Understanding the formulation of non-communicable disease policies in Nepal: a qualitative study

Few policies have focused specifically on the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. Health policy formulation plays a vital role in the allocation of resources to implement effective interventions and reforms; hence, a nuanced understanding of the health policy formulation process is essential. However, there is limited evidence about the process through which NCD policies were formulated in Nepal. This study used Kingdon's multiple streams framework to explore how NCDs were recognized and prioritized, how policy alternatives were decided, how policy windows were opened, and which contextual factors influenced the policy formulation process. A qualitative case study approach was applied to gain a comprehensive understanding of the formulation of major NCD-related policies in Nepal. Semi-structured interviews were conducted with 12 key stakeholders and policy documents were analyzed using framework analysis. The NCDs were gradually recognized and prioritized through the convergence of global and local evidence, sustained advocacy, and international commitments. Policymakers encountered several challenges, such as competing health priorities, the chronic nature of NCDs, donor preferences for communicable diseases, financial constraints, and multisectoral complexities of NCDs. The Package of Essential Non-communicable diseases interventions were adopted as a policy alternative, informed by global evidence, World Health Organization recommendations, and lessons from other countries. While coordinated efforts by stakeholders brought the problem, policy, and politics streams together, the role of policy entrepreneurs was found to be less relevant in Nepal's context. The findings highlight the need to consider external influences while conducting similar studies in low- and middle-income countries. Further research is needed on strategies to address persistent structural and financial challenges in NCD policy formulation.