Nepal's NCD and mental health load: what STEPS 2019 and the national mental health survey mean for local programmes

In 2023 I served as focal officer for the NCD and Mental Health Section at the Epidemiology and Disease Control Division, liaising with WHO Nepal and other partners. The consistent experience was this: Nepal's national evidence on non-communicable disease and mental health is far better than its local use of that evidence. Surveys are cited in workshops and then not reflected in the municipal annual plan that decides what actually gets delivered.

1. What the STEPS survey 2019 gives you

The Nepal STEPS Survey 2019, conducted by the Nepal Health Research Council with MoHP and WHO and fielded between February and May 2019, is the country's fourth national application of the WHO STEPwise approach to NCD risk-factor surveillance. It measures behavioural risk factors (tobacco, alcohol, diet, physical inactivity) alongside physical and biochemical measurements (blood pressure, body-mass index, blood glucose and lipids). A widely-cited PLOS One analysis of the same survey, published in 2021, is the standard peer-reviewed reference for prevalence and determinants of NCD risk factors in Nepal.

Because STEPS is nationally representative rather than municipality-representative, its correct use at local level is as a prior, not as a local estimate. It tells a health chief what proportion of adults are likely to have raised blood pressure or use tobacco, which lets a municipality forecast screening yield and plan drug quantification before it has any local data at all.

2. Mental health: from invisible to measured

The National Mental Health Survey 2019-2020, published in the Journal of Nepal Health Research Council in 2022, produced Nepal's first nationwide and provincial prevalence estimates for common mental disorders and suicidality. The WHO Special Initiative for Mental Health situational assessment for Nepal, published in 2022, then mapped the service side: workforce, facility availability, and the gap between prevalence and treatment capacity. In 2025 the Epidemiology and Disease Control Division published an investment case for the prevention and management of mental health conditions in Nepal — the most useful single document if you need to argue for mental health money rather than describe mental health need.

• Prevalence data exist at provincial level, so a provincial health directorate has no methodological excuse for planning mental health services without an estimate of need.
• The treatment gap is a workforce and integration problem more than a diagnosis problem — which is why mhGAP-style task-sharing at primary care is the operative strategy.
• Suicidality data change the priority ordering: means restriction and crisis pathways belong in the plan, not only counselling capacity.
• An investment case converts prevalence into avoidable economic loss, which is the language a municipal or provincial budget discussion responds to.

3. Tobacco and alcohol: the policy levers, honestly assessed

Nepal has strong tobacco legislation on paper — graphic health warnings covering a large share of the pack, advertising restrictions and public-place bans. The WHO Report on the Global Tobacco Epidemic 2023 country profile for Nepal documents the weak points: affordability of cigarettes and enforcement consistency. WHO's 2019 STEPS tobacco fact sheet for Nepal summarises the use patterns behind that policy picture, including the significant share of smokeless tobacco use that pure cigarette-focused policy misses.

For a municipality, the realistic levers are enforcement of smoke-free public places, licensing conditions for vendors near schools, and brief-advice cessation integrated into every outpatient contact. Excise policy is federal, but demand-side enforcement is local — and it is the part most often left out of annual plans because it produces no visible event to photograph.

4. Designing a municipal NCD programme that can actually run

1. 01Define one screening pathway and stick to it: blood pressure and blood glucose for adults over 40 at every facility contact, with a written referral rule for elevated values.
2. 02Quantify medicines against expected yield before the fiscal year, using national prevalence as the planning prior — stock-outs destroy treatment continuity faster than any other single failure.
3. 03Register and follow up: an NCD programme's real indicator is the proportion of diagnosed patients still on treatment at six months, not the number screened.
4. 04Integrate mental health through task-sharing: train the same primary-care staff who run NCD clinics, and define a referral route for severe presentations before you start case-finding.
5. 05Add one enforcement action per year on tobacco or alcohol, with documented compliance checks rather than awareness events.
6. 06Report a one-page NCD scorecard to the municipal assembly quarterly, so the programme survives changes in political leadership.

The measure of an NCD programme is not how many people it screened. It is how many people it kept on treatment.

5. Where the research gaps are

• Implementation determinants for the WHO PEN package in Nepali primary care: what makes it stick in one health post and lapse in the next, framed with CFIR-type determinant analysis.
• Treatment-continuity cohorts: prospective follow-up of hypertension and diabetes patients registered at municipal facilities, with loss-to-follow-up as the primary outcome.
• Adolescent risk-factor prevention delivered through schools, with measured behavioural outcomes rather than knowledge scores.
• Integration cost studies: what it actually costs a municipality to add mental health task-sharing to an existing NCD clinic.