Meghnath Dhimal_02.25.26

Transcript

• 00:02Science, otherwise known as CMIPs.
• 00:04And I'm also professor of
• 00:06biostatistics here at the Yale
• 00:07School of Public Health.
• 00:10We are, this is our
• 00:11second
• 00:13seminar of the spring semester
• 00:14of this year. And I'm
• 00:16very pleased to have our
• 00:17guest speaker,
• 00:19Meghnath Dimal,
• 00:21who has been working with
• 00:22us in Nepal on several
• 00:24projects and also doing many
• 00:25other interesting things.
• 00:27He's an environmental health scientist
• 00:29with over twenty years of
• 00:31experience working in Nepal, the
• 00:33Maldives,
• 00:34Timor Leste, Sri Lanka,
• 00:37Germany,
• 00:38and the United States. His
• 00:40primary expertise is in health
• 00:41policy and system research,
• 00:43burden of diseases and global
• 00:45health with a strong focus
• 00:47on planetary health, which is
• 00:49sort of a new area
• 00:50that, there's a lot of
• 00:52interest in, here at Yale
• 00:54and around the world. So
• 00:55maybe we'll hear a little
• 00:56bit about that. He currently
• 00:58serves as chief research officer
• 01:00at the Nepal Research Council,
• 01:03government of Nepal, and as
• 01:04an associate academician
• 01:07at the Nepal Academy of
• 01:08Science and Technology.
• 01:11He's also a fellow of
• 01:12the International Science Council and
• 01:14member of the WHO
• 01:16Strategic Technical Advisory Group on
• 01:19Prevention and Control of Noncommunicable
• 01:21Diseases.
• 01:23He's a visiting faculty
• 01:25at the,
• 01:26department of environmental health as
• 01:28Tripovans University.
• 01:30He's course director of climate
• 01:31and health in South Asia
• 01:32and a Fulbright
• 01:34visiting scholar for postdoctoral
• 01:36research in the department of
• 01:37nutrition
• 01:38at the Harvard TH Chan
• 01:40School of Public Health.
• 01:41As a principal investigator,
• 01:44Doctor. Dimal has led numerous
• 01:45research projects on environmental
• 01:48health and climate change, noncommunicable
• 01:51diseases,
• 01:53neglected tropical diseases, burden of
• 01:55disease and health systems research
• 01:57in Nepal.
• 01:58He has also contributed to
• 01:59the development of several national
• 02:01and international
• 02:02policies and strategic plans
• 02:05in the health population environment
• 02:07sectors.
• 02:08In recognition of his contributions
• 02:10to climate change and health,
• 02:12Doctor. Dimao has received new
• 02:15multiple prestigious awards,
• 02:17including the Young Scientist Award
• 02:19of the Year,
• 02:21winner of the new voices
• 02:22in global health program at
• 02:23the World Health Summit, the
• 02:25Outstanding Health Research Award from
• 02:27the Nepal Health Research Council
• 02:29and the National Science Technology
• 02:31and Innovation Award award of
• 02:33the health sector in twenty
• 02:35twenty two from the Ministry
• 02:36of Education, Science and Technology,
• 02:39Government of Nepal.
• 02:41Doctor. Dimal has published over
• 02:42three hundred technical reports
• 02:44and peer reviewed research articles
• 02:46and has extensive
• 02:47experience
• 02:48working with UN agencies and
• 02:50international organizations
• 02:52including
• 02:53W. H. O. UNICEF UNDP
• 02:56IPCC
• 02:57UNEP
• 02:58UNFCCC,
• 03:00the Welcome Trust, the Bill
• 03:01and Melinda Gates Foundation, Future
• 03:03Earth, Save the Children and
• 03:05I N G S A.
• 03:06He completed his PhD in
• 03:08Geosciences,
• 03:09Environmental Health Sciences
• 03:11at the Goethe Institute Frankfurt
• 03:14in Germany in twenty fifteen
• 03:16and earned his master's degree
• 03:18in environmental sciences from Tripovans
• 03:20University Kathmandu
• 03:22Nepal in two thousand and
• 03:24four.
• 03:25So I'm happy to turn
• 03:26the podium over to Doctor.
• 03:28Dimal, who's going to discuss
• 03:30addressing Nepal's growing noncommunicable
• 03:32disease burden,
• 03:33bridging research policy and practice.
• 03:36And one thing just to
• 03:37let you know,
• 03:38especially I think because of
• 03:39the weather today, we probably
• 03:41have, I don't know the
• 03:42number, Ellie could tell us,
• 03:43probably many people on Zoom.
• 03:45And, they're from all over
• 03:47the world,
• 03:48Latin America, Africa,
• 03:50various parts of Asia, United
• 03:52States, and even probably locally
• 03:54today because of the weather.
• 03:55So just know that you
• 03:56have a big Zoom audience
• 03:58out there as well. So
• 04:00welcome, and we look forward
• 04:01to hearing your time.
• 04:05Thank you so much, professor
• 04:06Donna, for a very nice
• 04:07introductions,
• 04:08and thank you so much
• 04:10for having me here. And
• 04:11it's my great pleasure to
• 04:12be here.
• 04:16And,
• 04:18there are all the colleagues
• 04:19who have joined the Zoom
• 04:20and also in person.
• 04:22Today, I'll talk about addressing
• 04:23Nepal's growing noncommunicable
• 04:25disease burden
• 04:26by linking the research evidence,
• 04:29policy, and practice.
• 04:32Before starting
• 04:33my presentation,
• 04:34let me declare my
• 04:39disclaimer.
• 04:40The views expressed in this
• 04:42presentation
• 04:43are all of mine and
• 04:44not, represent my interest in,
• 04:46you know, affiliated.
• 04:52On today's presentations,
• 04:53I'll talk broadly on the
• 04:55five domains.
• 04:56First,
• 04:57I start from the epidemiological
• 04:59transmission of disease in Nepal,
• 05:01like, globally.
• 05:03The epidemiological transition of Nepal
• 05:04is very rapid.
• 05:06So I'll highlight how the
• 05:08individual transmission
• 05:09of disease, specific people disease
• 05:11burden occurring in Nepal.
• 05:13Then I'll talk about the
• 05:15risk factors and the prevalence
• 05:16of selected noncommunicable disease in
• 05:19the context of Nepal.
• 05:21Sorry. I'm just trying to
• 05:22we always have this problem.
• 05:23And after that, I'll talk
• 05:24about the missed burden of
• 05:26disease.
• 05:28And based on these,
• 05:30research evidence, how we formulate
• 05:32the policy plans and what
• 05:34is the current,
• 05:35implementation status. I'll talk about
• 05:37this translation of evidence to
• 05:39policy and practice in the
• 05:40context of Nepal. And, definitely,
• 05:42we have a several still
• 05:43gaps and challenges, and that
• 05:45I'll come at the in
• 05:46as a way forward.
• 05:51So when you talk the
• 05:52epidural transition of disease, means
• 05:54Nepal is well into this
• 05:55transition
• 05:56with particular
• 05:58tier triple volume of disease.
• 05:59That means we have
• 06:01still unfinished agenda of the
• 06:03infectious disease, like communicable disease,
• 06:11At the same time, it
• 06:12is a increasing growing burden
• 06:14of
• 06:15the noncommunicable
• 06:16disease.
• 06:18And, also, there is a
• 06:20rising
• 06:23burden of injuries, trauma, and
• 06:25also mental health conditions.
• 06:27So how to allocate the
• 06:28resource in a tactful way
• 06:30is a major concern now
• 06:32because the issues are limited.
• 06:34So the key drivers for
• 06:36this part is some to
• 06:37the people born in the
• 06:39disease are mainly because of
• 06:41the urbanized and lifestyle.
• 06:44Like, every country, there is
• 06:46increasing urbanized and dead. More
• 06:48people are concentrated towards living
• 06:50in the urban areas.
• 06:52Right? And the people's lifestyle
• 06:54has also changed, like, a
• 06:55sedentary lifestyle. So these all
• 06:57are causing between
• 06:59burden of disease.
• 07:02Similarly, there is environmental changes.
• 07:04I'll come in detail later.
• 07:05Like, we broadly
• 07:06are globally modern sales and
• 07:08that we can also talk
• 07:09the planetary, a health landscape.
• 07:11So because of that, also
• 07:13several these are coming, like,
• 07:14well, because of the air
• 07:16pollution, because of the climate
• 07:17sales, and because of the
• 07:19microplastic
• 07:20pollution, several issues.
• 07:22And next is the source
• 07:23of socioeconomic development. Is the
• 07:25country are turning to the
• 07:26light from from lower to
• 07:28the middle and higher income
• 07:29country? And that that also
• 07:31send the lifestyle of the
• 07:32people, and that also attribute
• 07:33to the,
• 07:35you know,
• 07:36attribution to the disease burden.
• 07:38For example,
• 07:40especially once the economic status
• 07:41get improved,
• 07:43normally,
• 07:43infected disease are reduced. But
• 07:45in the same time, the
• 07:46burden of NCDs grow up.
• 07:48Right? So that also cause
• 07:49this transition.
• 07:51There are also the demographic
• 07:52challenges. Like, the life experience
• 07:54of people have been changed
• 07:55over the last fifty years
• 07:56dramatically.
• 07:58And that also caused, like,
• 08:00more manic disease because the
• 08:02people are live living among
• 08:03the lifespan,
• 08:04but not healthy.
• 08:06They are living with the,
• 08:07you know,
• 08:09with the disability and also
• 08:10with the chronic care, etcetera.
• 08:12And finally, also the health
• 08:14system revolution is also in
• 08:15middle practice. Like in the
• 08:16past, there might be also
• 08:17several NCDs,
• 08:19noncommunicable, digital community, but might
• 08:20not be their diagnosis,
• 08:22might not be their treatment
• 08:23and, management. Right? But now,
• 08:27because of the modern medicines,
• 08:28people will increasingly
• 08:30people have the access to
• 08:31health care. I mean, that
• 08:32also,
• 08:33as a result of that,
• 08:34also, more cases are reported.
• 08:38Last question. Sure. Please. Let
• 08:39me go back. So I
• 08:41thought Nepal had basically resolved
• 08:43the maternal child health issues
• 08:45and had brought maternal mortality
• 08:48way down and under five
• 08:50child mortality way down. So
• 08:53why why is it still
• 08:54on here? And then another
• 08:55question is, with this kind
• 08:56of transition, it's the first
• 08:58time I've seen rising injuries.
• 08:59I'm guessing that's related to
• 08:59automobile accidents, but maybe there's
• 09:00many fewer people working in,
• 09:00like, far
• 09:03accidents, but maybe there's many
• 09:05fewer people working in, like,
• 09:06forestry
• 09:07and agriculture, and there's a
• 09:08lot of interest injuries with
• 09:10that as well. So I
• 09:11wonder if you could address
• 09:12those two points. Sure. Sure.
• 09:14That's very important points.
• 09:16So regarding the high maternal
• 09:18mortality that will reduce that
• 09:20is
• 09:21completely
• 09:22great estimate for Nepal. Like,
• 09:24in nineteen ninety six, it
• 09:25was, like, five hundred thirty
• 09:27nine per one live live
• 09:28bugs. But now we have
• 09:30reduced to one hundred fifty
• 09:31one
• 09:32or one hundred thousand life
• 09:34box. Right? But still that
• 09:36figure is high. So we
• 09:37need means continuous investment
• 09:40or, attending the sustainable development.
• 09:43Similarly, we have reduced
• 09:45drastically the child mortality rate,
• 09:47infant mortality rate, but still,
• 09:49we have quite high compared
• 09:51to the other country and
• 09:52our
• 09:53SDG target.
• 09:54So my concern here is
• 09:56that still we need the
• 09:57investment on this matter, neutral,
• 09:59and side health. But in
• 10:00the sense that we need
• 10:01to increase the invest
• 10:03or noncommunicable disease.
• 10:05And regarding injuries, the cases
• 10:07of injury are almost standing
• 10:09in the case of Nepal,
• 10:10not mass rising, not reducing.
• 10:12And that is mainly because
• 10:13of the road traffic exceeded
• 10:15and also because of the
• 10:16climate induced disaster. Like, every
• 10:17year, we have a disaster,
• 10:19and that disasters
• 10:20also cause several injuries,
• 10:23including the earthquake.
• 10:26Just in your figure here
• 10:27with the different tags on
• 10:28did you, choose the different
• 10:30colors to indicate, like, the
• 10:31magnitude of the driver? Or
• 10:33it's just
• 10:34it's bit random.
• 10:35Yeah. Not exactly. It's bit
• 10:37random. It's more qualitative.
• 10:38Yeah. So the main concern
• 10:40now here is how to
• 10:41allocate the resources because we
• 10:43cannot simply call the, resources
• 10:46currently invested in the,
• 10:48matter, neonatal, salial, and, infected
• 10:50disease and allocate to the
• 10:51NCDs.
• 10:52The aim should be to
• 10:53invest more on the health
• 10:54sector because the health sector
• 10:55budget is usually limited.
• 10:59So when you talk about
• 11:00this, risk factor driving the
• 11:02disease burden from the global
• 11:03burden of disease data means,
• 11:05usually top causes of the,
• 11:08risk factor are usually the
• 11:09air pollution. Number one pillar
• 11:10is the air pollution.
• 11:12Right? As for the latest
• 11:14finding of twenty twenty thirty.
• 11:16Previously, in twenty
• 11:18thirteen, it was, number two.
• 11:20Similarly,
• 11:21malnutrition.
• 11:23But good news is that
• 11:24over the years, the valleys
• 11:25contributed by the CR pollution
• 11:27malnutrition has reduced.
• 11:29But the,
• 11:32attribution, especially from the metabolic
• 11:34of, risk
• 11:36is increased over the years
• 11:37and also,
• 11:38in.
• 11:39And when you see the,
• 11:41mass causes of the death,
• 11:43top ten cause of death,
• 11:44most of them are from
• 11:45the noncommunicable disease.
• 11:47So the good news that
• 11:49we have reduced
• 11:50the burden from the, communicable
• 11:52disease, maternal, neutral, and neutral
• 11:54related disease, but the burden
• 11:56from NCD has drastically increased
• 11:57the cut.
• 12:00So later, I'll come back
• 12:01how we are locating the
• 12:02resources. We can tell it
• 12:03again mismatch between the budget
• 12:05allocation and disease burden. That
• 12:07part also I'll cover later.
• 12:09So to see that, global
• 12:10picture, like,
• 12:12globally, almost one foot, twenty
• 12:14four percent disease burden, that
• 12:15is, like, thirteen million is
• 12:17just from the environmental risk
• 12:18factors.
• 12:19And care pollution alone caused
• 12:21seven million death per year.
• 12:24Right? And this stage is,
• 12:25like, almost four point two
• 12:27million death from the ambient
• 12:28air pollutions and three point
• 12:30eight million death per year
• 12:31by the household air pollutions.
• 12:33So in case of Nepal,
• 12:34the good news is that
• 12:35over the years, we have
• 12:36reduced the borrowing from the
• 12:37household air pollution because of
• 12:39the massive intervention in the
• 12:41energy sectors. We have promoted
• 12:43the clean energy.
• 12:44But because of the increasing
• 12:46urbanization and the, you know,
• 12:47transportations,
• 12:49then Air pollution has increased.
• 12:51And so borrowing from the
• 12:52Air pollution has increased.
• 12:54Right? But the good news
• 12:55again is that
• 12:56now Nepal is the second,
• 12:59let's say, largest buyer of
• 13:01the e vehicles
• 13:02after the Norway.
• 13:04So the means some raise
• 13:05of hope are also there.
• 13:06Right? So just want to
• 13:08conclude that air pollution is
• 13:10the second leading cause of
• 13:11the death globally and number
• 13:13one killer in Nepal. So
• 13:15when we talk about the
• 13:16incident prevention and control,
• 13:18we should
• 13:19focus to both office team
• 13:20drivers
• 13:21by the air pollution, climate
• 13:23change, and others, and also
• 13:24the,
• 13:25you know,
• 13:26downstream drivers, like the behavior
• 13:28scene of the people and
• 13:29others.
• 13:33And next, equally important,
• 13:35that means, major threat of
• 13:37twenty first century means even
• 13:39has also declared that climate
• 13:40change is not one year
• 13:41in monoclonal. It is a
• 13:42public crisis. Right? So climate
• 13:45change also affect the people
• 13:46in the life, different life
• 13:48force efforts
• 13:49starting from the fetus to
• 13:51the dead of the people.
• 13:52Right? So that part also
• 13:53need to be addressed. For
• 13:54example,
• 13:55those people who are exposing
• 13:57to the heat waves,
• 13:59they are facing the different
• 14:01heat related in place,
• 14:02unless including the product in
• 14:04the disease. Right? So such
• 14:06part also need to be
• 14:08considered when we design the
• 14:09policy and plants.
• 14:11That means our policy and
• 14:13plans should be holistic,
• 14:15taking the consideration of the
• 14:17vulnerability factors, biological factors, and
• 14:19health status of the people
• 14:20as well as geographical factors
• 14:22because the blanket level doesn't
• 14:24work. Especially, at least in
• 14:25case of Nepal, we have
• 14:26a so high microclimatic
• 14:28variation
• 14:29means, like, the lower land,
• 14:30high land. Low land is
• 14:32a high risk of the
• 14:32heat waves, also cold waves,
• 14:34but middle land are also
• 14:35different types of risks, like,
• 14:36both for the, like, landslide
• 14:38and foreign.
• 14:39And highlight is like the
• 14:40glass and leak out cross
• 14:41part and all that. So
• 14:42this different part need to
• 14:44be considered when designing the
• 14:45prevention measure, let's say, for
• 14:46injuries or the infected disease
• 14:48or even from the noncommunicable
• 14:49disease.
• 14:52And quite important is also
• 14:53socioeconomic
• 14:54factors, like, in case of
• 14:55Nepal, still out of pocket
• 14:56experience is very high. So
• 14:58when you design the, program
• 15:00means that,
• 15:02that need to be taken
• 15:03considers. Otherwise, because of the
• 15:05NDC,
• 15:06poor become poor people people
• 15:07become more poorer.
• 15:09And, also, we need to
• 15:10see from the equity lens,
• 15:12right, like in other programs.
• 15:16So let me talk from
• 15:17the broader aspect of the
• 15:18planet and health.
• 15:20We have the several underlying
• 15:22drivers
• 15:23between environmental changes
• 15:25and proximate causes, modifying factors,
• 15:27and finally, actually, we get
• 15:28the health impacts. So
• 15:30our cultural values and behaviors,
• 15:32consumption patterns,
• 15:34population size,
• 15:35demographics,
• 15:36and the technological change set
• 15:38the stage for how we
• 15:39interact with the planet.
• 15:42In the same time, core
• 15:43environmental changes just because of
• 15:45the, humanity's,
• 15:47footprint
• 15:48benefits is like the biodiversity,
• 15:50loss,
• 15:51nutrition
• 15:55overloading, climate change, and disease
• 15:56scarcity, and marine diseases.
• 15:59And as a result, the
• 16:00proximal,
• 16:01causal pathways such as those
• 16:03in manifested
• 16:04into
• 16:06six direct exposure. For example,
• 16:08poor poor air quality, limited
• 16:10or contaminated
• 16:12wastewater,
• 16:13etcetera. And finally, there will
• 16:14be
• 16:17modifying vulnerability factors such as
• 16:19individual and community outcomes, which
• 16:21are,
• 16:22set by
• 16:23ethnicity, race, gender,
• 16:25age,
• 16:26wealth, governance, social position, and
• 16:28the impact that are present.
• 16:30And finally, there will be
• 16:31the diverse health impact. That
• 16:32means the individual spends
• 16:35malnutrition and, nutritional
• 16:37disease, infected disease, noncommunicable disease
• 16:39or chronic disease,
• 16:41and direct injuries,
• 16:43etcetera,
• 16:45and also the mental health
• 16:47programs. So
• 16:48these are actually the health
• 16:51issues. Right? So we need
• 16:52to see the drivers from
• 16:53upstream to the downstream.
• 16:55And then if we can
• 16:56design a holistic plan, like,
• 16:58for example,
• 16:59when you talk about the
• 17:00nutrition, normally, we focus to
• 17:02health sector, like managing the
• 17:03owner citizen or senior citizen.
• 17:05But that part should be
• 17:06starting from the agriculture sector.
• 17:08There, like, food, safety, security,
• 17:10etcetera. Right? Similarly, like, for
• 17:12air quality, that should go
• 17:13from, like, transport sector, environment
• 17:15sector, etcetera. Right? So these
• 17:16all part need to be
• 17:18considered when designing this, multi
• 17:20sector plan for the, previous
• 17:21and control of noncommunicable entities.
• 17:26And, actually, Nepal,
• 17:28back to, like, nineteen seventy,
• 17:29there were also the several
• 17:30studies are noncommunicable disease, like
• 17:32chronic,
• 17:33of, after the pulmonary disease,
• 17:35bronchitis,
• 17:36etcetera, like, caused by the
• 17:37household air pollution. Right? And
• 17:39this are also published in,
• 17:40like, hemisphere, like, Lancet, etcetera.
• 17:45But the national level study
• 17:46is just started after two
• 17:48thousand one
• 17:49because initially, people thought these
• 17:51are the problem of the
• 17:52risk country risk people.
• 17:54And we are all suffering
• 17:55from the infected diseases,
• 17:57either diarrhea or the tuberculosis
• 17:59or the malaria,
• 18:00etcetera. Right? So
• 18:02in Nepal, the first pilot
• 18:04study to, assess the risk
• 18:05factor of the LCD started
• 18:07in two thousand three.
• 18:09Just doing one pilot study
• 18:10in three districts of Kathmandu.
• 18:13Then the first national w
• 18:15three step survey, which essentially
• 18:16a risk factor for noncommunicable
• 18:18disease were done in two
• 18:19thousand seventeen,
• 18:21taking two years.
• 18:22And it was carried out
• 18:23from January two thousand seven
• 18:25to August two thousand eight.
• 18:27But in that time, only
• 18:28two steps means of,
• 18:30behavior,
• 18:31assessment and the physical measurement
• 18:33were only done. The part
• 18:34is spent like the biological
• 18:35measurement was not done. But
• 18:37the first time, Nepal Health
• 18:38Research Council
• 18:40conducted the step survey twenty
• 18:42thirty and which actually include
• 18:44all the three component. That
• 18:46means behavior, physical, and the
• 18:48biological,
• 18:49risk factors.
• 18:51And in between in two
• 18:52thousand nine, we did one
• 18:53study, hospital based prevalence of
• 18:56selected noncommunicable disease in Nepal,
• 18:57which actually acquired high prevalence.
• 19:00And then we realized that
• 19:01we need the population based
• 19:02studies. So we elaborated that
• 19:04study in the national levels,
• 19:07and we did this first
• 19:08NCD step survey in twenty
• 19:10thirteen. And after having the
• 19:12picture of this popular hospital
• 19:14based prevalence of NCD
• 19:16and also the risk factor
• 19:17survey, we realized that
• 19:19NCD is already a epidemic
• 19:21in Nepal. So we need
• 19:22a multisexure action plan.
• 19:24So then two thousand fourteen,
• 19:26we developed the first
• 19:28multisexure NCD action plan for
• 19:30the prevention and control of
• 19:31NCD in Nepal, and I'll
• 19:32go back to later on
• 19:34that.
• 19:36So WHO has a so
• 19:38this did a different
• 19:39strategy for prevention and control
• 19:41of NCDs starting from strengthening
• 19:43the technical and institutional surveillance
• 19:45capacity.
• 19:46So they support to the
• 19:47developing country, and this is
• 19:48the NCD step survey is
• 19:49a global survey. And And
• 19:51all the member country mostly
• 19:52member country carried out, and
• 19:53Nepal is continuously carrying out
• 19:55this every five, six years.
• 19:57Second is undertake the periodic
• 19:59risk factor surveys that is
• 20:00also come under the NCD
• 20:02step survey. Third is the
• 20:03integrated surveillance into the National
• 20:04Health Information Systems. So, initially,
• 20:07the indicator related with the
• 20:08noncommunicable
• 20:09disease. Mental health. We have
• 20:10not interpreted our health management
• 20:13information system. But after, since
• 20:15last three, four years, we
• 20:16have started in this. So
• 20:18it is a completely new
• 20:20program. So the this, new
• 20:22indicator are incorporated. Right? And
• 20:24next is the extent in
• 20:25the system
• 20:26and cancer risk.
• 20:29Though our modeling data is
• 20:30quite good from the health
• 20:31management in currency system, but
• 20:33it still challenging
• 20:34the cause update.
• 20:35And I think it's, it's
• 20:37not only for Nepal or
• 20:38many country because I work
• 20:39as a collaborator of the
• 20:40Institute of Mathematics
• 20:42and, Evaluation, University of Washington,
• 20:44and we are working on
• 20:45the, smart vehicles and etcetera.
• 20:48But the good news in
• 20:49case of Nepal that we
• 20:50have started both hospital based
• 20:52cancer ISD and the population
• 20:53based cancer ISD. I'll share
• 20:55the final later.
• 20:56And next is the monitoring
• 20:57the trends and determinants of
• 20:58NCD and evaluating the progress
• 21:00is one of the objective
• 21:01of the global action plan
• 21:02and multi sector action plan.
• 21:04Like, after the formulation of
• 21:05the first multi sector, incident
• 21:07action plan in Nepal, we
• 21:08did the evaluation.
• 21:10And we gave you a
• 21:11central conclusion.
• 21:12How can we improve in
• 21:13the second phase? For example,
• 21:15the first action plan was
• 21:16not cost reduction plan. But
• 21:18second, we made cost reduction
• 21:20plan. Next, we realized that
• 21:22after the federal system is
• 21:23we need a clear role
• 21:24in the density of three
• 21:25tiers of government, like the
• 21:27federal government, provincial government, and
• 21:29the local government. That part
• 21:30is also it is.
• 21:32But still there are some
• 21:33challenges. I'll I'll come later
• 21:35on that spectrum.
• 21:37So NCD's,
• 21:38evidence to policy cycle
• 21:40is
• 21:41Please. Yeah. Sure. Because these
• 21:46activities
• 21:46are purely
• 21:48monitoring and data collection,
• 21:50but what about, like, doing
• 21:51something? Mhmm. Where is that?
• 21:54The program, I mean, you
• 21:55mean. Right? Yeah. Exactly. Yes.
• 21:56Yes. I'll comment that. Okay.
• 21:57I'll comment. So these are
• 21:58just some of their suggestions.
• 22:00Yes. It is a solution.
• 22:01Just monitoring. Exactly. That actually
• 22:04prevent or control
• 22:05activities.
• 22:06So what I do later
• 22:07is that based on these
• 22:09guidance, what we are doing
• 22:10in the part of the
• 22:10practice part, I'll come later.
• 22:12Thank you. Okay. Can I
• 22:13ask you a quick question?
• 22:14Please. Has this the WHO's
• 22:16depth survey been repeated since
• 22:19twenty thirteen? Yes. Yes. I'll
• 22:21I'll send my name. Sure.
• 22:22Yes.
• 22:23Please.
• 22:24I just wanted to ask
• 22:25about, how Nepal builds up
• 22:26the workforce within Nepal or
• 22:28build capacity to be able
• 22:29to carry out these, different
• 22:31surveillance programs.
• 22:32Were they pretty existing before
• 22:33two thousand three, or was
• 22:34it, like, a mass work
• 22:35first development thing? Yeah. That's
• 22:37very good questions.
• 22:39Yes.
• 22:40Actually, like, the first one,
• 22:41each service capacity means we
• 22:43are doing this all from
• 22:44the Nepal Health Council now.
• 22:46And even there is a
• 22:47funding call from WHO.
• 22:49They now came through my
• 22:50only the technical. So no
• 22:51any financial support. But we're
• 22:53continuing for survey. Now currently,
• 22:54also, we are planning the
• 22:55step survey twenty five twenty
• 22:57six. Right? So we are
• 22:59enhancing our capacity ourselves and
• 23:01with the legal, you know,
• 23:02support from the WSU, we
• 23:03are being able to do.
• 23:05So so because of the
• 23:06that panel come also later
• 23:07means we have, like, now
• 23:08at least publicly, you know,
• 23:10universities.
• 23:11We can please, you know,
• 23:12publicly
• 23:13program,
• 23:14then the PhD program, like,
• 23:16also organized there and all
• 23:17that. So means we have,
• 23:18like,
• 23:19several activities, which is hands
• 23:21the health of course in
• 23:22the country. Like, initially, we
• 23:24have, like, one, two two
• 23:25hundred psychiatrists in the country
• 23:27per month mental health care.
• 23:28But now we are including
• 23:29every year parties, additional parts.
• 23:31Right? So this part, I'll
• 23:32come later. Thank you so
• 23:33much for reading this. So,
• 23:37like, as I discussed in
• 23:38the previous slide, I mean,
• 23:39that is a WSL generic.
• 23:41But what what we are
• 23:42doing in the fall means
• 23:43we are doing this NCC
• 23:44step survey
• 23:46and population based prevalence of
• 23:47selected NCD that's finding out
• 23:49here.
• 23:49And, also, we did the
• 23:50nestled mental health survey. We
• 23:52have a population based cancer
• 23:54registry, and we have also
• 23:55periodic evaluation like that. We
• 23:56have a pain program, pain
• 23:58plus program, and we have
• 23:59also evaluated. And this finding
• 24:01have been incorporated in the
• 24:03revised excellent plan. Right?
• 24:06And we have also not
• 24:07a global bottleneck, which is
• 24:08and also we have a
• 24:09desktop volume of DG report.
• 24:10Every,
• 24:11cycle we publish. Like, in
• 24:12seventeen, in nineteen, in twenty
• 24:14one, twenty third, initially, we
• 24:16are also publish.
• 24:17So that keep the picture,
• 24:19especially where to allocate the
• 24:20resources and how this end
• 24:21we can allocate the resources.
• 24:25So let me just share
• 24:26the finding of first population
• 24:27based prevalence of selected noncommunicable
• 24:29disease in Nepal. Initially, we
• 24:31thought we can do the,
• 24:33make common end series prevalence
• 24:34in community like cancer,
• 24:36diabetes mellitus,
• 24:39chronic obstructive pulmonary disease, chronic
• 24:41kidney disease, and coronary artery
• 24:43disease.
• 24:44But later on, we found
• 24:45with that it's very difficult
• 24:47to to the population based
• 24:48prevalence of cancer because it
• 24:50is still quite rare. Right?
• 24:52So then based on that
• 24:53lesson, we shifted towards the
• 24:55population based cancer registry, and
• 24:57I'll share the final details.
• 24:58But this survey covered these
• 25:00four digits, and it was
• 25:01the committee based cross section
• 25:02of distributed study
• 25:04conducted
• 25:06in three years
• 25:07because of the research limitations,
• 25:09because it's required a huge
• 25:11amount of money and in
• 25:12the single year, government doesn't
• 25:14and all the survey were
• 25:15carried out with the government
• 25:16money. No idea external support.
• 25:18Because still,
• 25:20handling external support from hormone
• 25:22infected disease. And it's still
• 25:23this is still neglected.
• 25:26Right? And the target population
• 25:27where the main and women,
• 25:28it was is twenty years
• 25:29and above who had been
• 25:30living at the a place
• 25:31of residence for at least
• 25:32six months and beyond.
• 25:34And we had seventy five
• 25:36district at that time to
• 25:37now seventy seventh. We took
• 25:39from the seven to twenty
• 25:39district out of seventy five.
• 25:41There are four hundred clusters,
• 25:43and we did the multi
• 25:43state cluster sampling, and total
• 25:45sample size were thirteen thousand
• 25:46two hundred. And it is
• 25:47actually quite big sample size
• 25:49for a country like Nepal.
• 25:52Please. Thank you. Yes. I'm
• 25:54just wondering about that exclusion
• 25:56criteria of living at their
• 25:57place of residence for at
• 25:59least six months and beyond.
• 26:01From what I understand,
• 26:03there's a lot of movement
• 26:04of people in Nepal.
• 26:05For example, lots of younger
• 26:07men and even women go
• 26:09abroad to work and sending
• 26:10money back. I don't know
• 26:12how
• 26:13large a fraction of the
• 26:14population that is.
• 26:16And then I think people
• 26:18seem to also be moving
• 26:19back and forth between villages
• 26:21and Kathmandu.
• 26:23So I thought, do you
• 26:24think this is a this
• 26:25sort of exclusion criteria is
• 26:27gonna interfere with the generalizability
• 26:30and representativeness
• 26:31of the sample?
• 26:33Yeah. That's a very good
• 26:34questions. But in from a,
• 26:36other side, other perspective, if
• 26:38we don't make this cut
• 26:39off, then we need to
• 26:40count everyone because so many
• 26:42product publishers also there. Like,
• 26:43someone comes, just say the
• 26:45CWM magnet from India, some,
• 26:46like, oh, India from Bangladesh
• 26:48and others.
• 26:49Difficult. So what we thought
• 26:50is that just to confirm
• 26:51that from that population, because
• 26:53mobility is quite high, we
• 26:55thought better to make a
• 26:56cut off of the six
• 26:57months. Okay. Yeah. Thank you.
• 27:01And what we got is
• 27:02that the prevalence of COPD
• 27:04in the country was eleven
• 27:06point seven percent.
• 27:07But there was a huge
• 27:08disparity answered laterals. Like in
• 27:10some province, like, Karnali province,
• 27:12it was twenty five percent.
• 27:14Because most of the people
• 27:16still rely on the
• 27:18household,
• 27:19energy like the the dog.
• 27:21Solid biomass, purely the household.
• 27:24And the prevalence of smoking
• 27:25also quite high.
• 27:27But in other places, it's
• 27:28below, like, laminate fat percent.
• 27:31Similarly, for diabetes mellitus, it
• 27:32is eight point five percent
• 27:33less than figure, but it's
• 27:35also a huge disparity. Like,
• 27:36in the bank monthly province
• 27:37where government is located, it
• 27:38is even, like, twelve percent.
• 27:40Because once the organization rate
• 27:42increase, the diabetes also increase.
• 27:44Right?
• 27:45And for the chronic kidney
• 27:46disease, it is six percent,
• 27:48but it is almost similar
• 27:49in all province of the
• 27:50country.
• 27:51For the coronary artery disease,
• 27:52it is two point nine
• 27:53percent, almost three percent.
• 27:56You didn't look at hypertension?
• 27:58Yeah. I saw. I saw.
• 28:00So the the eyes are
• 28:01so there's, like, the major
• 28:02disease, and we have to
• 28:04get, like, hypertension. And there
• 28:05is a, like, risk factors
• 28:06here, actually.
• 28:07But we still we can
• 28:08think it's, like, hypertension is
• 28:10also disease. And are these
• 28:12based on self report or
• 28:13a combination of self reports
• 28:15and measured Measurement. Measurement also.
• 28:17Yes. Measurement. So
• 28:19if we have was follow
• 28:20all the standard protocol that
• 28:22is developed globally.
• 28:24So, like, the COPD measurement,
• 28:25CKD measurement, even the biological
• 28:27measurement, even follow-up and there
• 28:29also. I can explain everything
• 28:31because I am not a
• 28:32expert, like, from clinical background,
• 28:33but I just can say
• 28:35that, okay. We have used
• 28:35the standard protocol, and we
• 28:37have used all the biological
• 28:39measurement, physical everythings, not only
• 28:41self report.
• 28:42So
• 28:43for
• 28:44example,
• 28:45the CKD, six percent national
• 28:47levels, COPD, twelve percent.
• 28:49And if you see by
• 28:50the province, there are the
• 28:51difference in the different provinces.
• 28:53Like I said, in Karnali
• 28:55province, like, twenty five percent.
• 28:56So
• 28:58immediate another question is that
• 29:00what
• 29:02contribute that high burden of
• 29:03COPD in, let's say, Karnali
• 29:05province. Right? Means such research
• 29:06question are still there. But
• 29:08our further study, like, the
• 29:10risk factor survey and others
• 29:11have also confirmed this.
• 29:13But these all are the
• 29:14again, I'll say cross sectional
• 29:16study, descriptive study, and we
• 29:18cannot confirm the causal relations.
• 29:20So these are the area
• 29:21for the future studies, or
• 29:23let me say, for the
• 29:23studies.
• 29:26Now let me see how
• 29:26the finding flow and, actually,
• 29:28these all are already published.
• 29:29So I just saw
• 29:31one figure one, but, you
• 29:33can read all this, in
• 29:34the open access
• 29:35article. Yeah.
• 29:37Next is the finding from
• 29:38the cancer registry. We started
• 29:39the population based cancer registry
• 29:41in twenty,
• 29:43eighteen January.
• 29:45And we got actually quite
• 29:46interesting finding, like the blue
• 29:47background data
• 29:49and this our own data
• 29:50showed the quite
• 29:52defense. For example, blue again
• 29:53data show, okay, number one
• 29:54killer is the lung cancer
• 29:56for both male and female.
• 29:57But indeed, in the practice,
• 29:59we found that breast cancer
• 30:00is the number one in
• 30:01populations.
• 30:03But if it will again
• 30:04disintegrate this data by organular,
• 30:06cervical cancer is the number
• 30:07one killer for the female
• 30:09among the cancer diseases.
• 30:11Right? But for male,
• 30:13lung cancer. So means there's
• 30:15a different pattern. Means that
• 30:16this is the,
• 30:18different pattern in
• 30:21in the real public. Safe
• 30:23in, like, twenty,
• 30:25nineteen. And, similarly, we are
• 30:26following up and more people
• 30:27are coming. We have already
• 30:28compiled and, you know, updated
• 30:30the report till twenty twenty
• 30:31two, and still we are
• 30:32working on. This is a
• 30:33continuous project like the survey
• 30:34and so on.
• 30:36Now let me share another
• 30:37finding from the National Mental
• 30:38Health Survey twenty twenty.
• 30:40Right? Because we had no
• 30:42data before this on the
• 30:43National
• 30:44on the prevalence of mental
• 30:45health in the country. We
• 30:46had only the, like, small
• 30:47hospital ministry or some district
• 30:49or some municipalities.
• 30:53So this was also the,
• 30:55cost sectional study, and we
• 30:57covered the two types of
• 30:58population. One is the adolescent
• 31:00population is thirteen to seventeen
• 31:01years, and next to the
• 31:02adult is eighteen years and
• 31:04above.
• 31:06And it was also one
• 31:07of the largest,
• 31:09sample size study with the
• 31:10fifteen thousand population and almost
• 31:12six thousand adults in and
• 31:13nine thousand adults.
• 31:16And it was the face
• 31:17to face interview. Actually, this
• 31:19is the mostly based on
• 31:20on self reported because there
• 31:22is no measurement for the
• 31:23case of mental health, though
• 31:24there are some,
• 31:25validated tools. So, actually, we
• 31:28use the mini,
• 31:29mini versions.
• 31:31Normally, globally, there are two
• 31:32tools around one CD tool.
• 31:34Next is the mini tools.
• 31:34And this mini tools was
• 31:36developed by the professor,
• 31:37David Shen from the Florida
• 31:39University.
• 31:40He provided generously and clear
• 31:41cost to us, and we
• 31:42could use it. The the
• 31:43cost is very high. For
• 31:44the paper person, for one
• 31:46person, we have to pay
• 31:47the twenty US dollar and
• 31:48just calculate it. It's a
• 31:49huge amount. Actually, more expensive
• 31:51than real data collection. But,
• 31:52fortunately, he visited Nepal, and
• 31:54he just give the tools
• 31:55free of cost to us.
• 31:58And, also, we have used
• 32:00that, like, the base tools
• 32:01and others.
• 32:03So this study show that
• 32:05the mental health disorder lifetime
• 32:07is ten percent
• 32:09in overall
• 32:10country. Suicide,
• 32:12third, current, seven percent, quite
• 32:14high.
• 32:15And suicidal later, lifetime, one
• 32:16percent.
• 32:17Right? And current having the
• 32:19mental disorder, four percent, and,
• 32:21alcohol is disorder, four percent,
• 32:23and child,
• 32:24adults with the mental health
• 32:25issue, twenty percent.
• 32:27And if you see by
• 32:28the provinces, there is also
• 32:29the huge disparity.
• 32:31Big difference. For example, we
• 32:33in the Madhush,
• 32:34province, which is in the
• 32:35southern Nepal, border with the
• 32:36India, it is only two
• 32:38percent. But we all know
• 32:39that it is not two
• 32:40percent
• 32:41because it is also affected
• 32:43by the several other factors.
• 32:45For example, stigma.
• 32:47Stigma is very rare idea.
• 32:48And next is the language
• 32:50barrier.
• 32:50Right? So though we know
• 32:53this is under reported, but
• 32:54still we have to report
• 32:56without limitation.
• 32:57Right?
• 33:01So as a result of
• 33:02that one previous data, the
• 33:04overall prevalence has declined or
• 33:06let's say reduced to ten
• 33:07percent. But, actually, we estimate
• 33:08that it should be between
• 33:09thirteen to fifteen percent based
• 33:11on our pilot study data.
• 33:14Next, we do regularly the,
• 33:16step survey for the risk
• 33:17factor assessment, and the aim
• 33:19is to, assess the training,
• 33:21the key behavior and, physical,
• 33:23physical
• 33:24risk factors that affect the
• 33:25major noncommunicable disease.
• 33:27Second is to understand, service
• 33:29utilization,
• 33:30like uptake of early detection
• 33:32and treatment service for the
• 33:33key digital based service. For
• 33:34example, cervical cancer screening.
• 33:37Next is the understand the
• 33:38type of facility, like primary,
• 33:40secondary, public, private, approach by
• 33:42the people for the care
• 33:42and treatment.
• 33:46So,
• 33:48as I mentioned earlier, we
• 33:49did this complete nationwide,
• 33:52totally
• 33:53all these steps,
• 33:57following survey,
• 33:58from the Nepal Health Business
• 33:59Council, and this step survey
• 34:01twenty twenty five twenty six
• 34:02is currently in preparation. And
• 34:04we hope that we finish
• 34:05by twenty twenty six.
• 34:07But these are the this
• 34:08time, we are completely
• 34:10from our own resources with
• 34:11the minimum technical support from
• 34:12the business because
• 34:14of funding crisis.
• 34:18So as a matter, I
• 34:19think everybody know just to
• 34:20highlight that there were we
• 34:22collect the three types of
• 34:23data in this system survey.
• 34:24First is the social demographic
• 34:25and behavior information. For example,
• 34:27tobacco use, alcohol consumption, diet,
• 34:30physical activities.
• 34:32Second, we do the physical
• 34:33measurements such as the height,
• 34:34weight, and blood pressure and,
• 34:37measure.
• 34:38Third is the biochemical measurements
• 34:40such as the blood glucose,
• 34:41blood cholesterol. And in first
• 34:43time, in twenty nineteen, we
• 34:44also estimate the salt consumption.
• 34:46So we have a data
• 34:47of urinary
• 34:49sodium potassium and credit.
• 34:52So what does these services
• 34:54I just I'll share the
• 34:55finding of twenty,
• 34:56nineteen survey.
• 34:59In Nepal, the current tobacco
• 35:00use is twenty nine percent.
• 35:02But if you, again, disagree
• 35:03by the male and female,
• 35:04for the male, it is,
• 35:05like, forty eight percent and
• 35:06female lower. So there is
• 35:08also different by the six.
• 35:10And current alcohol use is
• 35:11twenty four percent.
• 35:13In some physical activity, it's
• 35:14seven point four percent. And
• 35:16this is one of the
• 35:16very dangerous sign for Nepal
• 35:18because it was only two
• 35:19point three percent in twenty
• 35:20thirteen. And so it's almost
• 35:22double
• 35:23in the just five years.
• 35:25And I hope that
• 35:27when you complete the survey,
• 35:28twenty twenty six is made
• 35:29plus fourteen percent.
• 35:31So sedentary lifestyle is becoming
• 35:33a major
• 35:34risk factor for increasing the
• 35:36incidence in the past.
• 35:37And high BMI, like, twenty
• 35:39nine percent. And, again,
• 35:42this is also different by
• 35:43male and female, and it's
• 35:44higher among the female in
• 35:45Nepal.
• 35:47So and if you see
• 35:48by the province, that is
• 35:49also differences. I'll not go
• 35:50in detail of this. And
• 35:52one important point is that
• 35:53ample use of alcohol is
• 35:54seven percent also, which is
• 35:56very high,
• 35:57for all adults, and this
• 35:58is thirty point one percent
• 35:59for men and one point
• 36:01eight percent of women. And
• 36:02in testing in Nepal, what
• 36:04we found is that female
• 36:05are more
• 36:07consuming the domestic
• 36:09manufacture alcohol or male
• 36:12towards the man let's say,
• 36:13branded one. And that there
• 36:15is also a standard difference.
• 36:16There might be several digits.
• 36:18What's the definition of harmful
• 36:20use alcohol?
• 36:21I think WHO has given
• 36:23quite precise definition and threshold.
• 36:25Based on that, we can't
• 36:26bear this.
• 36:27Thank
• 36:28you.
• 36:29And similarly, first time we
• 36:31did,
• 36:32assist of, consumption of salt.
• 36:35And we found the mean
• 36:36salt in there is nine
• 36:37gram, and that is also
• 36:39different by male and female.
• 36:41Right? And it is also
• 36:42almost double than the double
• 36:43digit recognition of
• 36:45five grand per day.
• 36:48And there are also different
• 36:49tackle for this. Like, one
• 36:51is the increasing consumption of
• 36:52the processed food. Second is
• 36:54the Nepali style of food,
• 36:55like, eating every time, salty
• 36:57food, like, like, putting, like,
• 36:59pickle or the curry.
• 37:00Right? But mainly, it's activated
• 37:02by the processed food.
• 37:07And
• 37:09people have also the, you
• 37:10know, the knowledge. Like, at
• 37:11least eighty percent think that
• 37:12doing,
• 37:13salt is important. But in
• 37:15practice, still, consumption is high.
• 37:17So translating the knowledge into
• 37:19practice also outstanding and that
• 37:20link with the be aware
• 37:21of the people.
• 37:25And next is the hypertension,
• 37:26like, professor was asking earlier,
• 37:28means we found twenty five
• 37:29percent. And it is also
• 37:30different by male and female,
• 37:32by provinces also. It's different.
• 37:36And diabetes, six percent, and
• 37:38high cholesterol, like eleven percent.
• 37:39And CBD risk, that means
• 37:42depending the thirty percent or
• 37:43higher predicted ten years CBD
• 37:45risk is, like, also thirty
• 37:46point three per point high.
• 37:50And now
• 37:52very important point from health
• 37:54system perspective is the, you
• 37:55know,
• 37:56many people who are even
• 37:58diagnosed with the, let's say,
• 37:59hypertension
• 38:00or those,
• 38:02blood sugar
• 38:03are not under treatment.
• 38:05Means treatment on compliance cascade
• 38:07among those told to have
• 38:09raised blood pressure is very
• 38:10high. There's almost fifty percent
• 38:12people are beyond health systems,
• 38:14are not under
• 38:16treatment,
• 38:18error rates.
• 38:20Same goes for the blood
• 38:21sugar.
• 38:22Previous one is for the
• 38:23hypertension,
• 38:24blood blood pressure. Yes.
• 38:27And this also blood sugar.
• 38:30I'm a little confused. I'm
• 38:31sorry if you go back.
• 38:32So
• 38:33just eighty three percent have
• 38:35been told the past twelve
• 38:36months they have hypoarthritis. Sorry.
• 38:38It's one CSK.
• 38:39It's possible in the blood
• 38:40pressure. But among, oh, among
• 38:42those ever told. I see.
• 38:44So that's if among those
• 38:45who have ever told they
• 38:47have hypertension,
• 38:48were they told that in
• 38:49the past twelve months?
• 38:53Because I guess sometimes we
• 38:54look at it as among
• 38:56anyone who's been diagnosed with
• 38:58hypertension.
• 38:59So it could be anytime.
• 39:00Yeah. It doesn't really go
• 39:01away. It's considered once you're
• 39:03diagnosed.
• 39:04It's forever.
• 39:05Mhmm. And then of those,
• 39:06how many were prescribed?
• 39:08Yeah. That would be another
• 39:09way of looking at the
• 39:10cascade.
• 39:11But exactly, we follow this
• 39:12WHO recommendation, and we've got
• 39:14this. Oh, okay. Yeah. So
• 39:16this is, it's not actually
• 39:17a blood pressure. This is
• 39:18the the hypertension one. So,
• 39:20like, sixty let's say, sixty
• 39:22eight percent or toll in
• 39:24the past twelve month have
• 39:25high blood pressure among those
• 39:27ever told. Right? But, actually,
• 39:29in the current taking medication
• 39:31to the control blood pressure
• 39:32is one in thirty two
• 39:33point eight percent. Means almost
• 39:34fifty percent people are not
• 39:35taking medicines.
• 39:38And same goes for the,
• 39:40blood sugar. Like, eighty two
• 39:41let's say, eighty three percent
• 39:42told in the past twelve
• 39:43month that they have raised
• 39:45blood sugar.
• 39:46But current taking medicine to
• 39:48the control person is one
• 39:49in fifty five percent.
• 39:54And now let me shift
• 39:56towards little bit on the
• 39:57burden of disease aspect, like
• 39:59cause of mortality.
• 40:01So in the part is
• 40:01for this twenty nineteen data.
• 40:03I can also present twenty
• 40:04thirteen, but this is not
• 40:05complete, so I just highlighted
• 40:07this one. Seventy one percent
• 40:08disease are caused by the
• 40:09noncommunicable
• 40:11disease and
• 40:13twenty one percent by
• 40:15the communicable
• 40:16maternal
• 40:17and neutral and nutrient related
• 40:18disease and eight percent by
• 40:20the injuries.
• 40:21So when you see this
• 40:22by the male and female,
• 40:24this is similar, but among
• 40:26the female, it's important is
• 40:27higher.
• 40:29And if you see the
• 40:30death by injuries, it is
• 40:31more among the male because
• 40:33of the higher,
• 40:35accident among the male because
• 40:37the driver in Nepal is
• 40:38usually in the male.
• 40:39And alcohol consumer are also
• 40:41more
• 40:41male. Right? So several reasons.
• 40:45And overall burden of disease,
• 40:47if you see, the NCD
• 40:48contribute sixty one percent, CMNN,
• 40:51this is contribute twenty nine
• 40:52percent, and the injury cost
• 40:54ten percent.
• 40:58And this factor activity date
• 40:59means over the years, they
• 41:01are changing,
• 41:02and now the air pollution
• 41:03monitors in the major ones.
• 41:06So
• 41:07as for twenty nineteen risk
• 41:09factors, if you combine
• 41:10the household air pollution and
• 41:12ambient air pollution, it will
• 41:13be, like, twenty point five
• 41:14percent. So number one killer
• 41:16in case of Nepal is
• 41:18the air pollution
• 41:19followed by the smoking, then
• 41:20the high systolic blood pressure.
• 41:23But when you see the
• 41:24research allocation, health expenditure and
• 41:26the NCDs
• 41:27means,
• 41:28like, our eighty three point
• 41:30two one percent budget goes
• 41:32to
• 41:33the communicable maternal nutrient and
• 41:34nutritionities because
• 41:36they are,
• 41:51then the is one seventy
• 41:53one percent in our agencies.
• 41:54Right? So the critical challenge
• 41:56here is that how to,
• 41:58you know, make a more
• 41:59efficient resource allocations
• 42:01and how to convince to
• 42:02the, you know, other sectors
• 42:03like the minister of finance
• 42:05to invest more in the
• 42:06health centers. Because they usually
• 42:07think
• 42:09the health sector has a
• 42:10expenditure.
• 42:11They don't think as a
• 42:12investment.
• 42:13But now we have to
• 42:14convince that based on the
• 42:16disease burden, see, already,
• 42:18there is a communicable matter
• 42:20and neutral,
• 42:21a neutralization
• 42:22disease. We reduce. That is
• 42:24a waste estimate. We need
• 42:25to sustain. So we need
• 42:27constrained
• 42:28budget,
• 42:29but the burden of density
• 42:31is much more. Means we
• 42:32cannot call the budget here,
• 42:34but we need the new
• 42:34budget. So initially, we need
• 42:36to convince to the ministry
• 42:38of highlights. And good news
• 42:38that over the years, we
• 42:39have been successful.
• 42:41So we're gradually scaling up
• 42:42the line. The pen program
• 42:44of WHO, now it's a
• 42:45nationwide country,
• 42:47program from pilot district to
• 42:48the whole this country.
• 42:50And similarly, mental health program
• 42:51are also scaling up, means
• 42:52we need more resources.
• 42:56So now let me come
• 42:57to the response, policy studies
• 42:59and intervention part.
• 43:04There are the central,
• 43:06you know, policy document plan,
• 43:08etcetera,
• 43:09to address the increasing burden
• 43:11of NCD in Nepal.
• 43:13I will just hire some
• 43:14few of them because of
• 43:15the time.
• 43:16First,
• 43:17this is also,
• 43:18you know, included in the
• 43:20STG,
• 43:21you know, agenda for twenty
• 43:23thirty.
• 43:24So there are certain indicators
• 43:25related to the NCDs, and
• 43:27there is a commitment of
• 43:28the nation. And accordingly, we
• 43:29have the multicentre NCD action
• 43:31plan. There are also target.
• 43:32But the sad news is
• 43:34that instead of, you know,
• 43:36reducing,
• 43:37all are increasing.
• 43:39So that's a big challenge.
• 43:42I'll not go in detail.
• 43:43So, like, if you see
• 43:44the NCDX in part twenty
• 43:45twenty and twenty five, the
• 43:46visa is healthy and productive
• 43:48citizen,
• 43:50citizen fee,
• 43:52three of, half prevent, NCDs.
• 43:55And the goal is reduce
• 43:56the burden of disease due
• 43:57to the NCD through the
• 43:58health in all policy efforts.
• 44:00And there are separate targets,
• 44:02and it the main target
• 44:04is twenty five percent reduction
• 44:05in NCD modality. But, unfortunately,
• 44:08instead of reducing
• 44:09either from the injuries or
• 44:10the NCD, they are increasing.
• 44:12That's a big challenge.
• 44:15And there are the NCD
• 44:16action plan with the four
• 44:17action areas
• 44:18and different study across for
• 44:20implementation. I'll not go in
• 44:21detail here.
• 44:23And, also, we have a
• 44:23national health policy that has
• 44:25also given the responsibility for
• 44:27the prevention and control of
• 44:28NCDs, but in twenty twenty
• 44:29fourteen, national health policy and
• 44:31revised this latest twenty nineteen.
• 44:34And there are also the
• 44:35dietary risk factors, services, and
• 44:37how to increase. Everything is
• 44:38done in the policy. So
• 44:40in term of policy, no
• 44:41any gap, but the gap
• 44:42is in the practice.
• 44:45Also, Nepal health literacy study
• 44:46plan has also the different
• 44:47goals, outcome, and output related
• 44:49to the noncommunicable disease.
• 44:51We have a national program
• 44:53and studies in the mental
• 44:54health. After this data, after
• 44:55this mental health, we have
• 44:56several programs,
• 45:00like the digital mental health
• 45:01program twenty twenty two, ten
• 45:02new mental health national guideline,
• 45:04recording and reporting tools integration
• 45:06in the health management intelligence
• 45:07system,
• 45:08and several, you know, even
• 45:10though we have now,
• 45:12child mental health program and
• 45:13also the, helpline,
• 45:15etcetera.
• 45:17There are also the other
• 45:18program like the suicide prevention
• 45:20and others,
• 45:21and they are integrated in,
• 45:22care delivery. Also, we have
• 45:24a school mental health programs
• 45:26and also mental health service
• 45:28expansion,
• 45:29a media guideline and responsible
• 45:31reporting to suicide. Several activities
• 45:32are there. So in terms
• 45:34of policy and plan.
• 45:35We we have also Nepal
• 45:36road safety action plan to
• 45:38reduce the injuries.
• 45:41And incident intervention are like
• 45:43the, incorporating the basics, health
• 45:45service packages.
• 45:46And, also, we have a
• 45:47paint programs
• 45:48of, like, the district hospitals,
• 45:51and we have also the
• 45:52pain plus by in the
• 45:53referral hospitals.
• 45:56So
• 45:57in practice also, diff different
• 45:59activities are there, not only
• 46:00developing a policy and plan.
• 46:03Right? But still, we need
• 46:04a more effective one. So
• 46:05what we have done means
• 46:06we have evaluated the paint
• 46:07package programs.
• 46:08Now we are working on
• 46:09the paint plus. Right? So
• 46:11based on this evaluation, what
• 46:13we do means we revise
• 46:15our action plan. So the
• 46:16current we are looking to
• 46:17to develop the multi set
• 46:18and selection plan for twenty
• 46:20twenty six to twenty thirty,
• 46:21and I hope that this
• 46:23finding will be utilized.
• 46:25So there are the gap
• 46:26across the research policy practice
• 46:28continuum. For example, of course,
• 46:30research means there are the
• 46:31limited research posting. Second, most
• 46:32of the research that we
• 46:33conduct are cross sectional.
• 46:35Third, they are mostly descriptive,
• 46:37and there are the very
• 46:38few action oriented
• 46:40context specific
• 46:41implementation research.
• 46:43So in terms of policy
• 46:44also, we have, several policy
• 46:46and plans on NCDs,
• 46:48but the major concern is
• 46:50that there are the not
• 46:52allocated
• 46:52enough resources,
• 46:54let's say budget, to implement
• 46:56implement this policy provision into
• 46:57practice.
• 47:01So a frame of hard
• 47:02bridging the risk policy practice,
• 47:04what can be means we
• 47:05can change the relevant dividends,
• 47:07and we can co produce
• 47:09with the policy option means
• 47:10onboarding to policy maker from
• 47:12very start beginning, starting from
• 47:14the richest questions.
• 47:15And we need to test
• 47:16and adapt
• 47:18in the local context.
• 47:20Otherwise, they may not work
• 47:21in the blanket across.
• 47:23And we need to embed
• 47:24into the system through guidelines,
• 47:26financing, and have the information
• 47:27system. And finally,
• 47:30continuous learning is very important.
• 47:32So we need the monitoring
• 47:33feedback and integration mechanics.
• 47:36So from to policy, how
• 47:38we engage with the decision
• 47:39makers? That means,
• 47:41for example, when we develop
• 47:43the this,
• 47:44NCD step survey, we just
• 47:46onboard them. There are the
• 47:47optional models. So based on
• 47:48the country countries, like, we
• 47:49use, like, oral health model
• 47:51and sometime mental health models.
• 47:53And based on the finding,
• 47:54we just presented them. Then
• 47:56we convince to them to
• 47:57make a plan and policies.
• 47:59And now we have a
• 48:00plan and policy, but we
• 48:01need to increase the investment.
• 48:03So for that, we are
• 48:04also sitting with the, you
• 48:05know, provincial government, even local
• 48:07government because we have a
• 48:08three tier sub government. We
• 48:09are convincing that we need
• 48:11to look at more resources.
• 48:13And And still focuses on
• 48:14the treatment side, like
• 48:16giving the money for the
• 48:17treatment of the disease like
• 48:18cancer or the heart disease,
• 48:20etcetera. But what we are
• 48:21saying that we need
• 48:23the public health measures.
• 48:25We need a population health
• 48:26approach, like reducing the salt
• 48:28consumption,
• 48:29smoking consumption reduction. So that
• 48:31that has a huge
• 48:32benefit. Mean, we need to
• 48:33now more economic evaluation also.
• 48:37So there are opportunities.
• 48:39Actually, there are the challenges.
• 48:41Like, we have already policy
• 48:42study, plans, different initiative. We
• 48:45have a local level governance.
• 48:47We have the, like, reporting
• 48:48mechanism of, in the, you
• 48:49know, regular
• 48:51means monthly indicator are also
• 48:53coming in the health management
• 48:54in person systems.
• 48:56There is a integrated care
• 48:57delivery systems, and there are
• 48:58the periodic step survey and
• 49:00other survey. These are the
• 49:01opposite. But the salary are
• 49:03still to change the behavior
• 49:05of the peoples. And if
• 49:06you if you take integration
• 49:07of NCDX plan, especially starting
• 49:09the multicellular
• 49:10engagement.
• 49:11Like, let's say we consider
• 49:13the new decision means there
• 49:14is a there is an,
• 49:15there's a need of the
• 49:16different sectors joint
• 49:18report. But sometime, we may
• 49:20not have a common language,
• 49:22common agenda. Right? Same, like,
• 49:24for the,
• 49:25air pollution and others.
• 49:27And, similarly, balancing that trade
• 49:28off with the, communicable disease,
• 49:30RMNCS
• 49:31conditions,
• 49:32competing priorities, also out of
• 49:34pocket expenses
• 49:35high, especially for the NCDs.
• 49:37And all not all the
• 49:38best buys including the intervention
• 49:40package.
• 49:41Right? So when consideration about
• 49:43the cost effective intervention as
• 49:45for the feasibility and context
• 49:46is important, but we need
• 49:47more research for this. So
• 49:49effective routine monitoring of the
• 49:51intervention cover and then periodic
• 49:52evaluation is very important.
• 49:55Now let me come,
• 49:57when is a gap.
• 49:59Right? We have evidence.
• 50:01We have a policy. We
• 50:02have a plans. We have
• 50:04also practice. And our aim
• 50:05is we have a intervention.
• 50:07There should be the improvement
• 50:08in health means reduction in
• 50:10the, let's say, burden of
• 50:11NCDs in the country.
• 50:15Right? But we don't know
• 50:16what is the problem in
• 50:17these implementations.
• 50:20Means we either say it
• 50:21is a black box.
• 50:23Right? So we need to
• 50:24shed light on this black
• 50:25box means we need more
• 50:27implementation. This has to understand
• 50:29this.
• 50:32So we need the evidence
• 50:33based intervention. So, yes, based
• 50:35on the best price, based
• 50:36on the global recommendation, based
• 50:38on the confidence, we have
• 50:39the policy and plans. But
• 50:40still there is a implementation
• 50:42gap. So we have the
• 50:43NCD account for seventy percent
• 50:44of death in twenty twenty
• 50:45third also as per the
• 50:46global model of disease.
• 50:48Right?
• 50:50So we need
• 50:52the implementation research, which is
• 50:54essential for entry in Nepal
• 50:55for informing policy,
• 50:57support the imminent space advocacy,
• 51:00pace different delivery models,
• 51:02guiding the resource use, like,
• 51:04especially to convince the minister
• 51:05of finance, optimize the interventions,
• 51:08assess the barriers,
• 51:10engage to the different stakeholders
• 51:12from the very beginning, and
• 51:13ensure all the equity. And,
• 51:14actually, I learned all these
• 51:16things
• 51:17from professor Donna and team
• 51:18when I joined as a
• 51:20coinvestigator in the NSBL funded
• 51:22project
• 51:23in twenty seventeen to twenty,
• 51:24I think you are, twenty
• 51:26one, twenty two, five years
• 51:27project. Otherwise, I had yeah.
• 51:29Well, not hard also, you
• 51:30know, the intermediate services. I
• 51:31was just thinking, okay, operational
• 51:33research and the interested is
• 51:34in the same thing.
• 51:35Right? So, what I, I
• 51:37want to say here is
• 51:38that implemented research concern is
• 51:39completely new for Nepal. It
• 51:41is just the last decade
• 51:42we are just discussing. And
• 51:44doctor also is the one,
• 51:45pioneer one, which actually, you
• 51:47know, making the large number
• 51:49of health reports in the
• 51:50country. Right?
• 51:52So what we have done
• 51:53is recently, I'm pleased to
• 51:55share here that we have
• 51:56developed the implementation,
• 51:58business manual.
• 51:59Right?
• 52:01So we'll share very soon
• 52:03with all the community.
• 52:04It is our PDF version
• 52:05is also ready. It's currently
• 52:07in the press, so I
• 52:08I I did not, put
• 52:09fully help. So what how
• 52:11we are doing the capacity
• 52:12building on implementation in Nepal
• 52:13means through the structured training
• 52:15pathways. Now we have even
• 52:16the fellowship program on improvement
• 52:18services.
• 52:19In collaboration with the,
• 52:20public health, faculty university, Nepal
• 52:22health council, we have a
• 52:23fellowship program. We have also
• 52:25short term training from the
• 52:26different academic institution. We go
• 52:28and teach. Right? But the
• 52:29four teaching, we have only
• 52:30four five percent. That's the
• 52:31problem.
• 52:33And we have a system
• 52:34wide sensitization.
• 52:35Right? We are also
• 52:37need to sensitize this to
• 52:38the, you know, in it
• 52:40is committing members. Otherwise, they
• 52:42will reject our proposal. They
• 52:43say it's a program.
• 52:44Why you need to do
• 52:45this?
• 52:46So we're also some
• 52:48providing orientation to our IT
• 52:50committee members. So we have
• 52:51now central IT city board
• 52:52and also sixty five community
• 52:54across the country, so we
• 52:55are working with them. And
• 52:56also the practical support for
• 52:58the local research. So for,
• 52:59like, the local level also,
• 53:00we are promoting some implement
• 53:02services so that they can
• 53:03direct you to the finding.
• 53:04I mean, this should not
• 53:06be only the information supplier,
• 53:07but this should be also
• 53:08a user of the.
• 53:12So implement services in Excel.
• 53:14Some example. For example, we
• 53:15did this,
• 53:17exploring barrier facility of the
• 53:19multi step extent plan in
• 53:20Nepal. And based on that,
• 53:21we use,
• 53:22some timing. And, similarly, there
• 53:24are we have also done
• 53:24the mapping of implementation in
• 53:26Nepal twenty fifteen, twenty two,
• 53:28but very few. But now
• 53:29good news that over the
• 53:30last three, four years, there's
• 53:32quite increasing number especially
• 53:34from MIS funding and also
• 53:35some European one.
• 53:38So the, gap challenge in
• 53:40current and city ports are
• 53:41first like national level challenges,
• 53:43like weak multi sector coordination,
• 53:44weak surveillance and data and
• 53:46policy implementation gap.
• 53:48So in terms of the
• 53:49health,
• 53:50health care system level challenge,
• 53:51limited primary care capacity, workforce
• 53:54status,
• 53:55quality and,
• 53:56readiness gaps, fragmented care and
• 53:59infrastructure and supply chain and
• 54:00financing within the health system.
• 54:02And when you see that
• 54:02the grass root level with
• 54:03the local level means low
• 54:05awareness in the literacy, even
• 54:07many people don't know
• 54:08and cities are still in
• 54:09casings, and we need to
• 54:10dis, look at the resources.
• 54:12And geographic and economic balance
• 54:14also main reasons. And finally,
• 54:16lifestyle and social factors. And
• 54:17some are linked also in
• 54:18the cultural factors,
• 54:20like alcohol consumption and others.
• 54:24So as a way for,
• 54:25we need to stand in
• 54:25the data and evidence. I'll
• 54:27not go in detail. I
• 54:28think we're beyond time.
• 54:30And we need to provide
• 54:31that the cost effective
• 54:33population policy.
• 54:34We need to reorient the
• 54:35primary care to our NCDs.
• 54:37We need the integrations.
• 54:39We need to support frontline
• 54:40implementation capacity.
• 54:41Similarly, we need to enhance
• 54:43the policy research, practice linkages.
• 54:46And finally, we need to
• 54:47reduce the inequalities because what
• 54:49I presented on there is
• 54:49that even for the prevalence
• 54:51of the risk factor, there
• 54:52is big inequalities,
• 54:53like twenty five percent prevalence
• 54:55in one province and just
• 54:56seven percent in another means
• 54:58such inequality we need to
• 54:59reduce.
• 55:02Thank you so much, and
• 55:03I'm very, very grateful to
• 55:04professor Donna
• 55:05for,
• 55:06these invitations
• 55:08and opportunity and also the
• 55:09team here, Lee and others.
• 55:12And thank you all for
• 55:13your time in facets.
• 55:19Thank you.
• 55:22Let's see. Where is it
• 55:23at?
• 55:25So we have three minutes.
• 55:26Yeah. Some students, I think,
• 55:28that could be
• 55:30no. Right away. Yeah. We're
• 55:31twenty minutes late for Oh,
• 55:32no. Class. We don't think
• 55:33we'll think we'll know. College.
• 55:35But she doesn't understand.
• 55:37So I guess our audience
• 55:39here now is getting very
• 55:40limited. Sorry about a discuss
• 55:41of the weather. But did
• 55:43you wanna say anything,
• 55:44Yeah. Well, I would thank
• 55:46you. I I did come
• 55:47in a couple of minutes
• 55:48late, but I I was
• 55:49here for the vast majority
• 55:50of it. But thank you
• 55:51so much.
• 55:52I was just wondering just
• 55:53some questions about,
• 55:55the ability to potentially
• 55:57collaborate on
• 55:58analysis using the population based
• 56:01registry, cancer registry.
• 56:03You also mentioned, you know,
• 56:05the twenty nineteen,
• 56:07the twenty thirteen and twenty
• 56:08nineteen WHO step step surveys.
• 56:10Are those available for you
• 56:12know, to collaborate with if
• 56:14we have some project ideas
• 56:15or if we have, you
• 56:16know, students who wanna do
• 56:17a thesis that we could
• 56:18work together on a potential
• 56:20analysis?
• 56:21Yeah. For the NCD state
• 56:22survey, I think you can
• 56:23get the data from WSO
• 56:25portal as well as you
• 56:26can make a request with
• 56:27us so we can easily
• 56:28collaborate. No problem. Even for
• 56:29twenty thirteen and twenty nineteen
• 56:31data, even earlier we can
• 56:32find.
• 56:33For the population based prevalence
• 56:35of this mental health and
• 56:36all that selected entity also,
• 56:37we can collaborate because we
• 56:39have already published our first
• 56:40paper. So for further analysis,
• 56:42no problem.
• 56:43And regarding population based cancer,
• 56:45we have already published six,
• 56:46seven, but, after especially COVID,
• 56:49you know,
• 56:50the
• 56:52it is very difficult, you
• 56:53know,
• 56:54to enhance the quality of
• 56:55data because it saw the
• 56:57decline, but in the population
• 56:58is increasing. Right? So we
• 56:59are further doing validation. So
• 57:00these are not it's still
• 57:01probably doing and not published.
• 57:03But once they are also
• 57:04published, means for the published
• 57:06result, for the analysis is
• 57:07also possible. So we are
• 57:08very happy to, you know,
• 57:10to enhance for the for
• 57:12the analysis and collabers.
• 57:15Great. Thank you. Yeah. So
• 57:16we have a lively audience
• 57:18here on chat, and I
• 57:19can read a few comments,
• 57:22and maybe you can respond
• 57:23to them. One was,
• 57:25with increasing migration, there's been
• 57:27increasing
• 57:28chronic kidney disease in young
• 57:30migrant workers coming back from
• 57:32heat induced,
• 57:34chronic kidney disease.
• 57:36The suicide rate, it was
• 57:38noted that it was higher
• 57:39among women in Nepal.
• 57:41It was hypothesized
• 57:42that it could be stemming
• 57:43from domestic violence
• 57:46and,
• 57:47sorry,
• 57:48domestic violence in early marriage.
• 57:51There was a question about
• 57:52how mean salt intake was
• 57:54calculated.
• 57:55And,
• 57:58the,
• 57:59somebody
• 58:00has a comment that the
• 58:01biggest challenge to improve
• 58:03on follow-up and treatment for
• 58:05MCDs
• 58:06is, to
• 58:07re
• 58:09in order to reduce mortality
• 58:11and morbidity from MCDs,
• 58:13we need to improve follow-up
• 58:14and treatment rates.
• 58:16And what,
• 58:17this question was more generally,
• 58:18what can countries do to
• 58:19improve that? So that's a
• 58:21lot of different comments, but
• 58:22we've actually run out of
• 58:23time. So maybe you can
• 58:24just choose whatever.
• 58:27Yes.
• 58:27So I say most of
• 58:29them are basic comments rather
• 58:30than questions. I know. Yeah.
• 58:32So, yes. So Nepali, I
• 58:34have the, one of the
• 58:35highest, you know, prevalence of
• 58:37the suicide. And I think
• 58:38we need to study further
• 58:39or whatever the reason, maybe
• 58:40one is the domestic,
• 58:42violence, maybe intimate partner violence
• 58:44and several reasons
• 58:45Regarding the, how did you
• 58:47calculate the salt consumption? Maybe
• 58:49it was the export delivery
• 58:50collection and testing the lab.
• 58:52So we have a standard
• 58:53protocol and we use that
• 58:54and that all
• 58:55is available in our policy
• 58:56code and, also manuscript
• 58:58so that, you know, and
• 59:00final question, yes. The big
• 59:02big challenge is that still
• 59:03the compliance is very low.
• 59:05And let's say fifty percent
• 59:06people are beyond the treatment
• 59:07means
• 59:08we need a mechanisms,
• 59:10right, for the referral or
• 59:12the, you know, accessing the
• 59:13care.
• 59:14And we need some more,
• 59:16I'll say, implementation research to
• 59:17understand the mechanism there because
• 59:19these are all the discrete
• 59:20study. Right? They just saw
• 59:22the figure.
• 59:23But, I don't have a
• 59:25explanatory note because of that.
• 59:27Right? So maybe that could
• 59:28be another area for the
• 59:29future collaboration studies. Thank you.
• 59:33Thank you. Okay. Thanks, everybody.
• 59:35Thank you to the audience,
• 59:36the Zoom audience, and yeah.
• 59:38So we're good now.
• 59:41So did you see that