HEALTH SITUATION Nepal has made progress in raising the health status of its citizens. Under-five mortality has been reduced by 67% and infant mortality by 59% during the twenty-year period. Similarly, maternal mortality has been reduced significantly (56%) between the period of 1996 and 2016. The immunization coverage since 2011 had consistently remained above 90% for DPT3 and Polio, however slightly decreased during 2015 – 2016. On the other hand, measles coverage has been improved and reached 88% in 2016 from 83% in 2014, which may be due to health sector efforts toward measles elimination. The country has achieved polio eradication and measles elimination is targeted for 2019. The “Full Immunization Declaration” approach aims at immunizing all children through a strong community engagement. Leprosy is at the elimination stage and malaria is in pre-elimination phase. Considerable efforts have been made to halt and reverse the trends of tuberculosis and HIV. New HIV infections have been significantly declined; however, the gap still remains between the estimated and identified HIV infection, resulting in low treatment coverage of 30% in 2015. Despite the stable CPR, the Total Fertility Rate (TFR) declined significantly from 5 births per women in 1990 to 2.6 in 2011 and 2.3 in 2016. The increasing trend of migration is exposing labor migrants to certain health risks and poses an additional challenge to address their health needs. Tuberculosis (TB) remains as a public health problem in Nepal. However, the programme is able to achieve high success rate for treatment of TB, which was 90% for new and relapse cases in the last five year-period. In the urban areas inadequate physical activity and rapid and unplanned urbanization are posing a number of health challenges including increased risk of non- communicable diseases. Air pollution is becoming an ever-increasing problem, both in the Kathmandu Valley and in the southern Terai Region. Mental health problems are also increasing and further aggravated by migration, ageing population, poverty and widespread unemployment. Moreover, Nepal is prone to natural disasters, which pose their own health problems. Despite the significant increase in government expenditure on health, out-of-pocket expenditure remains high (60% in 2010/2011). The Current Health Expenditures (CHE) in 2015 were 6.15% of Nepal’s GDP, or 44.4 US$ per capita. Nepal has been gearing towards addressing equity gaps and increasingly focused on making services accessible to the population in need. It has introduced free health care programmes, targeted health package schemes and a safe delivery incentive scheme to minimize the equity gap. However, despite this, the country still faces many health challenges. The recent “Nepal Health Facility Survey” clearly shows challenges in delivering quality health services, retaining appropriate skilled human resources, and maintaining regular availability of essential commodities to deliver basic health care. HEALTH POLICIES AND SYSTEMS The Government of the Nepal has developed policies for delivering better health services to people of Nepal. The citizens have the constitutional right to access basic care free of charge. The National Health Policy 2014 and the National Health Sector Strategy 2015 - 2020 guide the overall health plans for Nepal. The Policy puts Universal Health Coverage at the center and stresses the need for quality equitable access to health care. The National Health Strategy has prioritized the health system improvement in Human Resources for Health (HRH), public financial management, infrastructure, procurement and health governance. Both health policy and health strategy are in line with the major priorities focused on in the Sustainable Development Goals. The results framework of NHSS 2015-2020 have indicators at goal, outcome and output levels and are not only focused on traditional SDG-related indicators, but also include indicators identified for addressing mental health, injuries, financial hardship in accessing health care and different components of health systems like HRH and health infrastructure. The strategy also identifies evidence-based policy planning and stresses the use of modern technologies for improved and informed planning and monitoring. A basic health care package has been defined and an insurance act has been recently enacted as part of a plan to address equity gaps and move towards universal health coverage. Under the Constitution, promulgated in September 2015, the country has become a Federal State. This will in the future affect the way the health system will be organized and operated, given that local levels will play a more significant role in all developmental and administrative areas. Currently, health services are provided at peripheral level through 202 Primary Health Care Centres, 3803 Health Posts and 129 Urban Health Clinics. More serious cases are referred to 83 secondary level district hospitals, 15 tertiary level hospitals (zonal and above) and 8 specialized hospitals (all located in the Kathmandu Valley). In addition, there are more than 400 private hospitals, mostly in the urban areas. COOPERATION FOR HEALTH The main donor and partner agencies are: the World Bank, DFID, GAVI, GFATM, KOICA, USAID, GIZ, KFW (German Development Bank), USAID, UNAIDS, UNICEF, UNFPA and WHO. Nepal has Sector-Wide Approach (SWAp) in Health and partners support is based on Joint Financial Arrangement (JFA). A new JFA has been agreed to support the implementation of new Nepal Health Sector Strategy (NHSS) for the period of 2015/16 – 2020/21. Key External Development Partners meet twice a month to coordinate and discuss key current issues around financial and technical support to MoH. Nepal http:// www.who.int/countries/en/ WHO region South-East Asia World Bank income group Low-income Child health Infants exclusively breastfed for the first six months of life (%) (2016) 66 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2016) 86 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 69.2 (Both sexes) 67.7 (Male) 70.8 (Female) Population (in thousands) total (2015) 28513.7 % Population under 15 (2015) 30.56 % Population over 60 (2015) 8.43 Poverty headcount ratio at $1.25 a day (PPP) (% of population) (2010) 24.8 Literacy rate among adults aged >= 15 years (%) (2007-2012) 57 Gender Inequality Index rank (2014) 108 Human Development Index rank (2014) 145 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 5.80 Private expenditure on health as a percentage of total expenditure on health (2015) 60.41 General government expenditure on health as a percentage of total government expenditure (2015) 5.6 Physicians density (per 1000 population) (2015) 0.52 Nursing and midwifery personnel density (per 1000 population) (2015) 2.25 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 21 Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 39 Maternal mortality ratio (per 100 000 live births) (2016) 239 Births attended by skilled health personnel (%) (2016) 58 Public health and environment Population using safely managed sanitation services (%) N/A Population using safely managed drinking water services (%) (2015) 27 (Total) 25 (Rural) 34 (Urban) Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (2018 – 2022) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Advancing universal health coverage in a federalized governance structure Strengthen health systems to deliver basic health services at local government level [assist in defining basic health services and minimum standards, build capacity of the health workers and administrators, and monitor, document and analyse implementation of basic health package] National oversight and policy development [support evolution of federal restructuring, support HR planning, development and management, support to institutionalize health resource tracking mechanism, facilitate health financing policymaking, build national capacity of regulatory authority, strengthen quality of care mechanisms and HMIS, develop eHealth architecture, interoperability framework and standards, stimulate health system research, and engage professional societies and academic institutions for institutionalizing continual professional development] STRATEGIC PRIORITY 2: Effective delivery of priority public health programs Tuberculosis control [support to improve diagnostic and treatment, integration of the TB and tobacco in primary care, advocate for private-public mix and community engagement, and support TB prevalence survey and drug resistance survey ] Elimination of measles, malaria and selected neglected tropical diseases [technical assistance for maintaining polio free status, achieving elimination targets for measles, malaria, lymphatic filariasis, trachoma, kala-azar and leprosy, and strengthen surveillance and laboratory diagnostic system for malaria and kala-azar] Introduction of new vaccines and control of vaccine preventable diseases, including combating hepatitis [technical assistance for introduction of new vaccines, support for improving immunization coverage, control of rubella, and development and implementation of hepatitis strategy] Promoting health through the life course [support implementation of MPDSR, capacity building for facility-based IMNCI, support for developing guidelines, plans and strategies on geriatric care, sub-fertility and infertility, women's and adolescent health] STRATEGIC PRIORITY 3: Enhance health security, disaster preparedness and response Achieve compliance to IHR (2005) [support to attain and sustain IHR core capacities for surveillance, response and points of entry ] Detect and respond to public health emergencies [strengthen disease surveillance system, enhance operational capacity to manage disease outbreaks, support to achieve cholera elimination, and maintain optimal emergency response capacities] Early warning, risk assessment, preparedness and emergency response to disasters [build disaster management capacity, establishment of hospital networks, and sector-wide and partner coordination] STRATEGIC PRIORITY 4: Multisectoral engagement and partnerships for improved health outcomes Combating antimicrobial resistance (AMR) [promote rational use of medicines, build capacity for laboratory-based surveillance, and awareness] Reducing risk factors for noncommunicable diseases [national multisectoral response for prevention and control of NCDs, implementation of FCTC, taxation and regulation of tobacco, alcohol and sugary drink, awareness to promote healthy lifestyles, and implementation of mental health action plan] Address the impact of environmental health and climate change [air-pollution, implement health component of national adaptation plan to climate change, and water quality surveillance] © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Nepal Updated May 2018
HEALTH SITUATION Nepal has made progress in raising the health status of its citizens. Under-five mortality has been reduced by 67% and infant mortality by 59% during the twenty-year period. Similarly, maternal mortality has been reduced significantly (56%) between the period of 1996 and 2016. The immunization coverage since 2011 had consistently remained above 90% for DPT3 and Polio, however slightly decreased during 2015 – 2016. On the other hand, measles coverage has been improved and reached 88% in 2016 from 83% in 2014, which may be due to health sector efforts toward measles elimination. The country has achieved polio eradication and measles elimination is targeted for 2019. The “Full Immunization Declaration” approach aims at immunizing all children through a strong community engagement. Leprosy is at the elimination stage and malaria is in pre-elimination phase. Considerable efforts have been made to halt and reverse the trends of tuberculosis and HIV. New HIV infections have been significantly declined; however, the gap still remains between the estimated and identified HIV infection, resulting in low treatment coverage of 30% in 2015. Despite the stable CPR, the Total Fertility Rate (TFR) declined significantly from 5 births per women in 1990 to 2.6 in 2011 and 2.3 in 2016. The increasing trend of migration is exposing labor migrants to certain health risks and poses an additional challenge to address their health needs. Tuberculosis (TB) remains as a public health problem in Nepal. However, the programme is able to achieve high success rate for treatment of TB, which was 90% for new and relapse cases in the last five year-period. In the urban areas inadequate physical activity and rapid and unplanned urbanization are posing a number of health challenges including increased risk of non- communicable diseases. Air pollution is becoming an ever-increasing problem, both in the Kathmandu Valley and in the southern Terai Region. Mental health problems are also increasing and further aggravated by migration, ageing population, poverty and widespread unemployment. Moreover, Nepal is prone to natural disasters, which pose their own health problems. Despite the significant increase in government expenditure on health, out-of-pocket expenditure remains high (60% in 2010/2011). The Current Health Expenditures (CHE) in 2015 were 6.15% of Nepal’s GDP, or 44.4 US$ per capita. Nepal has been gearing towards addressing equity gaps and increasingly focused on making services accessible to the population in need. It has introduced free health care programmes, targeted health package schemes and a safe delivery incentive scheme to minimize the equity gap. However, despite this, the country still faces many health challenges. The recent “Nepal Health Facility Survey” clearly shows challenges in delivering quality health services, retaining appropriate skilled human resources, and maintaining regular availability of essential commodities to deliver basic health care. HEALTH POLICIES AND SYSTEMS The Government of the Nepal has developed policies for delivering better health services to people of Nepal. The citizens have the constitutional right to access basic care free of charge. The National Health Policy 2014 and the National Health Sector Strategy 2015 - 2020 guide the overall health plans for Nepal. The Policy puts Universal Health Coverage at the center and stresses the need for quality equitable access to health care. The National Health Strategy has prioritized the health system improvement in Human Resources for Health (HRH), public financial management, infrastructure, procurement and health governance. Both health policy and health strategy are in line with the major priorities focused on in the Sustainable Development Goals. The results framework of NHSS 2015-2020 have indicators at goal, outcome and output levels and are not only focused on traditional SDG-related indicators, but also include indicators identified for addressing mental health, injuries, financial hardship in accessing health care and different components of health systems like HRH and health infrastructure. The strategy also identifies evidence-based policy planning and stresses the use of modern technologies for improved and informed planning and monitoring. A basic health care package has been defined and an insurance act has been recently enacted as part of a plan to address equity gaps and move towards universal health coverage. Under the Constitution, promulgated in September 2015, the country has become a Federal State. This will in the future affect the way the health system will be organized and operated, given that local levels will play a more significant role in all developmental and administrative areas. Currently, health services are provided at peripheral level through 202 Primary Health Care Centres, 3803 Health Posts and 129 Urban Health Clinics. More serious cases are referred to 83 secondary level district hospitals, 15 tertiary level hospitals (zonal and above) and 8 specialized hospitals (all located in the Kathmandu Valley). In addition, there are more than 400 private hospitals, mostly in the urban areas. COOPERATION FOR HEALTH The main donor and partner agencies are: the World Bank, DFID, GAVI, GFATM, KOICA, USAID, GIZ, KFW (German Development Bank), USAID, UNAIDS, UNICEF, UNFPA and WHO. Nepal has Sector-Wide Approach (SWAp) in Health and partners support is based on Joint Financial Arrangement (JFA). A new JFA has been agreed to support the implementation of new Nepal Health Sector Strategy (NHSS) for the period of 2015/16 – 2020/21. Key External Development Partners meet twice a month to coordinate and discuss key current issues around financial and technical support to MoH. Nepal http:// www.who.int/countries/en/ WHO region South-East Asia World Bank income group Low-income Child health Infants exclusively breastfed for the first six months of life (%) (2016) 66 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2016) 86 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 69.2 (Both sexes) 67.7 (Male) 70.8 (Female) Population (in thousands) total (2015) 28513.7 % Population under 15 (2015) 30.56 % Population over 60 (2015) 8.43 Poverty headcount ratio at $1.25 a day (PPP) (% of population) (2010) 24.8 Literacy rate among adults aged >= 15 years (%) (2007-2012) 57 Gender Inequality Index rank (2014) 108 Human Development Index rank (2014) 145 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 5.80 Private expenditure on health as a percentage of total expenditure on health (2015) 60.41 General government expenditure on health as a percentage of total government expenditure (2015) 5.6 Physicians density (per 1000 population) (2015) 0.52 Nursing and midwifery personnel density (per 1000 population) (2015) 2.25 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 21 Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 39 Maternal mortality ratio (per 100 000 live births) (2016) 239 Births attended by skilled health personnel (%) (2016) 58 Public health and environment Population using safely managed sanitation services (%) N/A Population using safely managed drinking water services (%) (2015) 27 (Total) 25 (Rural) 34 (Urban) Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (2018 – 2022) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Advancing universal health coverage in a federalized governance structure Strengthen health systems to deliver basic health services at local government level [assist in defining basic health services and minimum standards, build capacity of the health workers and administrators, and monitor, document and analyse implementation of basic health package] National oversight and policy development [support evolution of federal restructuring, support HR planning, development and management, support to institutionalize health resource tracking mechanism, facilitate health financing policymaking, build national capacity of regulatory authority, strengthen quality of care mechanisms and HMIS, develop eHealth architecture, interoperability framework and standards, stimulate health system research, and engage professional societies and academic institutions for institutionalizing continual professional development] STRATEGIC PRIORITY 2: Effective delivery of priority public health programs Tuberculosis control [support to improve diagnostic and treatment, integration of the TB and tobacco in primary care, advocate for private-public mix and community engagement, and support TB prevalence survey and drug resistance survey ] Elimination of measles, malaria and selected neglected tropical diseases [technical assistance for maintaining polio free status, achieving elimination targets for measles, malaria, lymphatic filariasis, trachoma, kala-azar and leprosy, and strengthen surveillance and laboratory diagnostic system for malaria and kala-azar] Introduction of new vaccines and control of vaccine preventable diseases, including combating hepatitis [technical assistance for introduction of new vaccines, support for improving immunization coverage, control of rubella, and development and implementation of hepatitis strategy] Promoting health through the life course [support implementation of MPDSR, capacity building for facility-based IMNCI, support for developing guidelines, plans and strategies on geriatric care, sub-fertility and infertility, women's and adolescent health] STRATEGIC PRIORITY 3: Enhance health security, disaster preparedness and response Achieve compliance to IHR (2005) [support to attain and sustain IHR core capacities for surveillance, response and points of entry ] Detect and respond to public health emergencies [strengthen disease surveillance system, enhance operational capacity to manage disease outbreaks, support to achieve cholera elimination, and maintain optimal emergency response capacities] Early warning, risk assessment, preparedness and emergency response to disasters [build disaster management capacity, establishment of hospital networks, and sector-wide and partner coordination] STRATEGIC PRIORITY 4: Multisectoral engagement and partnerships for improved health outcomes Combating antimicrobial resistance (AMR) [promote rational use of medicines, build capacity for laboratory-based surveillance, and awareness] Reducing risk factors for noncommunicable diseases [national multisectoral response for prevention and control of NCDs, implementation of FCTC, taxation and regulation of tobacco, alcohol and sugary drink, awareness to promote healthy lifestyles, and implementation of mental health action plan] Address the impact of environmental health and climate change [air-pollution, implement health component of national adaptation plan to climate change, and water quality surveillance] © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Nepal Updated May 2018