Transforming Nepal’s primary health care delivery system in global health era: addressing historical and current implementation challenges

Nepal’s Primary Health Care (PHC) is aligned vertically with disease control programs at the core and a vast network of community health workers at the periphery. Aligning with the globalization of health and the factors affecting global burden of diseases, Nepal echoes the progressive increase in life expectancy, changes in diseases patterns, including the current impact of COVID-19. Nepal’s health system is also accommodating recent federalization, and thus it is critical to explore how the primary health care system is grappling the challenges amidst these changes. In this review, we conducted a narrative synthesis of literature to explore the challenges related to transformation of Nepal’s primary health care delivery system to meet the demands incurred by impact of globalization and recent federalization, covering following database: PubMED, Embase and Google Scholar. Of the 49 articles abstracted for full text review, 37 were included in the analyses. Existing theories were used for constructing the conceptual framework to explain the study findings. The results are divided into four themes. Additional searches were conducted to further support the narrative synthesis: a total of 46 articles were further included in the articulation of main findings. Transforming Nepal’s primary health care system requires a clear focus on following priority areas that include i) Revised efforts towards strengthening of community based primary health care units; ii) Adapting vertical programs to federal governance; iii) Reinforcing the health insurance scheme; and iv) Strengthening an existing network of community health workers and health human resources. This review discusses how these broad goals bear challenges and opportunities

Economic Costs Associated with Motorbike Accidents in Kathmandu, Nepal

Background: Road traffic accidents, considered as global tragedies, are in increasing trend however, the safety situation is very severe in developing countries incurring substantial amount of human, economic and social costs. Motorcycle crashes, the commonest form, occur mostly on economically active population. However, there is limited coverage of studies on economic burden of motorcycle crashes. This study aims to estimate the total cost and DALYs lost due to motorbike accidents among victims of Kathmandu Valley.Materials and Methods: Retrospective cross-sectional study was conducted among the patients having history of motorbike accidents within past twelve months and at least 3 months from the date of data collection. Interview was conducted using proforma among 100 victims of accidents and their care giver in case of death from November 15, 2014 to May 15, 2015. Cost estimation of motorbike accident was done based on human capital approach. Data collection tool was pretested and collected data were analyzed by SPSS and Microsoft excel. Results: Males (79%) belonging to the economically productive age group shared the highest proportion among total accidents victims. Most common reason for accidents was reported to be poor road condition (41%). Indirect cost was found to be significantly higher than direct costs highlighting its negative impact on economy of family and nation due to productivity loss. Total Disability Adjusted Life Years (DALYs) lost per person was found to be 490 years and national estimation showed large burden of motorbike accidents due to huge DALY loss.Conclusions: For low resource countries like Nepal, high economic costs of motorbike accidents can pose additional burden to the fragile health system. These accidents can be prevented, and their consequences can be alleviated. There is an urgent need for reinforcement of appropriate interventions and legislation to decrease the magnitude of it and its associated grave economic consequences so as to nib this emerging epidemic in the bud

Remittances, migration and inclusive growth : the case of Nepal

‘Inclusive growth’ is understood to encompass both a lasting reduction in absolute poverty and a more equitable distribution of the gains from growth. In other words, the focus has shifted from quantity to quality of growth. Remittances can have impacts beyond simply increasing household spending power: they can alter behavior in other social spheres as well, for example, by changing attitudes towards gender, education or participation in the labour market. These changes can also potentially contribute to reduction in poverty and income inequality

Health system’s readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey

BACKGROUND: The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal. METHODS: This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities. RESULTS: Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (β = 2.87, 95%CI: 2.42-3.39), diabetes (β =3.02, 95%CI: 2.03-4.49), and CRDs (β = 15.95, 95%CI: 4.61-55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (β = 1.99, 95%CI: 1.02-1.39). Service readiness for CVDs (β = 1.13, 95%CI: 1.04-1.23) and diabetes (β = 1.78, 95%CI: 1.23-2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (β = 0.83, 95%CI: 0.73-0.95) had lower, and province 4 (β =1.24, 95%CI: 1.07-1.43) and province 5 (β =1.17, 95%CI: 1.02-1.34) had higher readiness index for CVDs. CONCLUSION: This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities

Malnutrition and Associated Factors with Nutritional Status among Orphan Children: An Evidence-Based Study from Nepal

Background: Malnutrition is a common public health problem among children in low and middle-income developing countries. Orphan's children are vulnerable and neglected groups in society and are more prone to malnutrition. The study aims to identify the prevalence of underweight, stunting, thinness, and factors associated with nutritional status among orphan children. Methods: Quantitative method & analytical cross-sectional research design were used to assess the nutritional status and its associated factors among orphan children in Pokhara Valley, Nepal. The sample size of 160 children was obtained by a simple random technique. The semi-structured questionnaire, digital bathroom scale, stadiometer was used as the data collection technique. Data management and analysis were done from Epi-info, SPSS 25 version, and WHO Anthro plus. Findings: The majority of children were malnourished (80.6%) with the prevalence of stunting (55.1%), thinness (13.8%), and overweight (6.9%). Prevalence of underweight, stunting, and thinness was high among the boys (85.5%, 26.3%, and 15.8%), but overweight was more prevalent among the girls (7.1%). Ethnicity, sex, age, stay duration in an orphanage, and education of caregivers was associated with the nutritional status of orphan children (p <0.05). Non-privileged children and children below 11 years were more prone to malnutrition. Conclusion: Malnutrition is highly prevalent in orphan children and needs to be addressed. There is still limited study available on the nutritional status of orphan children in Nepal. Nutritional status should be monitored regularly for early identification and timely intervention of malnutrition to promote the nutrition health status of orphan childre

‘The broker also told me that I will not have problems after selling because we have two and we can survive on one kidney’: findings from an ethnographic study of a village with one kidney in Central Nepal

Kidney selling is a global phenomenon engraved by poverty and governance in low-income countries with the higher-income countries functioning as recipients and the lower-income countries as donors. Over the years, an increasing number of residents in a village near the capital city of Nepal have sold their kidneys. This study aims to explore the drivers of kidney selling and its consequences using ethnographic methods and multi-stakeholder consultations. An ethnographic approach was used in which the researcher lived and observed the residents’ life and carried out formal and informal interactions including in-depth interviews with key informants, community members and kidney sellers in Hokse village, Kavrepalanchok district. Participants in the village were interacted by researchers who resided in the village. In addition, remote interviews were conducted with multiple relevant stakeholders at various levels that included legal workers, government officers, non-government organization (NGO) workers, medical professionals, and policymaker. All formal interviews were audio-recorded for transcription in addition to field notes and underwent thematic analysis. The study identified processes, mechanisms, and drivers of kidney selling. Historically, diversion of a major highway from the village to another village was found to impact the livelihood, economy and access to the urban centres, ultimately increasing poverty and vulnerability for kidney selling. Existing and augmented deprivation of employment opportunities were shown to foster emigration of villagers to India, where they ultimately succumbed to brokers associated with kidney selling. Population in the village also maintained social cohesion through commune living, social conformity (that had a high impact on decision making), including behaviours that deepened their poverty. Behaviours such as alcoholism, trusting and following brokers based on the persuasion and decision of their peers, relatives, and neighbours who became the new member of the kidney brokerage also contributed to kidney selling. The other reasons that may have influenced high kidney selling were perceived to be a poor level of education, high demands of kidneys in the market and an easy source of cash through selling. In Hokse village, kidney selling stemmed from the interaction between the brokers and community members’ vulnerability (poverty and ignorance), mainly as the brokers raised false hopes of palliating the vulnerability. The decision-making of the villagers was influenced heavily by fellow kidney sellers, some of whom later joined the network of kidney brokers. Although sustained support in livelihood, development, and education are essential, an expanding network and influence of kidney brokers require urgent restrictive actions by the legal authority

Health-Seeking Behaviors and Self-Care Practices of People with Filarial Lymphoedema in Nepal: A Qualitative Study

Background. Lymphatic filariasis is endemic in Nepal. This study aimed to investigate health-seeking behaviors and self-care practices of people with filarial Lymphoedema in Nepal. Methods. A cross-sectional study was conducted using qualitative methods in three endemic districts. Twenty-three patients with current Lymphoedema were recruited in the study. Results. Hydrocele was found to be a well-known condition and a major health problem in the studied communities. People with Lymphoedema primarily sought health care from traditional healers, whereas sometimes home-based care was their first treatment. Later Ayurvedic and allopathic hospital-based care were sought. Respondents reported various psychological problems such as difficulty in engaging in sexual intercourse, anxiety, worry and stress, depression, low self-esteem, feeling weak, fear of being abandoned, and fear of transmitting disease to the children. Standard foot care practices except washing were largely absent. Conclusions. Lymphoedema in the limbs and hydrocele were found to be major health problems. The traditional health care providers were the first contact of care for the majority of respondents. Only a few patients had been practicing standard foot care practices

Poor Thermal Care Practices among Home Births in Nepal: Further Analysis of Nepal Demographic and Health Survey 2011

Introduction - Hypothermia is a major factor associated with neonatal mortality in low and middle income countries. Thermal care protection of newborn through a series of measures taken at birth and during the initial days of life is recommended to reduce the hypothermia and associated neonatal mortality. This study aimed to identify the prevalence of and the factors associated with receiving ‘optimum thermal care’ among home born newborns of Nepal. Methods - Data from the Nepal Demographic and Health Surveys (NDHS) 2011 were used for this study. Women who reported a home birth for their most recent childbirth was included in the study. Factors associated with optimum thermal care were examined using Chi-square test followed by logistic regression. Results - A total of 2464 newborns were included in the study. A total of 57.6 % were dried before the placenta was delivered; 60.3% were wrapped; 24.5% had not bathing during the first 24 hours, and 63.9% were breastfed within one hour of birth. Overall, only 248 (10.7%; 95% CI (8.8 %, 12.9%)) newborns received optimum thermal care. Newborns whose mothers had achieved higher education (OR 2.810; 95% CI (1.132, 6.976)), attended four or more antenatal care visits (OR 2.563; 95% CI (1.309, 5.017)), and those whose birth were attended by skilled attendants (OR 2.178; 95% CI (1.428, 3.323)) were likely to receive optimum thermal care. Conclusion - The current study showed that only one in ten newborns in Nepal received optimum thermal care. Future newborn survival programs should focus on those mothers who are uneducated; who do not attend the recommended four or more attend antenatal care visits; and those who deliver without the assistance of skilled birth attendants to reduce the risk of neonatal hypothermia in Nepal

Assessment of a substitute or complement for inpatient and outpatient care of visceral leishmaniasis in Nepal (Journal of Vector Borne Diseases, 49: 242-248)

Background & objectives: The burden of visceral leishmaniasis (VL) in Nepal, as in other developing countries, falls disproportionately upon the rural poor. Promoting use of outpatient (OP) care, an alternative to inpatient (IP) care has long been advocated to reduce cost of care in both the demand and supply sides as substitution of relatively cheaper resources for expensive resources in the production of health care services. The paper aims to assess the intensity of demand for VL care and explore possibilities of the substitutability or complementation patterns between OP care and IP care of VL. Methods: In order to explore the possibility of substitute (or complement) of OP care for IP care, we exploited the ordinary least squared method by utilizing recently collected data from the VL endemic districts of Nepal. The sample size represented >25% of the population of VL of the country. The paper measured the sensitivity analysis of demand for OP and IP cares using appropriate demand models. Results: The coefficients of demand models gave negative relationship between quantity demanded for health care and their prices. It is plausible that OP price has strong power than IP price to determine the respective quantity demanded for health care. As expected, income has negative sign, but not significant that means income has no effect on determining the demand for health care because VL is a disease of poor. Conclusion: Recently, improvements in treatment and diagnostic techniques suggest a substitute of OP care for IP care; however, the OP and IP cares are complements due to behavioural factors