Political commitment a must for sustainability of hypertension management program: Nepal’s success story

4th June 2019Lisa Woodward

Political commitment a must for sustainability of hypertension management program: Nepal’s success story

The MMM Nepal team had an incredible MMM19 and spoke to us about their MMM Success.

Byline: Shiva Raj Mishra & Nepal MMM Team

“Building on the successes of past May Measurement Month (MMM) programs, this year’s program aims to screen 50,000 individuals at the risk of cardiovascular diseases whilst increasing awareness on hypertension in Nepalese society.

The program is led by the International Society of Hypertension in collaboration with the Ministry of Health and Population of Nepal, Nepal Development Society, medical student associations and a dozen of other organizations in Nepal. In the past few years, it has been able to reached to nearly 25,000 by providing a simple and cost-effective blood pressure screening and lifestyle counselling.

Figure: Volunteers conducting blood pressure among urban residents in Kathmandu.

“Many people in Nepal live far off from health centres and they don’t often come into the contact of health system, unless they need it badly” says Hari Krishna Bhattarai, director of MMM campaign 2019 in Nepal. “Therefore, blood pressure screening has to be community-oriented, to target a larger mass of people who are not captured in routine health system”, he says.

“Our aim is to incorporate MMM into the existing health system. The longer hopes here is to establish it as a national priority program that can be owned by the local health system”, says Dr. Dinesh Neupane who is the MMM country coordinator for Nepal. Highlighting on the low availability of hypertension management services at the local health system which is currently marred by a higher rate of communicable, material, new born and nutrition (CMNN) related problems, he says “political commitment is critical for bringing non communicable diseases like hypertension into the focus in current circumstances”. His arguments are further supported by the recently released report of Global Burden of Disease report which showed that hypertension currently causes an estimated 25,000 deaths every year, which is higher than those caused by CMNN. It is not surprising that these deaths are happening in young ages. A report released last year by Nepal Non communicable disease and poverty commission(NCDI) suggested that non communicable diseases like hypertension is currently responsible for nearly half of deaths in those aged less than 40 years.

Figure: Graph showing the total deaths contributed by non communicable disease risk factors in Nepal based on Global Burden of Disease Data 2017.

‘It is not the time to standstill and wait until big funders will support in non communicable disease management’, Bhattarai claims. His claims are echoed by the recently released report of NCDI commission which revealed that despite contributing to nearly two thirds of deaths, non communicable disease currently receives a disproportionate share of total health spending (i.e. 6.4%). MMM team is trying  to raise fund, “We tried reaching local agencies for support but have not been successful so far. “Non communicable disease is not a funding priority”, Bhattarai further says. “Therefore, the initiatives have to be directed towards tapping local resources, engaging political leaders and key opinion makers of our society. Moral support from these actors worth more than the dollar bills”, he clarifies.

Nepal’s MMM program is getting wide spread acceptance. Nearly 17 of Nepal’s 75 district health offices have already started screening blood pressure locally. Other districts will start in weeks from now. Several hundred volunteers have been mobilized across these districts. Until this report was being prepared, an estimated 18,000 have already been screened.

Nepal’s success in hypertension management is inspiring. As a reporter and writer, I was interested in knowing what made this program so successful. When asked, Dr. Neupane added “we did not believe in the beginning that the program will receive a wide acceptance. He credits the success of the program to  the incredible volunteers the campaign has.

Kathmandu is Nepal’s biggest metropolitan. It has inadequate urban space for physical activity, and the dietary practices of most of residents is based on rice—a staple that is often consumed with a minimal intake of fruits and vegetables. “Healthy dietary habit and lifestyle is key to cardiovascular health”, says Professor Dr. Bhagwan Koirala from Manmohan Cardiothoracic Vascular and Transplant centre, Nepal. ‘Blood pressure screening is a simple way to know one’s heart health’, he further says. Dr. Mrigendra Raj Pandey, a pioneer in the field of preventive cardiology, further suggested awareness on healthy lifestyle and dietary practices, and a targeted blood pressure screening should be conducted among all population groups to tame the burden of hypertension which has increased by triple folds in past thirty years. Social development minister of province-3 honourable Yuvraj Dulal said that MMM campaign is pivotal for beating non communicable disease (NCDs) in Nepal. Currently province-3 has launched the ‘chief minister citizen’s health check-up program’ targeted to screen major NCDs in 5 districts of province-3.

Engaging volunteers for blood pressure screening is crucial for reducing the burden on the health system. Sweta Mahato, the national manager for MMM campaign in Nepal further says, “training of grass root health service providers like Female Community Health Volunteers (FCHVs) for routine blood pressure screening and basic health education on hypertension, can be of value in screening the unreached and leaving no one behind”. This is echoed by the fellow provincial managers of MMM campaign (namely Arun Karki, Bishal Subedi, Chetan Nidhi Wagle, Dr. Sandip Paudel, Dr. Surya Parajuli, Tara Ballav Adhikari, Dr. Vivek Gyawali) who further stressed on importance of training these volunteers on blood pressure management whilst engaging both public and private providers of health services. Further, “student-volunteers can be mobilized alongside FCHVs”, says Dr. Pawan Gyawali, student coordinator of MMM campaign. “Engaging these two [FCHVs’ and students’ network]is currently our key recipe for achieving high coverage of blood pressure screening”, he further says.

Another local activist, Kamal Ranabhat, the former national leader of MMM, has closely witnessed Kathmandu’s changing food culture. Many of his colleagues are suffering from hypertension. He blames this on unhealthy lifestyle and food habits. He further added that not just the lay people, even the political elites have fallen prey to hypertension and other non-communicable diseases. “Now, non-communicable disease is everyone’s problem: poor, rich, commoners, and elites. Now we should unite to build a strong force to tackle this problem”, he further says.

Recently in May 6, he and his team invited the federal speaker of house of Representatives, right honorable Krishna Bahadur Mahara, for participation in the program. Honourable speaker Mahara was screened for blood pressure at his residence in Kathmandu. Subsequently, Honourable speaker happily accepted the offer to conduct further screening among House of Representatives. This will add another milestone in Nepal’s hypertension screening program, further building a synergy between the researchers, activists, policy-makers and leaders.

Figure: Volunteers conducting blood pressure at House of Representatives’ residence in Kathmandu

Figure: Honourable deputy prime minister and health minister of Nepal, Uprendra Yadav is seen taking blood pressure measurement at the House of Representatives in Kathmandu.

Figure: Volunteers conducting blood pressure at the house of representatives in Nepal

While political commitment for hypertension management is growing, Nepal is still juggling to stabilize its budding economy which was hit hard in last ten years by the civil war and the protracted political crisis that went on for more than nine years. However, Dr. Neupane has hopes for country’s future hypertension management program and firmly believes that programs like MMM can potentially reach millions of population who are at the risk of cardiovascular diseases. “Removing delays in blood pressure screening, is crucial for reducing future cardiovascular deaths”, Dr Neupane says. He further added, “screening is the first step in the management of hypertension. We need to expand the treatment services up to community level in order to achieve high control rate.”

Finally, the Nepal MMM team would like to recognize the valuable contribution of our fellow national and provincial-managers of MMM campaign, volunteers, well-wishers and supporters, without whom the implementing this campaign was impossible. Also would like to thank Dr. Guna Raj Lohani, Director General of Department of Health Services, Ministry of Health and Population, Nepal for support in planning and implementation of the campaign.”