Health in Nepal

Much of rural Nepal is located in hilly or mountainous regions. Nepal's rugged terrain and the lack of properly enabling infrastructure make it highly inaccessible, limiting the availability of basic health care in many rural mountain areas.[30] In many villages, the only mode of transportation is by foot. This results in a delay of treatment, which can be detrimental to patients in need of immediate medical attention.[31] Most of Nepal's health care facilities are concentrated in urban areas. Rural health facilities often lack adequate funding.[32]

In 2003, Nepal had 10 health centers, 83 hospitals, 700 health posts, and 3,158 "sub-health posts," which serve villages. In addition, there were 1,259 physicians, one for every 18,400 persons.[18] In 2000, government funding for health matters was approximately US$2.30 per person and approximately 70% of health expenditure came from contributions. Government allocations for health were around 5.1% of the budget for the 2004 fiscal year, and foreign donors provided around 30% of the total budget for health expenditure.[5]

Nepal's health care issues are largely attributed to its political power and resources being mostly centered in its capital, Kathmandu, resulting in the social exclusion of other parts of Nepal. The restoration of democracy in 1990 has allowed the strengthening of local institutions. The 1999 Local Self Governance Act aimed to include devolution of basic services such as health, drinking water, and rural infrastructure but the program has not provided notable public health improvements. Due to a lack of political will,[33] Nepal has failed to achieve complete decentralization, thus limiting its political, social and physical potential.[23]

In 2010, the average Nepalese lived to 65.8 years. According to the latest WHO data published in 2012, life expectancy in Nepal is 68. Life expectancy at birth for both sexes increased by 6 years over the year 2010 and 2012. In 2012, healthy expectancy in both sexes was 9-year(s) lower than overall life expectancy at birth. This lost healthy life expectancy represents 9 equivalent year(s) of full health lost through years lived with morbidity and disability[11]

Diseases burden in Nepal

According to the Global Burden of Disease Study 2017, the eight leading causes of morbidity (illness) and mortality (death) in Nepal are: Neonatal disorders[34] (9.97%), Ischaemic Heart Disease (7.55%), COPD (5.35%), Lower respiratory infection (5.15%), Diarrhoeal disease (3.42%), Road injury[35] (3.56%), Stroke (3.49%), Diabetes (2.35%).[36]

The chart shows the burden of disease prevalence in Nepal over a period of time. Diseases like neonatal disorder, lower respiratory tract infection, and diarrhoeal diseases have shown a gradual decrease in prevalence over the period from 1990 to 2017. The reason for this decrease in number is due to the implementation of several health programs by the government with the involvement of other international organizations such as WHO and UNICEF for maternal and child health, as these diseases are very common among the children. Whereas, there is a remarkable increment in the number of other diseases like Ischemic heart disease (IHD), Chronic obstructive pulmonary disease (COPD), Road injuries, Stroke, and Diabetes.

Ischemic Heart Disease (IHD) is gradually emerging as one of the major health challenges in Nepal. It is the most common type of heart disease and cause of heart attacks. The rapid change in lifestyle, unhealthy habits (smoking, sedentary lifestyle etc.), and economic development are considered to be responsible for the increase. Despite a decrease in Ischemic Heart Disease mortality in developed countries, substantial increases have been experienced in developing countries like Nepal. IHD is the number one cause of death in adults from both low and middle-income countries as well as from high-income countries. The incidence of IHD is expected to increase by approximately 29% in women and 48% in men in the developed countries between 1990 and 2020.

A total of 182,751 deaths are estimated in Nepal for the year 2017. Non-communicable diseases (NCDs) are the leading causes of death – two-thirds (66%) of deaths are due to NCDs, with an additional 9% due to injuries. The remaining 25% are due to communicable, maternal, neonatal, and nutritional (CMNN) diseases. Ischemic heart disease (16.4% of total deaths), Chronic obstructive pulmonary disease (COPD) (9.8% of total deaths), Diarrheal diseases (5.6% of total deaths), Lower respiratory infections (5.1% of total deaths), and Intracerebral hemorrhage (3.8% of total deaths), were the top five causes of death in 2017[37]

Ischemic Heart Disease is second burden of disease and the leading cause of death in Nepal for the last 16 years, starting from 2002. Death due to IHD is increasing an alarming rate in Nepal from 65.82 to 100.45 death per 100,000 from 2002 to 2017.[38] So, the large number of epidemiological research is necessary to determine the incidence & prevalence of IHD in Nepal and to identify the magnitude of the problem so that timely primary and secondary prevention can be done. As it is highly preventable and many risk factor are related to our lifestyle like; smoking, obesity, unhealthy diet, etc. So, knowledge and awareness regarding these risk factors are important in the prevention of IHD. Shahid Gangalal National Heart Center conducted a cardiac camp in different parts of Nepal from September 2008 to July 2011. The prevalence of heart disease was found higher in urban areas than rural areas where hypertension claims the major portion. The huge proportion of hypertension in every camp suggests that Nepal is in daring need of preventive programs of heart disease to prevent the catastrophic effect of IHD in near future. Also, according to this study the proportion of IHD ranges from 0.56% (Tikapur) to 15.12% (Birgunj) in Nepal.[39]

Among WHO region in the European region, African region, Region of the Americas and Eastern Mediterranean death rate is in decreasing trend while in Western Pacific, South East Asia it is increasing.

[38] Table 1: Comparison of Death per 100,000 due to Ischemic Heart Disease Between Nepal, Global and 6 WHO Region

Distribution according to age and sex :

Incidence of IHD occurs in men between 35 and 45 years age. After the age of 65 the incidence of men and women equalizes, although there is evidence suggesting that more women are being seen with IHD earlier because of increased stress, smoking and menopause. The risk of IHD increases as age increases. Middle-aged adults are mostly affected by IHD. For men, the risk starts to climb at about age 45, and by age 55, the risk becomes double. It continues to increase until, by age 85. For women, the risk of IHD also climbs with age, but the trend begins about 10 years later than in men and especially with the onset of menopause.

Tuberculosis (Nepali: क्षयरोग) , the world’s most serious public health problem is an infectious bacterial disease caused by the bacillus Mycobacterium.[40] Although most common Mycobacterium species which causes tuberculosis is M. tuberculosis, TB is also caused by M. bovis and M. africanum and occasionally by opportunistic Mycobacteria which are: M. Kansaii, M. malmoense, M. simiae, M. szulgai, M. xenopi, M. avium-intracellulare, M. scrofulacum, and M. chelonei.[41]

Tuberculosis is the most common cause of death due to single organism among person over 5 years of age in low-income countries. In addition, 80% of deaths due to tuberculosis occurs in young to middle age men and women.[42] The incidence of disease in a community may be affected by many factors, including the density of population, the extent of overcrowding and the general standard of living and health care. Certain groups like refugees, HIV infected, person with physical and psychological stress, nursing home residents and impoverished have high risk to develop TB.[43]

The goal 3.3 within the goal 3 of Sustainable Development Goals states “end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” and the targets linked to the end TB strategy are:

• Detect 100% of new sputum smear-positive TB cases and cure at least 85% of these cases.
• Eliminate TB as a public health problem (<1 case per million population) by 2050.[44]

In Nepal, 45% of the total population is infected with TB, out of which 60% are in the productive age group (15–45). Every year 40,000 people develop active TB, of whom 20,000 have infectious pulmonary disease.[45] According to national TB prevalence survey around 69,000 people developed TB in 2018. In addition, 117,000 people are living with the disease in Nepal.[46]

There are 624 microscopy centers registered whereas the National TB Reference Laboratories, National tuberculosis centre and GENETUP perform culture and drug susceptibility testing service in Nepal.[48]

Microbiologist researcher working at joint laboratory of National Tuberculosis Centre and SAARC TB and HIV/AIDS centre, Bhaktapur.

National Tuberculosis control program (NTP) employs directly observed treatment strategy (DOTS). In 1995, World Health Organization recommended DOTS as one of the most cost effective strategies available for tuberculosis control. DOTS is the strategy for improving treatment outcome by giving drugs to the patients under direct observation of health workers. DOTS has been found to be 100% effective for tuberculosis control. There are around 4323 TB treatment centers in Nepal.[48] Although introduction of DOTS has already reduced the numbers of deaths, however 5,000 to 7,000 people still continue to die each year.[49]

The burden of drug resistance tuberculosis is estimated at around 1500 (0.84 to 2.4) cases annually. But only 350 to 450 Multidrug resistance TB are reported yearly. So, in NTP's strategic plan 2016-2021, the main objective is to diagnose 100% of the MDR TB by 2021 and to successfully treat a minimum 75% of those cases.[48]

Making up approximately 8.1% of the total estimated population of 40,723, there were about 3,282 children aged 14 years or younger living with HIV in Nepal in 2013. There are 3,385 infections estimated among the population aged 50 years and above (8.3% of the total population). By sex, males account for two‐thirds (66%) of the infections and the remaining, more than one‐third (34%) of infections are in females, out of which around 92.2% are in the reproductive age group of 15‐49 years. The male to female sex ratio of total infection decreased from 2.15 in 2006 to 1.95 in 2013 and is projected to be 1.86 by 2020.[50] The epidemic in Nepal is driven by injecting drug users, migrants, sex workers & their clients and MSM. Results from the 2007 Integrated Bio-Behavioral Surveillance Study (IBBS) among IDUs in Kathmandu, Pokhara, and East and West Terai indicate that the highest prevalence rates have been found among urban IDUs, 6.8% to 34.7% of whom are HIV-positive, depending on location. In terms of absolute numbers, Nepal's 1.5 million to 2 million labor migrants account for the majority of Nepal's HIV-positive population. In one subgroup, 2.8% of migrants returning from Mumbai, India, were infected with HIV, according to the 2006 IBBS among migrants.[51]

As of 2007, HIV prevalence among female sex workers and their clients was less than 2% and 1%, respectively, and 3.3% among urban-based MSM. HIV infections are more common among men than women, as well as in urban areas and the far western region of Nepal, where migrant labor is more common. Labor migrants make up 41% of the total known HIV infections in Nepal, followed by clients of sex workers (15.5 percent) and IDUs (10.2 percent).[51]

Diarrhoeal disease is one of the leading causes of death globally which is mainly caused by bacterial, viral or parasitic organisms. In addition, the other factors include malnutrition, contaminated water and food sources, animal faeces, and person-to-person transmission due to poor hygienic conditions. Diarrhoea is an indication of intestinal tract infection which is characterized by the passage of loose or liquid stool three or more times a day, or more than a normal passage per day. This disease can be prevented by action of several measures including access to contamination-free water and food sources, hand washes with soap and water, personal hygiene and sanitation, breastfeeding the child for at least six months of life, vaccination against Rotavirus and general awareness among the people. Treatment is performed by rehydration with oral rehydration salt (ORS) solution, use of zinc supplements, administration of intravenous fluid in case of severe dehydration or shock, and the continuing supply of nutrient-rich food, especially to malnourished children.[52]

Global Burden of Disease Study shows that diarrhoeal diseases account for 5.91% of total deaths among all age groups of Nepal in 2017. In the same year, the data indicates that diarrhoeal diseases has the highest cause of death of 9.14% in the age group 5–14 years followed by 8.91% deaths in 70+ age group.[53]

A study showed the presence of enteropathogens in more than two-thirds of diarrhoeal faeces.[54] A survey done in Kathmandu showed the presence of Giardia cysts in 43% of the water samples tested.[55] Similarly, diarrhoea and dysentery causing bacteria such as Escherichia coli, Shigella species, Campylobacter species, Vibrio cholerae are found to be more common in contaminated drinking water of Nepal.[56] In 2009, a large cholera outbreak occurred in Jajarkot and its neighboring districts affecting around thirty thousand people and over five hundred deaths, and it's been endemic for a long time in different parts of Nepal.[57] Viral diarrhoea is mainly caused by Rotavirus but a few cases of Norovirus and Adenovirus was also observed in a type of study.[58]

The following table shows the prevalence of diarrhea among under-five children in all five development regions of Nepal in the year 2006, 2011 and 2016.

Maternal and neonatal health (MNH) is one of the top priorities of the Ministry of Health and Population of Nepal (MoHP). However, the country still has a high Maternal Mortality Ratio (MMR) (258 per 100,000 live births), compared to its neighboring South Asian countries such as India (174), Bhutan (148), Bangladesh (176), Myanmar (178), Pakistan (178), and Sri Lanka (30).[60] In spite of the fact that the rate has been stagnant over the last decade, there has been some decrease in the neonatal death rate (21 per 1,000 live births) in 2016 compared to 33 per 1,000 live births in 2011,[61] in the country. Nepal is also a signatory to the Sustainable Development Goals (SDGs), which have set ambitious targets for the country to reduce the MMR to 70 per 100,000 live births and neonatal mortality to 12 per 1,000 live births, and to achieve coverage of 90% for four ANC visits, institutional delivery, SBA delivery, and three PNC check-ups by 2030.[62]

Nepal has been implementing the Safe Motherhood Programme since 1997 with a goal to reduce maternal and neonatal morbidity and mortality and improve maternal and neonatal health through preventive and promotive activities and by addressing avoidable factors that cause death during pregnancy, childbirth and the postpartum period.[63] The main strategies of this programmes are birth preparedness, antenatal care (ANC) check-ups, institutional delivery or delivery by skilled birth attendants (SBA) both at health institution and home. Nepal has also introduced AamaSuraksha programme (Maternity Incentive Scheme), which is one of the milestone in promoting maternal and neonatal health in the country that is aimed towards reducing economic barriers for women who seek institutional delivery . Under this scheme, Nepalese women who deliver in a health institution receives a cash incentive of Nepali Rupees (NRs) 3,000 (mountain districts), NRs 2,000 (hill districts), and NRs 1,000 (Terai districts), with an additional NRs 800 to those women who complete four ANC visits per national protocol. Apart from cash incentives, this programme also provides free institutional delivery, essential newborn care, and care for sick neonates. MoHP also recommends three postnatal check-up (PNC) and has been providing PNC home visit at rural area. Similarly, for early identification of pregnant women at risk of obstetric complications, MoHP also run rural ultrasound programme at 14 remote district and give referral to comprehensive emergency obstetric and neonatal care (CEONC) centres.[63]

Despite all of the above-mentioned longstanding efforts of MoHP to improve maternal and neonatal health in Nepal, the progress has been slow and there is much more to improve to achieve the 2030 target. Economic, geographic and socio-cultural disparities are some of the bottlenecks in improving of maternal health services in the country.[64] Women living under poverty, remote areas and with less education are less likely to access maternal health services. Therefore, the government has to develop and implement the intervention and programmes that are more focused toward underserved and marginalized women population [65]

Table: Trends in maternal and neonatal health indicators [61]

Oral Health Check up

Oral health is an essential prerequisite for a healthy life. Attempting to maintain good oral health in developing countries like Nepal is a challenging task. According to the Annual report of Department of Health Services (2009/10),[66] 392,831 have dental caries/toothache, 73,309 have periodontal diseases, 62,747 and 113,819 have oral ulcer, mucosa and other related diseases. The data shows a high prevalence of oral health problems in the population of the country. Many of these diseases in the population are due to poverty and lack of oral health awareness. According to the Journal of Nepal Dental Association National Oral Health 'Pathfinder' Survey 2004[67] shows prevalence of dental decay in adolescents studying in school is lower, which is 25.6% for 12 to 16 years of age. This can be due to the use of fluoridated toothpaste and awareness in the school going adults. However, periodontal/gum diseases cases tends to be higher in adolescents which is 62.8% for 12 to 13 years and 61% for 15 to 16 years. And the incidence of oral cancer ranges from 1 to 10 cases per 1,000,000 populations in most countries[68]

In countries like Nepal where majority of people are living under poverty, access to healthcare, education and awareness programs have been major constraints in improving oral health. High consumption of both smoked and smokeless form of tobacco in the people has been strongly associated with the majority of the oral health problems. Prevalence of cleaning teeth at least once a day was 94.9% , while that of cleaning teeth at least twice a day was measured to be only 9.9%. Use of fluoridated toothpaste was seen among 71.4%. It is also very common among people in the rural area to brush their teeth with the thin bamboo stick which is called "Datiwan" in the local language, sand and ash. And only 3.9% have made a dental visit in the last 6 months.[69]

Table: Distribution of oral hygiene practices among different age groups

The government of Nepal does not advocate for institutions like WHO or UNICEF to provide the kind of support that they do for other medical issues because they do not prioritize oral health. Also, several misconceptions are very relevant among people like loosening of teeth is normal with increasing age, and losing some teeth won't kill people. The majority of people only seek treatment when the disease has worsen or causes unbearable pain.

Nepal is also on track to achieve MDG 4, having attained a rate of 35.8 under 5 child deaths per 1000 live births in 2015,[70] down from 162 in 1991[71] according to national data. Global estimates indicate that the rate has been reduced by 65% from 128 to 48 per 1000 live births between 1991 and 2013.[72] Nepal has successfully improved coverage of effective interventions to prevent or treat the most important causes of child mortality through a variety of community-based and national campaign approaches. These include high coverage of semiannual vitamin A supplementation and deworming; CB-IMCI; high rates of full child immunization; and moderate coverage of exclusive breastfeeding of children under 6 months. However, in the past few years, the NMR has remained stagnant with it being stated at around 22.2 deaths per 1000 live births in 2015. This compares to a rate of 27.7 in India (2015) and 45.5 in Pakistan (2015).[70]

The NMR is a serious concern in Nepal, accounting for 76% of the infant mortality rate (IMR) and 58% of the under 5 mortality rate (U5MR) as of 2015, and is one of its challenges going forward.[70] Typically, a history of conflict negatively affects health indicators. However, Nepal made progress in most health indicators despite its decade-long armed conflict. Attempts to understand this has provided a number of possible explanations including the fact that in most instances the former rebels did not purposely disrupt delivery of health services; pressure was applied on health workers to attend clinics and provide services in rebel base areas; the conflict created an environment for improved coordination among key actors; and Nepal's public health system adopted approaches that targeted disadvantaged groups and remote areas, particularly community-based approaches for basic service delivery with a functional community support system through female community health volunteers (FCHVs), women's groups and Health Facility Operational Management Committees (HFOMCs).[73]

The Nepalese Child Health Division of the Ministry of Health and Population (MOHP), has launched several child survival interventions, including various operational initiatives, to improve the health of children in Nepal. These include the Expanded Program on Immunisation (EPI), the Community-Based Integrated Management of Childhood Illnesses (CB-IMCI) program, the Community-Based Newborn Care Program (CB-NCP), the Infant and Young Child Feeding program, a micro-nutrients supplementation program, vitamin A and deworming campaign, and the Community-Based Management of Acute Malnutrition program.[66]^:29

The National Immunisation Program is a priority 1 (P1) program in Nepal. Since the inception of the program, it has been universally established and successfully implemented. Immunization services can be obtained for free from EPI clinics in hospitals, other health centers, mobile and outreach clinics, non-governmental organizations and private clinics. The government has provided all vaccines and immunization-related logistics without any cost to hospitals, private institutions, and nursing homes. Nepal has since gained recognition for the success of the program, in relation to its successful coverage of 97% population equally, regardless of wealth, gender and age. However, despite the widespread success of the National Immunisation Program, inequities still exist. Nevertheless, the trends in last past 15 years have shown promising positive changes indicating possibilities of achieving complete immunization coverage.[74] Two more vaccines were introduced between 2014 and 2015 – the inactivated poliomyelitis vaccine (IPV) and the pneumococcal conjugate vaccine (PCV). Six districts of Nepal are declared with 99.9% immunization coverage. Nepal achieved polio-free status on 27 March 2014. Neonatal and maternal tetanus was already eliminated in 2005 and Japanese encephalitis is in a controlled state. Nepal is also on track to meet the target of the elimination of measles by 2019.[66]^:i,⁠8 One percent of children in Nepal have not yet received any of the vaccine coverage.

The Community-Based Integrated Management of Childhood Illness (CB-IMCI) program is an integrated package that addresses the management of diseases such as pneumonia, diarrhea, malaria, and measles, as well as malnutrition, among children aged 2 months to 5 years. It also includes management of infection, Jaundice, Hyperthermia and counseling on breastfeeding for young infants less than 2 months of age. CB-IMCI program has been implemented up to the community level in all the districts of Nepal and it has shown positive results in the management of childhood illnesses. Over the past decade, Nepal has had success in reducing under-five mortality, largely due to the implementation of the CB-IMCI program. Initially, the Control of Diarrheal Diseases (CDD) Program began in 1982; and the Control of Acute Respiratory Infections (ARI) Program was initiated in 1987. The CDD and ARI programs were merged into the CB-IMCI program in 1998.[75]

The Nepal Family Health Survey 1996, Nepal Demographic and Health Surveys, and World Health Organization estimations over time have shown that neonatal mortality in Nepal has been decreasing at a slower rate than infant and child mortality. The Nepal Demographic and Health Survey 2011 has shown 33 neonatal deaths per 1,000 live births, which accounts for 61% of under 5 deaths. The major causes of neonatal death in Nepal are an infection, birth asphyxia, preterm birth, and hypothermia. Given Nepal's existing health service indicators, it becomes clear that strategies to address neonatal mortality in Nepal must consider the fact that 72% of births take place at home (NDHS 2011).[75]

Therefore, as an urgent step to reduce neonatal mortality, Ministry of Health and Population (MoHP) initiated a new program called 'Community-Based Newborn Care Package' (CB-NCP) based on the 2004 National Neonatal Health Strategy.[75]

The National Nutrition Program under the Department of Health Services has set its ultimate goal as "all Nepali people living with adequate nutrition, food safety and food security for adequate physical, mental and social growth and equitable human capital development and survival" with the mission to improve the overall nutritional status of children, women of childbearing age, pregnant women, and all ages through the control of general malnutrition and the prevention and control of micronutrient deficiency disorders having a broader inter and intra sectoral collaboration and coordination, partnership among different stakeholders and high level of awareness and cooperation of population in general.[76]

Malnutrition remains a serious obstacle to child survival, growth, and development in Nepal. The most common form of malnutrition is protein-energy malnutrition (PEM). Other common forms of malnutrition are iodine, iron, and vitamin A deficiency. These deficiencies often appear together in many cases. Moderately acute and severely acutely malnourished children are more likely to die from common childhood illnesses than those adequately nourished. In addition, malnutrition constitutes a serious threat to young children and is associated with about one-third of child mortality. Major causes of PEM in Nepal is low birth weight of below 2.5 kg due to poor maternal nutrition, inadequate dietary intake, frequent infections, household food insecurity, poor feeding behaviour and poor care & practices leading to an intergenerational cycle of malnutrition.[77]

An analysis of the causes of stunted growth in Nepal reveals that around half is rooted in poor maternal nutrition, and the other half in poor infant and young child nutrition. Around a quarter of babies are born with a low birth weight. As per the findings of Nepal Demographic and Health Survey (NDHS, 2011), 41 percent of children below 5 years of age are stunted. A survey by NDHS and NMICS also showed that 30% of the children are underweight and 11% of children below 5 years are wasted.[66]^:241

In order to address under-nutrition problems in young children, the Government of Nepal (GoN) has implemented:

a) Infant and Young Child Feeding (IYCF)

b) Control of Protein Energy Malnutrition (PEM)

c) Control of Iodine Deficiency Disorder (IDD)

d) Control of Vitamin A Deficiency (VAD)

e) Control of Iron Deficiency Anaemia (IDA)

f) Deworming of children aged 1 to 5 years and vitamin A capsule distribution

g) Community Management of Acute Malnutrition (CMAM)

h) Hospital-based nutrition management and rehabilitation

The hospital-based nutrition management and rehabilitation program treats severe malnourished children at Out-patient Therapeutic Program (OTP) centres in Health Facilities. As per requirement, the package is linked with the other nutrition programs such as the Child Nutrition Grant, Micronutrient powder (MNP) distribution to young children (6 to 23 months)[66]^:22,⁠24 and food distribution in the food insecure areas.

UNICEF and WHO recommended that children be exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life (WHO/UNICEF, 2002). The nutrition program under the 2004 National Nutrition Policy and Strategy promotes exclusive breastfeeding through the age of 6 months and, thereafter, the introduction of semisolid or solid foods along with continued breast milk until the child is at least age 2. Introducing breast milk substitutes to infants before age 6 months can contribute to breastfeeding failure. Substitutes, such as formula, other kinds of milk and porridge are often watered down and provide too few calories. Furthermore, possible contamination of these substitutes exposes the infant to the risk of illness. Nepal's Breast Milk Substitute Act (2049) of 1992 promotes and protects breastfeeding and regulates the unauthorized or unsolicited sale and distribution of breast milk substitutes.[78]

After six months, a child requires adequate complementary foods for normal growth. Lack of appropriate complementary feeding may lead to malnutrition and frequent illnesses, which in turn may lead to death. However, even with complementary feeding, the child should continue to be breastfed for two years or more.[78]

Adequate nutrition during infancy is crucial for child survival, optimal growth and development throughout life. It has been postulated that 13% of the current under-five mortality rate could be averted by promoting proper breastfeeding practices, which is seemingly the single most cost effective intervention to reduce child mortality in resource-constrained settings such as in Nepal. Childhood malnutrition and growth faltering affects more than half of children under five in developing countries, and usually starts during infancy, possibly due to improper breastfeeding and mixed feeding practices.[79]

According to WHO, exclusive breastfeeding is defined as no other food or drink, not even water, except breastmilk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines). Exclusive breastfeeding for the first 6 months of life is the recommended way of feeding infants, followed by continued breastfeeding with appropriate complementary foods for up to 2 years or beyond.[80]

As per the study carried out in Paropakar Maternity & Women's Hospital, Thapathali, 2017, the participants of normal delivery had an opportunity to breastfeed within an hour while almost all participants going through C-section were not offered to do so.[80]

The reason for participants to not practice breastfeeding within an hour were mother's sickness, unable to hold the baby due to suture, baby taken away from mother, and less or no production of breast milk soon after surgery to feed the child. In addition, (as shown in table below) 84.7% of normal delivery participants did not feed anything other than breast milk to their babies while 78% of C-sectioned participants fed formula to their babies after they had started breastfeeding.

The participants assumed that formula-fed babies were more likely to gain weight more quickly than breastfed babies. These might be the major increasing drawbacks for the practice of exclusive breastfeeding in Nepal.

The perspective towards breastfeeding is found to be optimistic, believing to the benefits of breastfeeding were not only for a limited period; is always convenient, healthier and cheaper than formula. Exclusive breastfeeding has always been considered as an ideal food for the baby up to six months after birth.

We can say that mode of delivery is significant with initiation of breastfeeding within an hour. This means the practice of exclusive breastfeeding is higher among normal deliveries than C-sections. From analysis of Nepal demographic and health survey, 2011; Two in every three mothers had initiated breastfeeding within one hour of childbirth.[80]

In some cultures including Nepal there is a preference for the introduction of prelacteal feeds. Economic status and the mother's education status were significant factors associated with the introduction of prelacteal feeds. The lower socio-economic groups have less access to the expensive prelacteal feeds such as ghee or honey and therefore exclusive breastfeeding is the only option available. This might be a reason for the reported lower prelacteal feeding practice rates amongst the poorest wealth groups in Nepal.[81]

An elder from Nepal

There are no active and effective policies and programs to mainstream aging population in national, social and political discourse in Nepal. About 9% of the total population accounts for 60+ populations and the number is projected to be around 20% by 2050. The decline in fertility rate and increased life expectancy is the main cause for the increased number of old age people in Nepal.[82] An increase in the number of aged people and availability of no healthcare services in a developing country like Nepal, aging could be a matter of challenge.

Out of 2.1million elderly people (2011 census), only 3 geriatric specialists are registered to take care of them. Nepal not only lacks geriatric specialists, but geriatric nurses and caregivers are also lacking.[83] There is only one shelter for elderly people run by the government (Pashupatinath Bridrashram) which was established in 1976 as the first residential facility for elders and has the capacity for only 230 elderly people. Official data of Social Welfare Council shows that the total number of old age homes (OAHs) registered as of 2005 was 153. However, most of these homes either do not exist today or operate in very poor condition. Only about twenty homes are currently functional throughout the country.[84] These organizations vary in their organizational status (government, private, NGO, personal charity), capacity, facilities, and the services they provide. Most of them are charity organizations. About 1,500 elders are living in these old-age homes at present.[85]

Government has initiated to provide geriatric care services by formulating certain plans and policies but these could not be effective due to lack of resources. Madrid Plan of Action on Aging (2002), Senior Citizen Policy (2002), National Plan of Action on Aging (2005), Senior Citizen Act (2006) and The senior Citizens regulations (2008) are the initiatives taken by Nepal government. The Ministry of Health and Population started social service units in 8 hospitals and geriatric wards in 3 hospitals. About 70 registered old age homes are available in the country out of which 11 get government grants.

In March 2012, a residential health care home for elderly people named Health Home Care Nepal with 15 beds was established by private investment. It aims to provide comprehensive holistic package services for needy elderly people. It was the first model care home managed by medical professionals.[86] Old age homes which are giving services for free in Nepal are listed below:

– Sri Sathya Sai Seva organisation

– Ageing Nepal

– Siddhi Memorial Foundation Nepal

– Pashupati Briddhashram

There is little baseline information on the prevalence of geriatric diseases among the elderly which is an obstacle for health care planning and management. Prevalence of chronic diseases in old age is a common phenomenon. Most of the common geriatric diseases in Nepal include gastritis, arthritis, hypertension, COPD, infections, eye problems, back pain, dementia, headache, diabetes, paralysis and heart problems.[84] Specific and exact data related to geriatric population is lacking behind as this section is not more concerned as that of child and women health. More research should be conducted from the public level to get the specific data which can give a focussed idea to develop effective health policies for the old people.

The table below shows the status of diseased state of elderly people in a certain number of aged people in Kathmandu.

source: Socio-Demographic and Health Status of Nepalese Elderly [87]

These are the only data from a specific place in a specific number of people. More research and studies are to be conducted at the national level to know the exact health status of elderly people in Nepal.

Road traffic injuries are one of the global health burdens, an eighth leading cause of death worldwide. Globally, approximately 1.25 million lives are cut short every year because of a road traffic injuries. Ranging from 20 to 50 million people become victims of non-fatal injuries, with many acquiring a disability for the rest of the life as a result of their injury.[88] In Nepal, a road traffic accident rank eighth among killer causes of disability-adjusted life years and also eighth among premature cause of death after Non-Communicable Diseases and Communicable Diseases.[89]

A substantial problem of road traffic accident with fatalities occurs mainly on highways caused by bus crashes in Nepal. Due to the country's geography, bus accidents mostly happen in the hilly region and along the long-distance route causing 31 percent of fatalities and serious injuries every year.[90] Accidents involving motorcycles, micro-buses, cars etc. highly prevail in the capital city, Kathmandu compared to other cities and lowland areas. The number of Road Traffic Accidents in the capital city was (53.5±14.1) of the number for the entire country.[91] People between 15 and 40 ages are the most affected group followed by those above 50 years and majorities were male making 73 percent of disability-adjusted life years. The number of registered vehicles in Bagmati Zone was 129,557, a 29.6 percent of the whole nation in fiscal year 2017/2018.[92][91]

The table below shows the trend of fatality per 10000 vehicles between 2005 and 2013.

source: Traffic Accidents Record, Traffic Directorate, Nepal Police, 2013.[92]

In terms of the network of mental health facilities, there are 18 outpatient mental health facilities, 3-day treatment facilities, and 17 community-based psychiatric inpatient units available in the country. The majority of the mental health service users are treated in outpatient facilities. Thirty-seven percent of patients are female. The patients admitted to mental hospitals belong primarily to the following two diagnostic groups: Schizophrenia, schizotypal and delusional disorders (34%) and Mood [affective] disorders (21%). On average, patients spend 18.85 days in mental hospitals. All of the patients spent less than one year in the mental hospital during the year of assessment.

Two percent of the training for medical doctors is devoted to mental health, and the same percentage is provided for nurses. One Non Government Organization is running a community mental health service in 7 of the 75 districts in the country. In other districts, community mental health services are not available, as mental health services are not yet integrated into the general health service system.

Even though Nepal's mental health policy was formulated in 1996, there is no mental health legislation as yet. In terms of financing, less than one percent (0.17%) of health care expenditures by the government are directed towards mental health. There is no human right review body to inspect mental health facilities and impose sanctions on those facilities that persistently violate patients' rights.[93]

Mental health is one of the least focused healthcare segment in Nepal. Less focused in terms of awareness and treatment. Now also most of the people choose to visit traditional healers, if it doesn't work psychiatrist will be the second choice. Very less number of psychiatrists and more number of psychiatric cases makes hospital crowded place, providing quality service is challenging.

Only few number of trained psychologists are working either in private clinic or very few in government hospitals. Most of the psychologists are working within Kathmandu Valley only.

There are around 25 private centers providing psychotherapy in Kathmandu. Few of them are listed here.

1. Bhatta Psychotherapy
2. Nepal Hypnosis Clinic
3. Antarang Counseling
4. TPO Nepal
5. CMC Nepal