Table 3 Health system gaps to deliver CVD prevention and management service

Equity

● More than 50% of the total health expenses are covered out-of-pocket, indicating a huge financial burden to the general population.

●The government budget for NCD including CVD is only 0.2% of the total government budget in health even though CVD is the topmost cause of death and disability in Nepal [6].

● Significant HRH gaps across all health cadres, and with nurses in particular. Doctor and nurse distribution is skewed toward private sector and urban centers.

● CVD services such as surgery and INR are available in the central tertiary hospitals.

Access

● Only 10% of the population is covered by national health insurance.

● Only 30 (out of 77) districts have PEN program that provide primary CVD care services.

● Specialty CVD care services are concentrated in urban areas

● One-fourth of the households in the mountains and 17% in hills are 60 min or more away from the nearest health facility.

Efficiency

● Shortage of human resources for CVD care.

● Procurements have lengthy administrative processes.

Quality (including safety)

● No national guidelines on clinical management of CVD

● Inadequate infrastructure and equipment for CVD care

● Medical products quality is not well monitored despite having policies and guidelines in place because implementation challenges such as limited training on guidelines, lack of supervision and monitoring, and resources constraints.

Sustainability

● Although there is policy to provide grants based on the performance, the policy is not functioning well.

● External resources covered 11% of the health spending.

● Health insurance premium collection is not sufficient as only 10% of the population are insured.