Tobacco consumption is one of the major public health problems in the world. Annually, 27 100 premature deaths are attributed to tobacco-related diseases in Nepal. Despite enacting different policies and strategies, the prevalence of tobacco consumption is still high. This study aims to synthesize prevalence, factors associated with its consumption and the policy initiatives for prevention and control in Nepal. This review includes peer-reviewed studies retrieved from two databases (PubMed and EMBASE) and published from 2000 to 2018, and policy initiatives on tobacco prevention and regulations in Nepal. A total of 32 studies and 5 policy documents were reviewed. Findings suggest that tobacco consumption was higher among men, illiterates, older people, people living in rural and mountainous areas and those who initiated smoking as adolescents. Peer pressure and parental/family smoking were major contributing factors for tobacco initiation. Policy analysis showed that low excise tax, weak monitoring mechanisms, poor compliance to bans on the advertisement and promotion of tobacco, smoke-free zones and insufficient programs on tobacco cessation were the major factors behind weak implementation of tobacco-control policies. Hence, targeted and high-risk group tobacco-cessation interventions, increasing taxation and strict policy implementation are crucial for effective tobacco prevention and control in Nepal.

Background Chhaupadi is a deeply rooted tradition and a centuries-old harmful religio-cultural practice. Chhaupadi is common in some parts of Karnali and Sudurpaschim Provinces of western Nepal, where women and girls are considered impure, unclean, and untouchable in the menstrual period or immediately following childbirth. In Chhaupadi practice, women and girls are isolated from a range of daily household chores, social events and forbidden from touching other people and objects. Chhaupadi tradition banishes women and girls into menstruation huts’, or Chhau huts or livestock sheds to live and sleep. These practices are guided by existing harmful beliefs and practices in western Nepal, resulting in poor menstrual hygiene and poor physical and mental health outcomes. This study examined the magnitude of Chhaupadi practice and reviewed the existing policies for Chhaupadi eradication in Nepal. Methods We used both quantitative survey and qualitative content analysis of the available policies. First, a quantitative cross-sectional survey assessed the prevalence of Chhaupadi among 221 adolescent girls in Mangalsen Municipality of Achham district. Second, the contents of prevailing policies on Chhaupadi eradication were analysed qualitatively using the policy cube framework. Results The current survey revealed that most adolescent girls (84%) practised Chhaupadi in their most recent menstruation. The Chhaupadi practice was high if the girls were aged 15–17 years, born to an illiterate mother, and belonged to a nuclear family. Out of the girls practising Chhaupadi, most (86%) reported social and household activities restrictions. The policy content analysis of identified higher-level policy documents (constitution, acts, and regulations) have provisioned financial resources, ensured independent monitoring mechanisms, and had judiciary remedial measures. However, middle (policies and plans) and lower-level (directives) documents lacked adequate budgetary commitment and independent monitoring mechanisms. Conclusion Chhaupadi remains prevalent in western Nepal and has several impacts to the health of adolescent girls. Existing policy mechanisms lack multilevel (individual, family, community, subnational and national) interventions, including financial and monitoring systems for Chhaupadi eradication. Eradicating Chhaupadi practice requires a robust multilevel implementation mechanism at the national and sub-national levels, including adequate financing and accountable systems up to the community level.

Background Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP. Methods We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums). Results Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation. Conclusions Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.

SummaryVarious factors limit access to and utilization of health services even when provided at subsidized cost. This results in poor utilization of services that contributes to further economic impoverishment and health care disparity. Many countries are experimenting with various approaches to tackle the poor utilization of health care services including demand‐side financing policy. This paper explains the policymaking process during the formulation of safe delivery incentive program, a conditional cash transfer program in Nepal using Kindgon's multiple streams framework. Analysis of earlier policies and programs around safe motherhood concludes that high transportation cost was a major cause for poor utilization of institutional obstetric care, despite being provided at free of cost. Health was recognized as fundamental constitutional right in 2007. This assured societal support and political commitments for protecting health constitutionally. Furthermore, there was commitment from external development partners (EDPs) for investment in maternal health. Together, these problem, policy, and politics opened Kingdon's “windows of opportunity” for formulation of conditional cash transfer policy. This paper presents evolution of Aama Surakshya Karyakram and uses Kingdon's multiple streams framework to explain how problem, policy, and politics streams converged together to allow this program to be introduced in Nepal.

The agenda of social protection has become very popular in recent years. Several social protection programs in healthcare are designed to increase the healthcare coverage, ensure financial protection and enhance the scope and quality of services and access to medicines which ultimately paves the way for universal health coverage. The national health insurance programme (NHIP) is one of the approaches implemented in Nepal to cover healthcare expenditure. This paper discusses the gradual development of the health insurance programme in Nepal and the key features of NHIP that have been implemented since 2016. It further highlights the implementation status of NHIP, the milestones it covered, and the role of political parties in implementing NHIP in Nepal. Furthermore, the paper discusses the challenges associated with enrollment of formal and non-formal sectors, the mismatch between geographical coverage and the number of service contact points, and commitment from the political parties for effective implementation of NHIP. It seeks major implementation reforms to ensure effective implementation of NHIP.