertisement through Mass Media and Sponsorship
Tobacco advertisementand sponsorship through all means is completely prohibited and smoking is banned in all public places. However, alcohol advertisement is not prohibited and advertisement is still allowed. Government of Nepal has prohibited use of alcohol in public ceremonies.

5.2.5. Financing of NCDs Prevention and Control Programme and Services
Revenue collected from alcohol, tobacco and others by Ministry of Finance, predetermined percentage of excise tax is deposited in health tax fund and this is utilized for services of cancer hospitals in public sectorand NGO sector and for health promotion activities.

5.2.6. Educationcurricula and NCDs
NCDs related topics included in curricula of grade 8, 9 and 10 in 2008.

5.2.7. Environmental Health and Air pollution
To reduce the indoor pollution, Government of Nepal has approved Renewable Energy Subsidy policy 2016 and under this scheme households of selected areas canrequest for support for installing the improved cook stove. Polluters pay policy in petrol has been implemented and this fund collects 50 paisa per liter, but till date this fund is not utilized for air pollution control.

5.2.8. Park and Garden
No policy found in park and garden and physical exercise

5.2.9. Legal enforcement to control alcohol and tobacco
There is legal enforcement provision in tobacco control act, but not much in alcohol.

5.2.10. Corporate social responsibility
Nepal Air Lines is providing free ticket to diagnosed cancer patient going abroad for treatment in its scheduled flights since 1984, and thousands of patients benefitted from it.

5.2.11. Role of civil society, NGO and private sector
Civil society and NGOs are playing important role in both health and non-health interventions especially in the field of advocacy, awareness, capacity development and service delivery, but role of private sector is limited to service delivery only.

6. Miscellaneous
6.1. Monitoring and evaluation
Annual Report is published by Department of Health Services and this includes NCDs report as well. Cancer registry is another method of monitoring. NCDs Risk Factor survey carried every five years is also a good source of analyzing risk factor trend.

6.2. Networkingof NCDs related organizations
There is no national level alliance or network of organizations working in NCDs. However, small alliances in cancer or heart or tobacco control are present.

6.3. Governance
Multi-sectoral coordination mechanism for prevention and control of NCDs- led by Chief Secretary of Government of Nepal. There are other committees at different levels.

Health tax fund- chaired by health secretary is responsible for allocation of funds for different activities and organizations and the ratio for preventive to curative is 15:85.

NCDs and Mental Health Section at Epidemiology and Disease Control Division, Department of Health Services- overall responsibility of NCDs related issues including implementation of PEN Package
Disease Control Section, Provincial Health Offices in all seven states
Health promotion-NHEICC is responsible for health promotion
Capacity building-NHTC is responsible for training related to NCDs
Legal enforcement-Assistant Chief District Officer in all district administration offices is responsible for legal enforcement

7. Impact of Health and Non-health Interventions
Despite major interventions against indoor air pollution and tobacco use, no improvement found in prevalence of Cardiovascular Diseases, CoPD, Diabetes Mellitus and Cancer and rather cases found increasing in between 1997-98 and 2016-17.

8. Policy Gaps NCDs Prevention and Control Policy and Programme
Policy gap found in integrated comprehensive NCDs Control and Prevention Policy and policy gap also found in alcohol control. Likewise, policy gap found in fruit and vegetable intake, physical exercise and nutrition for good health.

9. Challenges
Major challenge found is formulation of integrated NCDs prevention and control policy in new context of Nepal. Another challenge is legal enforcement is weak as experienced in tobacco control. Access to NCD related sick people to referral hospitals seem difficult as they are located nearby to Kathmandu. Lastly health promotion should get higher priority to intensify the anti-NCDs campaign and needs to allocate more resources.