It is evident from the data that NCDs are rapidly emerging as a major burden of illness in low and middle-income countries. According to the World Health Organization (WHO), NCDs in Nepal account for 55 percent of the total disease burden, including injuries. The prevalence of NCDs is substantial and is projected to rise over the years. The 2013 World Bank Report states that Nepal is the fastest urbanising country in South Asia. This rapid unplanned urbanisation comes with increasing air pollution and changes in lifestyle and nutrition. WHO has thus projected that 66 percent of deaths by 2030 will be due to NCDs.

Behavioural risk factors

NCDs affect all age groups and are on the rise due to socio-economic and demographic changes. However, they are largely preventable and share key behavioural risk factors. The four key risk factors are tobacco use, harmful alcohol use, unhealthy diets and physical inactivity. These factors can lead to high blood pressure, high blood glucose, high blood lipids and overweight/obesity. They contribute to the development of diabetes, cancer, cardiovascular diseases and chronic respiratory diseases.

But risk factors vary across countries. In South Asia, indoor air pollution due to burnt wood or biomass fuel is a major cause of chronic respiratory disease and chewed tobacco for oral cancer. Exposure to lead and asbestos in households has also been linked to cancer. WHO surveys in Nepal in 2008 estimated that 37 percent of adults use tobacco (out of which, 24 percent consume daily) and 28 percent consume unhealthy amounts of alcohol on a regular basis. The Nepal Demographic Health Survey states that 50 of men surveyed were smokers. Likewise, household consumption of sugar, oil/ghee and packaged foods has increased many folds.

Prevention and control

Nepal is one of 119 countries committed to the prevention and control of NCDs. This has manifested in various national policies. Nepal adopted the WHO Framework Convention of Tobacco Control (FCTC), which was ratified by the House of Representatives in 2006. The Parliament passed a tobacco product control and regulation act in 2011 and is coming up with anti-alcohol legislation. The Ministry of Health and Population (MoHP) formulated a draft NCD policy in 2009 along with a “National Policy, Strategy and Plan of Action for the Prevention and Control of Non-communicable Diseases”.

NCDs can also be effectively dealt through a setting-based approach. One such setting would be schools (taking into consideration that 37 percent of the Nepali population is below the age of 15 years) by reducing early life exposure. It is well-established that NCDs in adulthood are influenced by environmental factors in early life. Schools provide an important opportunity for the promotion of healthy behaviours, as was highlighted in a political declaration by a high-level meeting of the UN General Assembly on Prevention and Control of NCDs.

The Government of Nepal has recognised the importance of a healthy school environment and developed a minimum package for school health and nutrition. Yet, the challenge, as always, lies in implementation and thereby, helping all Nepali children make healthy choices irrespective of their socio-economic background. There is also a lack of data regarding knowledge attitudes and behaviours towards NCD risk factors among young school-age children. Such data is important if school settings are to be utilised for the control and prevention of NCDs.

Challenges and solutions

Although policies and legislation for the prevention of risk factors are in place, the Government of Nepal still needs to respond effectively to the growing burden of NCDs. The challenges are many, from financial resources, human resources, lack of coordination and commitments and to the failure to enforce existing laws. Nepal is part of the WHO FCTC but a major challenge still lies in the control of tobacco use due to a failure to fully implement FCTC regulations. Regulatory mechanisms have to be strengthened by making public places smoke free, publishing effective pictorial warnings on cigarette packages and controlling the illicit trade of tobacco products. The upcoming anti-alcohol legislation should enforce prohibitions on advertising alcohol in print and electronic media.

Prevention is a key to tackling NCDs. The economic consequences of NCDs are huge, with expensive health care costs and loss of economic productivity due to illness and premature deaths. According to reports of Department of Health Services, less than 1 percent of the US $370 million 2012-2013 National Health Budget is allocated for NCD- related activities. The government funding for NCDs is mainly focused towards providing specialized tertiary care and negligible funding for prevention. The financial burden of treating NCDs of individuals and families are enormous. NCD therefore, poses developmental challenges to many families, communities and the nation as a whole.

There is also a need for a public health approach, based on the principles of primary healthcare to combat NCDs, develop multi-sectoral public health programmes, strengthen existing policies and increase funding for primary prevention. Primary public health intervention has proven to be most cost effective in tackling the burden of NCDs. Enforcement of existing laws and focussing on behavioural change at all levels are keys to the prevention and control of NCDs, given the fact that risk factors are related to individual behaviours and broader social determinants.

Dr Prasai Dixit is national coordinator of the School Health and Nutrition Network and Joint Secretary of the Nepal Public Health Foundation