Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021
Bikram Adhikari, Achyut Raj Pandey, Bipul Lamichhane, Saugat Pratap KC, Deepak Joshi, Shophika Regmi, Santosh Giri, Sushil Chandra Baral
BMJ Open · 2023 · DOI: 10.1136/bmjopen-2023-072673
Countries: Nepal
What Was Studied
This cross-sectional study analysed secondary data from the nationally representative Nepal Health Facility Survey (NHFS) 2021, using a stratified random sample of 1,633 health facilities (effective analytic sample of 1,480 offering any NCD-related service) drawn from 5,681 eligible facilities across all 7 provinces and 77 districts. Using the WHO's Service Availability and Readiness Assessment (SARA) tool, researchers measured facility readiness — across guidelines/staff training, essential equipment/supplies, and essential medicines/diagnostics domains — to deliver services for cardiovascular disease (CVD), diabetes mellitus (DM), chronic respiratory disease (CRD) and mental health (MH), then used weighted univariate and multivariable logistic regression to identify correlates of readiness (setting, ecological region, province, facility type, external supervision, quality assurance activities, and client-opinion review).
What They Found
Facility readiness to deliver NCD services was very low nationwide: only 2.3% of facilities were 'ready' (score >=70/100) for CRD services, 3.8% for CVD, 3.6% for DM, and 3.3% for MH — despite mean readiness scores of 32.6, 38.0, 38.4 and 24.0 out of 100 respectively across the four service areas. The guidelines-and-staff-training domain scored lowest for every NCD service (median score of 0), while essential-equipment-and-supplies scored highest. Facilities run by local government (health posts, PHCCs, basic hospitals) were dramatically less ready than federal/provincial hospitals — only 1.5% of local HFs were 'ready' for CRD services versus 19.5% of federal/provincial hospitals, with 96% lower adjusted odds of CRD-readiness (AOR 0.04, 95% CI 0.02-0.09) and 88% lower odds of CVD-readiness (AOR 0.12, 95% CI 0.05-0.28) — while facilities receiving external supervision in the past 4 months had over 3 times higher odds of CRD-readiness (AOR 3.43, 95% CI 1.64-7.20) and 2.5 times higher odds of DM-readiness (AOR 2.51, 95% CI 1.26-4.99). Essential NCD medicines were often nearly absent: beclomethasone (an asthma/COPD inhaler) was available in only 3.9% of facilities, injectable insulin in 7.5%, and thiazide diuretics in 6.7%.
What This Means for Nepal
With NCDs causing 71.1% of deaths in Nepal (GBD 2019) and MoHP's WHO Package of Essential NCD interventions (PEN) now rolled out to all 77 districts to deliver NCD screening and management at health posts and PHCCs, this study's evidence that only 1.5% of local health facilities are 'ready' to manage CRDs (versus 19.5% of federal/provincial hospitals) shows the PEN rollout has reached facilities on paper but not equipped them in practice. DoHS and the provincial health directorates should prioritise two concrete actions: (1) fund and enforce the Basic Health Service Package (BHSP) essential NCD medicine list (part of Nepal's ~98-item Free Drug List) specifically at health-post and PHCC level, where medicines like beclomethasone, injectable insulin and thiazide diuretics were almost universally unavailable; and (2) scale up routine external supervision visits to local HFs, since facilities supervised in the past 4 months had more than 3 times the odds of CRD-readiness and 2.5 times the odds of DM-readiness — a comparatively low-cost governance lever within reach of provincial health directorates even amid Nepal's chronic administrative turnover.
Contextualisation
Nepal's NCD burden is severe — NCDs cause 71.1% of deaths (GBD 2019) and hypertension affects 24.5% of adults (STEPS 2019) — yet the health system remains structured around a three-tier federal split where local governments (Constitution Schedule 8) hold responsibility for 'basic health and sanitation,' including the roughly 3,778 health posts and 187 PHCCs that serve as most Nepalis' first point of contact. This study's finding that facilities managed by local government were 96% less likely to be ready for CRD services (AOR 0.04) than federal/provincial hospitals exposes a critical devolution gap just as MoHP's WHO PEN package and the NCD Multi-Sectoral Action Plan (2021-2025) depend on exactly these peripheral facilities for screening, diagnosis and referral.