KATHMANDU: From cities to villages, hospitals’ Outpatient Departments (OPDs) are increasingly crowded with patients suffering from non-communicable diseases (NCDs) such as diabetes, high blood pressure, heart disease, and cancer. These are slow-developing illnesses that rarely leave once they appear, often persisting until they claim lives.

But how is the government responding to this growing crisis? On one hand, the burden of disease is rising daily; on the other, investment in this vital sector is steadily declining. Caught in this contradiction, Nepal’s health policy appears adrift and lacking clear direction.

The number of NCDs has been increasing in Nepal recently. It is necessary to identify the reasons for the increase in disease and then create a budget and work plan accordingly. However, a uniform budget and work plan are being formulated across the country.

One often encounters many faces in the hospital who are struggling with heart problems, shortness of breath, hidden eye pain, and anxiety due to a lack of medication. However, the budget allocated for them is minimal. Before the physical body deteriorates, the government’s health policy is deteriorating.

The government is neglecting to consider what kind of programs should be run for the prevention and control of NCDs as they rise. Plans are not being formulated based on the identification of necessity and evidence.

Many developed nations worldwide have achieved positive results by investing heavily in the health sector. Countries like Canada and the United Kingdom have implemented universal healthcare systems, where citizens receive free healthcare services as needed. This has improved the standard of living for the citizens there and has also positively contributed to the country’s economic development.

Our neighboring country, Bhutan, has allocated a large portion of its national budget to healthcare services. Bhutan’s health policy is centered on health equality. A special fund is allocated for remote areas. The government provides services to citizens even in the most inaccessible parts of the country. Bhutan provides most healthcare services to its citizens free of cost and offers significant subsidies for services that incur some expenses.

In Nepal, a significant portion of the budget is spent on non-productive sectors, says public health expert Dr. Mahesh Maskey. He emphasizes that funds earmarked for structural development should not be treated as recurrent expenditure.

Currently, hospitals are being rapidly constructed at the local level. He suggests that attention must be paid to budget allocation because a complaint is emerging that ordinary citizens are not receiving quality services when the budget allocated for the health sector is spent only on infrastructure development.

Underfunded health sector

Former Health Minister Pradip Paudel has been stating in public programs that quality healthcare services could not be made accessible due to low budget allocation in health. Even when looking at the data from the past five years, the health budget does not show a significant increase. The World Health Organization (WHO) has been suggesting that developing countries like ours should allocate 10 percent of the budget to health.

According to the Ministry of Health data, during the two years of the COVID period, 6.15 percent and 7.35 percent, respectively, were allocated from the total budget. In the subsequent years, however, the health budget has not exceeded 4 to 5 percent.

In the current fiscal year 2025/26, Rs 95.81 billion was allocated. This time, the health sector was estimated to receive an Rs 100 billion budget. However, the budget was reduced. This amounts to only 4.77 percent of the total budget.

In the fiscal year 2024/25, only Rs 86.24 billion was allocated. This is only 4.63 percent of the total budget. Similarly, in the fiscal year 2023/24, the health budget allocated was Rs 83.99 billion, which is only 4.69 percent of the total budget.

Comparing the budgets of the last eight years, before the start of COVID-19 in 2019/20, it was Rs 68.78 billion. This was only 4.59 percent of the total budget. When COVID began, the health budget reached Rs 90.69 billion in 2020/21. This was a 6.15 percent increase compared to the previous year’s total budget. During the COVID pandemic itself, the government allocated Rs 122.77 billion once in 2021/22. This is the highest budget till now, which is 7.35 percent of the total budget.

These two years’ budgets were more focused on the control of infectious diseases. That’s why more budget was allocated, informs Dr. Prakash Budhathoki, spokesperson for the Ministry of Health and Population.

According to him, in the year following the pandemic (2022/23), the health budget saw a sharp decline and was limited to Rs 65.38 billion. This is only 3.86 percent of the total budget. In the fiscal year 2018/19, the health budget was only Rs 56.41 billion. This is only 4.52 percent of the total budget. Looking at the data, the health sector’s share was highest at 7.35 percent in the fiscal year 2021/22 and lowest at just 3.86 percent in 2022/23.

Ministry spokesperson Dr. Prakash Budhathoki states that they have been advocating to raise the health budget to 10 percent. He mentions that it is becoming difficult to provide quality healthcare services to all citizens because the budget has not increased. He says, “We have not stopped essential services.”

The rising burden of non-communicable diseases in Nepal

According to the Nepal Burden of Disease 2021 data, Nepal experiences an annual death toll of 193,331 people. The top three causes are heart disease, respiratory diseases, and cancer. Based on the data, we have analyzed the main diseases and infections causing deaths among local citizens.

The primary cause of death for most Nepali is heart and blood vessel-related diseases. These diseases cause the demise of 46,399 Nepalis annually. Following this, chronic respiratory diseases claim many lives. These diseases cause the death of 40,793 Nepalis annually.

Similarly, tumors and cancer cause the death of 21,653 Nepalis annually. Infections of the windpipe and tuberculosis claim 16,239 lives, diseases of the digestive system claim 11,406 people, and problems related to maternal and child health claim 10,053 lives.

Besides this, diabetes and kidney diseases caused 8,503 deaths, unforeseen accidents and injuries claimed 8,118 lives, intestinal infections claimed 6,959 lives, and mental health problems claimed 4,446 lives.

The main factor influencing the death of Nepalis is smoking. Smoking influences 18 percent of deaths, high blood pressure 12 percent, external air pollution 9 percent, and high blood sugar levels influence 8 percent of deaths.

For the provision of quality healthcare services in Nepal and according to the World Health Organization (WHO) standards, 10 percent of the total budget should be allocated only for health. However, during the two years of the COVID period, 6.15 percent and 7.35 percent, respectively, were allocated from the total budget. In the subsequent years, the budget has not even reached 5 percent. This budget is 50 percent less than the WHO standard.

While the impact of NCDs is increasing worldwide, it has also deeply affected Nepal. According to a 2019 report on NCDs based on population, 2.84 percent of coronary artery disease, 8.5 percent of diabetes, 6 percent of chronic kidney disease, and 11.6 percent of chronic obstructive pulmonary disease (COPD) have been observed.

Chronic kidney disease is primarily increasing in Nepal. Hospital-based national records show that cancer of the windpipe and lungs is the highest among both women and men. Similarly, breast and cervical cancer are prevalent in women, and stomach and throat cancer are prominent in men. Cervical cancer is higher in rural areas and breast cancer in urban areas. 26,143 new patients are diagnosed with cancer every year.

According to the Nepal NCD Poverty Commission’s report, the poorest communities are more affected by conditions like blocked blood supply to the brain, heart disease, chronic lung disease, bleeding blood vessels, stroke, and kidney disease. A survey conducted in 2019 by the STEPS Survey reveals that the main risk factors for the increase in NCDs in Nepal are smoking tobacco products, physical inactivity or lack of physical activity, substance abuse, unhealthy diet, and other lifestyle-related behaviors. These factors also play a role in increasing high blood pressure, sugar, cholesterol, obesity, and weight.

This is confirmed by the financial assistance provided by the Nursing and Social Security Branch of the Department of Health Services for NCDs over the past five years, from the fiscal year 2020/21 to 2024/25, in the name of destitution, to 206,712 people. The number of applicants for this service was 29,548 in the fiscal year 2020/21. The number of patients increased to 36,562 in the fiscal year 2021/22. The number of patients is 35,246 in the fiscal year 2022/23.

The number increased to 41,458 in the fiscal year 2023/24, which is 6,561 more compared to the previous year. The number further increased to 53,577 in the fiscal year 2024/25, which is 11,632 more. In the past year alone, 10,000 more people have availed of this facility. This data indicates that NCDs are increasing every year.

Similarly, in the fiscal year 2020/21, the total expenditure for providing financial assistance to NCD patients was Rs 2.14 billion.

In the fiscal year 2021/22, this amount increased to Rs 2.90 billion. In the fiscal year 2022/23, Rs 3.31 billion was spent on treatment.

In the fiscal year 2023/24, individuals suffering from NCDs received some Rs 4 billion. Similarly, in the fiscal year 2024/25, Rs 4.42 billion was spent on treatment.

To start the program for increasing NCDs nationwide, Rs 95.81 billion was allocated in the 2025/26 budget. This time, the health sector was estimated to receive an Rs 100 billion budget. This is only 4.77 percent of the total budget. Phanindra Baral, head of the Non-Communicable Disease and Mental Health Section under the Epidemiology and Disease Control Division, stated that a plan has been made to run various prevention programs to reduce the burden of NCDs. He says, “Without effective prevention programs due to the low budget, it is impossible to reduce the burden of these diseases.”

There is also a necessity to run a mental health program from the NCD budget. However, on December 2, 2024, the Supreme Court ordered that mental health and NCD programs should be run separately. That order is limited to paper.

Death rate increasing year by year

Data shows that the burden of NCDs has rapidly increased recently. According to the Nepal Burden of Disease 2017, at least 66 percent of the total deaths in the country were caused by NCDs. This figure increased to 71.1 percent in 2019.

According to the Global Burden of Disease 2021, this ratio has increased to 73 percent. It is anticipated to increase even further. According to Dr. Ramesh Raj Regmi, a cardiologist, the burden of NCDs is in a state of acceleration. “The government has not been able to adequately invest in the prevention and control of NCDs,” he says.

He suggests that the budget allocated to the health sector is mostly spent on infrastructure development, and the tendency not to pay attention to the quality of healthcare services must be abandoned.

According to Dr. Maskey, the budget allocated for structural development should not be considered a regular budget. Currently, hospitals are being rapidly constructed at the local level. His opinion is that attention must be paid to budget allocation because a complaint is emerging that ordinary citizens are not receiving quality services when the budget allocated for the health sector is spent only on infrastructure development.

“The budget is spent only on the construction of health structures,” he says. “We should also prioritize providing services with health technology and skilled manpower in the existing infrastructure.”

He suggests that the budget for the health sector should not be spent only on infrastructure development but should be spent on health supplies, human resources, capacity building, and management to ensure accessibility for ordinary citizens. He argues that the government must compulsorily increase the size of the health budget.

Since the absence of health infrastructure and human resources is the main problem in Nepal, even with the construction of health service buildings, he opines that it is necessary for the government to increase the budget for regular health services as well.

“To make basic health services accessible and provide quality services, the size of the health budget must now be increased. The health budget should reach at least 10 percent,” he says.

Investing in the health sector in the long term leads to increased productivity, reduced poverty, and sustained economic stability. Therefore, the Government of Nepal needs to prioritize the health budget even more, which will help ensure long-term economic and social benefits. Since a strong health system is the only thing that can make any nation prosperous, Nepal needs to understand health expenditure not as an expense but as an investment.

Call for long-term measures

The ‘National Health Financing Strategy 2023-33,’ brought forth by the Government of Nepal itself, also emphasizes that the health budget should be 10 percent. The strategy mentions emphasizing an arrangement where at least 10 percent of the budget from the federal, provincial, and local levels is invested in health. Even after two years since the strategy was passed, the government has not taken steps to increase the budget.

It is necessary to change the perspective of viewing the health budget merely as an expense. Investment in the health sector is a long-term investment for nation-building. Healthy citizens are the main foundation for the country’s economic and social development.

Although the constitution has established health as a fundamental right of the citizen, the reality is different. The health sector’s budget is allocated low, and even that is not spent effectively. The reason behind the inability to spend the allocated budget is the traditional method of budgeting and the creation of programs based on it. This makes it very problematic to achieve the goal of universal health coverage and quality healthcare services.

Health budget formulation is not based on the identification of necessity and evidence-based planning. The necessity for human resources, equipment, infrastructure, and services is not scientifically analyzed. The work of health sector budget formulation should be based on evidence and need.

Public health expert Dr. Mahesh Maskey says that in the current situation, more attention should be given to the minimization of NCDs. Many diseases can be prevented if the screening of diseases, including diabetes, high blood pressure, and cholesterol, is made free of cost.

Furthermore, investment must be made in campaigns to improve diet and physical activity. If sufficient investment is not made in prevention, the death rate due to NCDs in Nepal will increase even more in the coming decades.

Studies have shown that the use of alcohol, tobacco, salt, and junk food is increasing in Nepal, and the consumption of fruits and vegetables is inadequate. These habits increase the risk of heart disease, diabetes, heart attack, and cancer. The government has allocated a budget for a financial relief program for diseases like heart disease, cancer, respiratory diseases, Alzheimer’s, head or spinal cord injury, sickle cell anemia, and stroke, which cause a financial burden. According to Dr. Prakash Raj Regmi, a cardiologist, while financial relief helps fulfill immediate needs, it does not reduce the burden of the disease. This is because it is a treatment-centric program, not a prevention-centric one.

The government has arranged for treatment services worth up to Rs 200,000 through insurance for eight types of severe diseases (cancer, heart, kidney, head injury, spinal injury, sickle cell anemia, Parkinson’s disease, and Alzheimer’s).

According to the World Health Organization, there is a lack of detailed research, especially on heart disease, cancer, respiratory diseases, and diabetes in South Asian countries. The contributions of various risk factors associated with the increasing burden of NCDs have not been adequately studied.

Therefore, it is necessary to identify these risk factors and evaluate their impact to effectively address the challenge in South Asia.

The World Bank has classified Nepal as a lower-middle-income country. In 2022, Nepal’s Gross National Income (GNI) per capita was USD 1,350. In 2021, Nepal’s Human Development Index (HDI) was 0.602. This is the third worst rate in South Asia after Afghanistan and Pakistan. Nepal’s per capita health expenditure is only USD 58.3. This is very low compared to the South Asian average of USD 179. In 2021, the USPI score was at position 54.

Health is the foundation of social and economic development for any nation. Nonetheless, the expenditure made in the health sector is often viewed as a financial burden, whereas it is a strategic investment. This investment promotes productivity, reduces poverty, and fosters long-term economic growth.

Initial investment in the health sector reduces costs in the long run. Preventive services, screening campaigns, and primary healthcare services reduce the risk of complex diseases and treatment costs in the long term. The universal healthcare system in Japan, which focuses on prevention and early treatment, has ensured high average life expectancy and has successfully kept overall health costs low compared to other developed nations.