Burden of coronary heart disease in Nepal: current status
Dear Sirs,
As a part of an epidemiological shift from communicable to non-communicable diseases (NCDs), Nepal is facing a major burden of coronary heart disease (CHD).1,2 By 2025, the Government of Nepal (GoN) has pledged to reduce cardiovascular disease (CVD)-related mortality by 25% and manage 50% of eligible patients for ischaemic heart disease (IHD)-related treatment. A multi-sectoral action plan was developed in 2014, targeting behavioural and physiological risk factors to reduce “preventable morbidity, avoidable disability and premature death”.3 The sluggish progress of the dilapidated health system of Nepal puts it off course to achieve this.
Despite a lack of national data, studies suggest that there is high burden of CHD, which remains the predominant contributor to CVD mortality. The alarming pervasiveness of CHD is driven by risk factors such as smoking, alcohol, poor nutrition and physical inactivity. These are the areas targeted by the GoN through supportive policies, legislation and enforcement. The CHD epidemic has been further accelerated by an expansive ageing population, widened socio-economic inequality and an increase in rural–urban disparities.4 Historically, socially marginalised groups based on the caste system, referred to as ‘untouchables or Dalits’, had higher clustering of risk factors for CVD when compared with the privileged upper caste in rural Nepal, similar to other south Asian regions.
Community-based interventions mobilising female community health volunteers, peer groups, and influential people to advocate health literacy to empower communities and self-care has been advocated, focusing on those at greater risk. Inadequate healthcare coverage, where 80% of the population relies on an expensive out-of-pocket health model, compromises basic healthcare.5 The coverage plan in Nepal is in its infancy, focusing on subsidised treatment through limited government-owned facilities with interventions targeted at disease treatment.
Although prioritised, the target to expand care coverage has been thwarted by low enrollment and increased dropout rates. GoN provides free heart disease treatment to elderly patients over 75 years. But, in fact, over half of CVD-related Nepalese mortality occurs in those under 70 years. GoN has also provided roughly 850 USD as a one-off financial relief package per person for deprived communities to avail of treatment through its eight allocated centres throughout Nepal.6 The financial relief, however, falls short of the actual cost of primary management of acute coronary syndrome, for example, in government-owned hospitals.
Although accepting the adage that prevention is better than cure, the GoN needs to rapidly enact this principle in order to impact the CHD burden.
Conflicts of interest
None declared.
Funding
None.
Arun Kadel
FCPS Cardiology Trainee
Binay Kumar Rauniyar
Cardiologist
Department of Cardiology, Shahid Gangalal National Heart Center, Nepal
Neeti Bhat
Lecturer
Madan Bhandari Academy of Health Sciences, Hetauda, Nepal
References
1. Vaidya A, Pokharel PK, Nagesh S, Karki P, Kumar S, Majhi S. Prevalence of coronary heart disease in the urban adult males of eastern Nepal: a population-based analytical cross-sectional study. Indian Heart J 2009;61:341–7.
2. Bhattarai S, Aryal A, Pyakurel M et al. Cardiovascular disease trends in Nepal – an analysis of global burden of disease data 2017. Int J Cardiol Heart Vasc 2020;30:100602. https://doi.org/10.1016/j.ijcha.2020.100602
3. Government of Nepal. Multisectoral action plan for the prevention and control of non communicable diseases (2014–2020). Kathmandu: Government of Nepal, 2014. Available from: https://www.who.int/docs/default-source/nepal-documents/multisectoral-action-plan-for-prevention-and-control-of-ncds-(2014-2020).pdf?sfvrsn=c3fa147c_4
4. Dhungana RR, Thapa P, Devkota S et al. Prevalence of cardiovascular disease risk factors: a community-based cross-sectional study in a peri-urban community of Kathmandu, Nepal. Indian Heart J 2018;70:S20–S27. https://doi.org/10.1016/j.ihj.2018.03.003
5. Rajan S, Rathod SD, Luitel NP, Murphy A, Roberts T, Jordans MJD. Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal. BMC Health Serv Res 2020;20:250. https://doi.org/10.1186/s12913-020-05094-9
6. Government of Nepal. Ministry of Health and Population. Medical treatment of deprived citizens. Available at: http://mohp.gov.np/eng/program/medical-treatment-deprived-citizen [accessed 11 February 2021].
