Table 2 Health System building blocks on CVD prevention and care in Nepal

Governance

Nepal underwent a major political change in 2015 resulting in a restructuring of health-care systems with local empowerment. However, health care responses across the country vary substantially. The historical centralized governance of health potentially still survives in many parts of the country, whereas in some parts of the country, health care is governed by local governments. Private sector is the major provider of cardiovascular health-care. Nearly all private facilities offer CVD services compared to only 71% of public facilities [67], data specifically for CVD care were not available due to lack of CVD reporting in routine HMIS. Non-governmental organizations (NGOs) are a big part of the healthcare system, but have not yet played a major role in CVD care, except for Rheumatic Heart Disease.

Financing

The Government of Nepal spending on health care accounted for only 26.7% of the total health expenditure (THE) in FY 2015/16 [18]. The total spending on CVD was USD 2.8 million (2% of current health expenditure, 0.19% of THE) in the year 2015/16.

Service Delivery

National Health Policy 2017 ensures access to Universal Health Coverage to every citizen through a network of 836 hospitals including 2 public Cardiac specialized hospitals, 278 primary health centers, and 3840 Health posts [22]. National clinical guidelines on CVDs are not available [68]. Two major public cardiovascular disease hospitals (Sahid Gangalal National Heart Centre, and Manmohan Cardiothoracic Vascular and Transplant Center) are situated in the capital city. MoHP initiated PEN in February 2017 which covers screening, diagnosing, treating and referring services for CVD risk and hypertension at health posts, primary healthcare centers of 30 districts (out of 77 districts) of Nepal [69].

Human Resources

The ratio of doctors and nurses per 10,000 population is 8.9 and 20.8, respectively [20]. In 2019, 176 doctors were registered as cardiologist (154) or cardiothoracic surgeon (22) in Nepal (0.006 cardiologist/1000 population) [70].

Medical Products

The DDA regulates all functions relating to controlling the production, marketing, distribution, sale, export, import, storage and use of drugs [71]. There are 359 drugs listed on the National Essential Medicine List 2016. The government provides 70 of them for free as National Free Essential Medicines, which includes 9 CVDs drugs (Aspirin, Adrenaline, Atenolol, Amlodipine, Digoxin, Enalapril, Furosemide, Atorvastatin and Atropine) [72].

Information System

The Health Management Information System (HMIS) collects all health-related information from public and private health care. Only nine health conditions (Acute Rheumatic Fever, Bronchial Asthma, COPD, Cardiac failure, Heart failure, Hypertension, Ischemic heart disease, Rheumatic heart disease and other cardiac related conditions) are grouped under the cardiovascular and respiratory related problems. The national HMIS does not systematically collect and analyze CVD risk factors and CVD conditions and is not presented as a separate chapter in the annual health report [73].