Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (2014-2020)

Objectives

Nepal’s Multisectoral Action Plan for Prevention and Control of Non-communicable Diseases, 2014-2020, seeks to enable all people to attain the highest possible health, wellbeing and quality of life throughout life, free from preventable non-communicable diseases (NCDs), avoidable disability and premature death.[1]Its overarching goal is to reduce preventable morbidity, avoidable disability and premature mortality from NCDs through an equitable, life-course, evidence-based and multisectoral response.[1][2]

• Raise national political priority, leadership, governance, partnerships and resources for NCD prevention and control.[1][3]
• Reduce behavioural, environmental and metabolic risks, including tobacco use, harmful alcohol use, unhealthy diet, physical inactivity, raised blood pressure, obesity, diabetes, household solid-fuel use and indoor air pollution.[4][1][5]
• Address cardiovascular diseases, chronic respiratory diseases, cancers and diabetes, while incorporating oral health, mental health and road safety as national priorities.[1][6]
• Strengthen people-centred primary health care, universal health coverage, early detection, treatment, referral, palliative care, self-care and access to affordable essential medicines and technologies.[1][5][7]
• Reduce inequities associated with education, gender, socioeconomic status, ethnicity and migrant status.[1]
• Develop research, surveillance, monitoring and evaluation capacity to track NCD trends, determinants, interventions and progress.[1][8]

The plan responds to a substantial and growing burden: NCDs were estimated to account for 39% of total disease burden and nearly half of deaths in Nepal, while NCDs and injuries accounted for 60% of disability-adjusted life years by 2013.[9][10]It recognises that population ageing, unplanned urbanisation, poverty, low literacy, marketing of unhealthy products and wider social determinants shape NCD risk and outcomes.[10]

The framework sets ten targets for 2025, including reducing premature mortality from the four principal NCD groups, harmful alcohol use, tobacco use, salt intake, raised blood pressure, insufficient physical activity and household solid-fuel use; halting increases in obesity and diabetes; expanding cardiovascular risk-reduction therapy and counselling; and achieving 80% availability of affordable essential medicines and basic technologies.[1][2][5]It also seeks to strengthen oral-health prevention, community mental-health services, cancer palliative care and the prevention of road-traffic injuries.[5][11][12]

Implementation

Implementation combines population-wide prevention with strengthened health services, recognising that action on social, environmental and commercial determinants can reach larger populations and may be more cost-effective than clinical intervention alone.[10]Prevention is to follow a Health in All Policies model, while the Ministry of Health and Population leads early detection, treatment and health-system action.[13]

• Coordinate multisectoral action across health, agriculture, education, finance, information, urban planning, trade, transport, home affairs, local government, civil society, academia, communities, private organisations and development partners.[2][3]
• Govern implementation through a National Steering Committee chaired by the Chief Secretary, a national committee chaired by the Health Secretary, a Coordination Committee, and regional and district committees.[14][15]
• Establish and maintain a functional NCD Unit within the Ministry of Health and Population to coordinate the major disease groups, associated conditions and risk factors.[6][16]
• Use joint annual work planning and stakeholder workshops to identify gaps, endorse responsibilities, integrate actions into sectoral annual plans and improve transparency.[13][17]
• Implement Phase I to the end of 2016 through committee restructuring, establishment of the NCD unit, pilots, procurement and supply reforms, improved information systems and baseline data; scale up interventions during 2017-2020; and prepare a subsequent plan towards the end of 2019.[14]

Population-level action includes enforcing tobacco and alcohol regulations; using taxation and pricing measures; restricting marketing, advertising and sponsorship; promoting healthier food environments; reducing salt, trans fats and saturated fats; supporting fruit and vegetable consumption; increasing physical activity; improving urban design and active transport; and reducing household air pollution through cleaner energy and ventilation.[18][19][20][21][22]Community groups, schools, female community health volunteers, workplaces, media and civil-society organisations are intended to support prevention, behaviour change and local ownership.[18][21][23]

Health-system delivery is to pilot and expand the World Health Organization Package of Essential Non-communicable Disease Interventions in primary care, supported by essential medicines, diagnostics, workforce training and a three-tier referral system linking primary care, district and zonal hospitals, and specialist centres.[18][7][24]Planned measures also include cardiovascular risk assessment, cancer and diabetes screening, mental-health integration, oral-health outreach, palliative care and strengthened trauma services.[5][24][11][12]

Monitoring covers NCD morbidity and mortality, risk factors, health-system capacity and implementation.[25]Implementing partners are expected to submit six-monthly reports to the NCD Unit, while annual progress reports and independent stakeholder performance reviews are intended to inform accountability and adaptation.[25][17]Surveillance measures include five-yearly STEPwise risk-factor surveys, vital-registration improvement, routine hospital and private-hospital reporting, disease registries, burden-of-disease studies and integration of NCD and mental-health information into the Health Management Information System.[18][8][26]

Financing is expected to draw on increased domestic allocations, participating ministries’ annual budgets, tobacco and alcohol tax revenue, a proposed Health Tax Fund, donor proposals and continued support from the World Health Organization and other partners.[15][6][27][20][28]The supplied material does not specify a total implementation budget, programme-level allocations or quantified funding gap.[13][5]

Monitoring & Evaluation

The plan establishes a national monitoring, evaluation and accountability system for non-communicable diseases (NCDs), covering disease burden, risk factors, health-system capacity, implementation performance and progress towards 2025 targets. Overall monitoring responsibility sits with the Ministry of Health and Population under National Steering Committee guidance, supported by national, regional and district committee structures.[25][15]

• Track ten national 2025 targets, including premature mortality from cardiovascular disease, cancer, diabetes and chronic respiratory disease; harmful alcohol use; tobacco use; household solid-fuel use; salt intake; raised blood pressure; physical inactivity; obesity and diabetes; preventive treatment and counselling coverage; and availability of affordable essential medicines and technologies.[1]
• Measure a 25% relative reduction in premature mortality from the four main NCD groups, alongside at least 10% relative reductions in harmful alcohol use and insufficient physical activity. Core measures include the unconditional probability of death between ages 30 and 70, heavy episodic drinking and adolescent physical inactivity.[25]
• Use baseline and end-line measurement, including five-year measurement for selected behavioural indicators, through mortality analysis, adolescent or school health surveys and the STEPwise approach to NCD risk-factor surveillance (STEPS) Survey.[25]
• Conduct STEPS surveys every five years, including Step 3 and urine sodium collection, with urban and rural representation; undertake a burden-of-disease baseline study and pilot urinary sodium assessment.[8]
• Integrate NCD and mental-health indicators into the Health Management Information System, improve vital and civil registration and medical cause-of-death reporting, and introduce routine private-hospital reporting.[18][8][26]
• Use cancer, diabetes, mental-health and other disease registries, hospital data, vital registration and national surveys to assess disease burden, risk factors and programme performance.[26][29]

Reporting and review mechanisms combine routine implementation reporting with independent performance assessment. Implementing partners are required to submit standardised reports to the NCD Unit every six months; an annual progress report is to be published and disseminated through the media, informing the annual independent performance review.[25]Joint annual work planning requires stakeholders to present plans for technical endorsement before incorporating them into annual sectoral plans, helping identify gaps, clarify shared responsibilities and improve transparency.[17]

• Conduct biannual reviews of the multisectoral action plan, annual stakeholder performance reviews and annual NCD performance reporting through the Coordination Committee.[15]
• Assess annual implementation reviews using a standard tool covering the fidelity, dose and coverage of planned activities; reviews may be outsourced to an independent firm.[17]
• Require regional and district committees to coordinate work plans, support regulatory enforcement, facilitate learning and report implementation status to the Ministry of Health and Population Technical Committee.[15]
• Undertake a detailed Phase I evaluation at the beginning of 2016 and a further mid-term evaluation at the end of 2018, including assessment of achievements, shortcomings, strengths, weaknesses, opportunities and threats.[14]
• Undertake a mid-term assessment in 2017 and a five-year evaluation of the National Action Plan in 2020.[29]

Surveillance and evaluation also include programme-specific mechanisms. These encompass tobacco compliance studies, smoke-free-zone surveys, decoy purchases and market assessments; monitoring of alcohol marketing and drink-driving information; food testing for trans fat, sugar and salt; and monitoring of breast-milk substitute products.[19][20][30][31]A national database is planned to guide the transition to clean household energy, while mental-health reporting is to use core indicators developed for primary healthcare centres.[22][32]

Research and evidence generation are integral to accountability. Planned work includes national psychiatric morbidity and oral-health studies, fluoride and food-consumption assessments, diabetes prevalence research, suicide assessment, and evaluation of behaviour-change communication.[18][33]The plan also calls for training data analysts, surveillance personnel, researchers and policy officers, and for publishing stakeholder performance and periodic progress reports.[26][29][34]

Costing & Financing

The plan does not provide a quantified overall implementation budget, programme-level allocations, expenditure estimates, funding-gap amounts, unit costs or formal economic assumptions. It nevertheless frames population-wide and multisectoral prevention as more cost-effective than upper-level clinical interventions, while recognising that NCDs generate lifelong treatment costs, productivity losses and substantial household and societal burdens.[10][4]

• Mobilise domestic resources by increasing budgetary allocations for NCD prevention and control and considering revenues from tobacco and alcohol taxation.[6]
• Channel increased tobacco- and alcohol-tax revenue towards NCD activities, including health-promotion measures.[2][18]
• Establish a Health Tax Fund in 2015 to finance smoking and tobacco-control measures and prevention and control of tobacco-related diseases.[27]
• Dedicate a proportion of alcohol excise tax to NCD control and health-promotion activities, while using alcohol taxation and price measures to reduce harmful use.[20]
• Use fiscal policies, including taxes and subsidies, to influence healthier and less healthy food choices, although no monetary values are provided.[21]
• Support cleaner household energy through subsidies and incentives, increased government grants for non-governmental organisations working on alternative-energy projects, and support for biogas, improved cookstoves and related interventions.[22]

Financing responsibilities are intended to be embedded in multisectoral implementation. The National Steering Committee is expected to ensure that action-plan activities are reflected in participating ministries’ annual budgets and plans, while the National Committee for Control and Prevention of NCDs can require government and non-government entities to budget for and implement assigned activities.[14][15]Local-government budgets are also identified as a source for NCD promotion activities.[35]

External support is recognised but not quantified. Development of the multisectoral action plan received financial support from the World Health Organization and the Government of Russia between July and December 2013.[13]Continued partnership, support and guidance from the World Health Organization and other donors are treated as implementation assumptions, and the plan calls for donor proposals and resource-mobilisation plans across NCD risk factors and disease areas.[28][6]

• Seek sustainable financing by incorporating NCDs into universal-coverage policies and pursuing support through United Nations country teams.[16]
• Mobilise research funding through increased government and donor grants guided by a national NCD research-priority agenda, and explore resources available through existing initiatives including GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the United States Agency for International Development.[8]
• Improve affordability through regulation of prices for essential medicines and diagnostic tests, revised essential-medicines lists, procurement of diagnostic supplies and free provision of selected essential medicines.[7]

Resource requirements are described principally as capacity and service gaps rather than costed commitments. These include limited cancer facilities outside tertiary hospitals, shortages of mental-health professionals and beds, unmet oral-health needs, workforce development, improved information systems, medicine and technology availability, and primary-care expansion.[36][37][18]No funding gap or financing timetable is specified for meeting these requirements.[36][37]