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Aug 13, 2018

The Burden of Disease (BoD) and its cost implication in Nepal Post 17 / 24 (May 2018)

The constitution of Nepal (20 September 2015) has envisioned fundamental rights to be enjoyed by all Nepali citizen and duties of the state to make sure that these rights are secured relating to health, food, women’s health, child, senior citizens, housing, clean environment and all those rights that are directly or indirectly related with health and wellbeing of our people. In addition, Government of Nepal is committed in achieving key indicator targets that are set in United Nations Sustainable Development Goals (UNSDGs). Current global understanding as well as consensus is that “health and wellbeing” of our people is the key developmental agenda, which needs to be incorporated in every sectors of governance within our national as well as subnational planning process with “health in all” as a guiding principle. In order to achieve these national as well as global commitments, evidence based policy making or in other words, data based decision making is the best practice that has to be enacted in our work culture to deliver affordable, safe and quality public service care and sustain its positive impact in the people’s welfare in the community.

Scientific evidences suggest that the population health in Nepal is experiencing through the double burden of diseases such that there is rise in morbidity and mortality of non communicable diseases, while national health system is still overwhelmed dealing with communicable diseases compounded by rapid rise in urbanization and its population, environmental degradation and rising cross border “migration” related health issues. 2009 BOD study in Nepal reports  a shift over time from communicable diseases (primarily pneumonia and diarrheal diseases) to non-communicable diseases (primarily heart disease, COPD, and diabetes) as being the principal drivers of health loss. While understanding trends in the epidemiologic transition is critical to addressing population health, these trends are not immediately clear without comprehensive burden estimates from all conditions. Additionally, some top DALY contributors, including low back pain, migraine, hearing loss, and major depression, are major drivers of health loss; yet, they are largely unrecognized when looking specifically at fatal outcomes. Understanding the disease profile at a national level, and eventually subnational level, is critical to making the best and most informed decisions to improve health outcomes in Nepal at both the population and individual levels. In addition, 2018 Nepal multidimensional poverty index reported that 28.6 % of Nepal’s population is “multidimensionally poor’ and these “poors” as well middle class population are burdened by Out of Pocket Expenditure (OOP), which is alarming at 55.4 % of Current Health Expenditure  (CHE) in the year 2015/16.

In the previous and the existing recently organizational structure and its functional rearrangement, all experts and leadership agree that the health information system is functioning “inadequate” and its structure is fragmented and numerous information system running parallel contrary to the global practice of integrated and efficient health informatics system, which must function as the core system within the larger health system. Therefore, there is an acute need for the establishment of Health Informatics Unit, Monitoring and Evaluation Unit, Health Economics and Research unit within Ministry of Health and Population that work in close coordination and collaboration with Planning and Policy Division within health Ministry, National Health Research Council (NHRC), Central Bureu of Statistics (CBS), and various federal and provincial academic health research institutions.

Apart from small efforts in the 90s and 2006 -2008 there were not significant attempts to produce the BoD picture of Nepal so as to use it in the policy and planning. Whereas in the global arena, Institute of Health Metrics and Evaluation (IHME) at University of Washington produced the results of Global Burden of Disease (GBD) study 2010 in the year 2013 which also included the BoD estimates for Nepal. In November 2014, curative service division at the Ministry of Health and Population (MoHP) led a scoping exercise with technical collaboration with IHME which had the following aims:

  • Identify opportunities to refine country level burden estimates for Nepal;
  • Collaborate closely with country partners to ensure quality in country level estimates;
  • Determine feasibility of estimating burden at the subnational level for Nepal in the near future.
Currently there are two sources of BoD estimates for countries around the world, one is produced by World Health Organization (WHO) and the other is produced by IHME (commonly known as the Global Burden of Disease (GBD) study group). Both has their own strengths. However, IHME has been producing BoD estimates annually since 2015. Understanding the need to providing a single source of BoD estimates, IHME and WHO Headquarter have recently signed an agreement to produce the BoD estimates jointly. With this, countries will have a single BoD estimates to use for policy and planning for the year 2018 and this results are expected to be available early 2020.

To work in line with enhancing capacity of MoHP and concerned stakeholders in the areas of BoD, there has been a MoU signed recently with IHME by MoHP and the Nepal Health Research Council through which in the coordination of NHRC and in close collaboration with MoHP the process for refining BoD estimates for Nepal has been initiated.

In order to address these alarming health related expenditure and its burden to household, Government of Nepal has implemented health insurance as one of the vital and sustainable preventive measures to safeguards families against catastrophic health expenditure, which is the key objective of Universal Health Coverage (UHC) and to achieve this commitment (NHP 2014) is the sole duty of Government of Nepal. However, to achieve what we have envisioned and committed to Nepal citizen, there is an acute need for objective measurement of “biomedical” as well as “economic” burden of diseases and health related events. Also, we need to be cautious that the biomedical approach of measuring BOD only focuses on the individual who is ill, while ignoring the burden of disease for families, households, and social networks.  Therefore, if we are able to capture the near – truth BOD, it would provide us with a powerful tool to guide the policy and program decision making of a country.

Key Actions To be taken:

First and foremost, MoHP should initiate extensive review of literature, national and internationally published reports on “health” and “well being” related data utilizing national experts. This will provide all of us with the broad understanding of the landscape on health related broad scenario along with gaps in overall data science management. This will enable us with realistic framework to work on and guide us in establishment of “dedicated” health informatics unit in the ministry and its federal structure.  This review also needs to answer the following questions:

  • Which understanding of burden of disease is being used?
  • Which aspects of burden of disease are being measured?
  • Whose burden of disease is being measured and whose is not?
  • How and where should we intervene to have the greatest impact on burden of disease, including prevention, control, and treatment?
  • Who is likely to benefit least and most from specific interventions aimed at reducing disease burden?
  • Will decisions based on disease burden measures have the best outcomes for a population that is already advantaged?
  • How do we eliminate inequitable burden of disease?
   Secondly, establish an expert team under secretary of health to evaluate the need to establish a dedicated “health informatics center” that carry out health information management and that relates to data measurement like burden of disease (BoD) studies working closely with policy and planning division, monitoring and evaluation unit, information technology Unit, academic institutions, national health research councils and provincial wings of all health related bodies.

3     Specific Activities to be carried out to produce BoD for the country:

a.  Work closely with the GBD study group to fulfill the data gaps for Nepal both in the areas of morbidity and mortality.
b. Identify the gaps in data sources for disease and health conditions and plan surveys/researches or strengthening routine systems to collect the data on the areas where we need the most
c.   Initiate and expand the system for collecting cause of death data both from the hospitals as well as from the community
d.    For the cause of death data, the most important task that needs to be done in the next 5 years is having a good Civil Registration and Vital Statistics (CRVS) which can five death statistics including cause of death. For this in the initial stage we can follow sample registration system which has been globally adapted with success.
e.     Include all these improvised sources of data in the BoD estimation process.
f.    Be involved as closely as possible with the global groups working on BoD such that national capacity is enhanced, and with this in future Nepal can think of producing the Bod estimates on its own with only limited support from the global group.
g.    With this Nepal can also produce the provincial level BoD estimates in around 2 years’ time which is not available now.

Anuj in Himalayas

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