Nepal’s Health Policy Journey (1990–2025): A Comprehensive Review

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Introduction

Nepal’s health sector has undergone remarkable transformations since 1990. In the early 1990s, health services were heavily centralized and struggled to reach the rural majority. Maternal and child mortality were alarmingly high – one in seven children died before age five in 1990 and life expectancy was only about 54 years (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies). Over the next three decades, Nepal implemented a series of national health policies and reforms that expanded primary health care, targeted key public health challenges, and progressively enshrined health as a citizen’s right. As a result, health outcomes improved dramatically – for example, the maternal mortality ratio fell from around 850 per 100,000 live births in 1990 to under 200 by the late 2010s (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies) (Health in Nepal – Wikipedia), and formerly rampant infectious diseases were brought under control. Yet new challenges have emerged, including a growing burden of non-communicable diseases (NCDs) and the complexities of restructuring the health system under federalism.

This comprehensive review looks at Nepal’s national-level health policies from 1990 to 2025, across major domains: maternal and child health, infectious disease control, NCDs, health systems strengthening, and universal health coverage (UHC). It presents a timeline of key policies and reforms, and analyzes each policy’s intent, impact, successes, gaps, and implementation challenges. The aim is to provide health policy experts and professionals an engaging overview of how Nepal’s health system evolved and what lessons can be drawn from three and a half decades of reform.

Timeline of Major National Health Policies (1990–2025)

1991 – National Health Policy (NHP) 1991: The first comprehensive health policy of democratic Nepal focused on extending primary health care to rural populations. It called for establishing a health post or primary health center in every village development committee (~4,000 at the time) ( Health System Development in Nepal – PMC ). NHP 1991 prioritized preventive, promotive, and curative services, including Safe Motherhood as a national priority (setting a target to reduce the maternal mortality rate from ~850 to 400 per 100,000 by 2000) (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies). It also opened the door to private sector involvement in health care, allowing private hospitals and medical colleges to operate ( Health System Development in Nepal – PMC ).
1997 – Second Long-Term Health Plan (1997–2017): A 20-year strategic roadmap that set ambitious health goals (e.g. reducing infant and maternal mortality, increasing life expectancy) and guided sectoral investments. The plan emphasized essential health care services (EHCS) – a basic package of priority services – and laid the foundation for subsequent health sector programs and donor coordination.
1998 – National Safe Motherhood Policy: Building on NHP 1991, Nepal launched a dedicated Safe Motherhood Policy to address its high maternal mortality. This policy and its action plan (1998–2004) focused on expanding access to antenatal care, skilled birth attendance, and emergency obstetric care, and on community interventions for birth preparedness. It formally prioritized safe motherhood services at all levels of the health system and helped catalyze donor support for maternal health (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies) (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies).
2002 – Legalization of Abortion (Safe Abortion Policy): A major policy reform in reproductive health – Nepal legalised abortion in 2002, permitting abortion on request up to 12 weeks and under specific conditions thereafter (Abortion and Unintended Pregnancy in Nepal | Guttmacher Institute). The National Safe Abortion Policy 2003 integrated safe abortion services into public health care. This reform aimed to reduce the large share of maternal deaths due to unsafe abortion (estimated ~50% of maternal deaths in hospitals in the 1990s) and has contributed to a sharp decline in maternal mortality (Abortion and Unintended Pregnancy in Nepal | Guttmacher Institute).
2003/04 – Nepal Health Sector Programme-Implementation Plan (NHSP-IP) I: Nepal adopted a Sector-Wide Approach (SWAp) for health in 2004, launching NHSP-IP 2004–2009. Under government leadership and donor coordination, this plan focused on strengthening health systems and delivering an Essential Health Care Services package nationwide. It marked a shift from fragmented vertical projects to a coordinated sector strategy (National health policy 2071 | PPT). Subsequent five-year plans continued this approach (NHSP-II 2010–2015, and the Nepal Health Sector Strategy 2015–2020).
2006 – Skilled Birth Attendant (SBA) Strategy: To operationalize the Safe Motherhood Policy, Nepal introduced a Skilled Birth Attendant policy in 2006 defining SBAs and mandating training for health workers. It set out to increase the proportion of deliveries assisted by a trained provider (doctor, nurse, or midwife) by improving training, deployment, and incentives for SBAs, especially in rural areas.
2007 – Interim Constitution and Free Health Care Initiative: The Interim Constitution of 2007 declared health a fundamental right, stating that “Every citizen shall have the right to get basic health service free of cost” (Fed_Draft-01_19Apr09). In line with this, the Ministry of Health began rolling out a Free Essential Health Care Services policy in phases from 2006/07. By early 2008, all services and essential drugs at health posts and sub-health posts were made free for everyone (Fed_Draft-01_19Apr09). By 2009, this was expanded – under the “New Nepal, Healthy Nepal” initiative, all citizens gained free outpatient, emergency and inpatient services (with essential medicines) at district hospitals and primary health care centres (Fed_Draft-01_19Apr09). (Earlier, in 2006, free hospital care had initially been provided only to targeted vulnerable groups (Fed_Draft-01_19Apr09)).
2011 – Tobacco Control and Regulatory Act: Nepal passed the Tobacco Product (Control and Regulatory) Act 2011, aligning with the WHO Framework Convention on Tobacco Control. It introduced strong measures including large graphic health warnings on cigarette packs (later expanded to cover 90% of the pack, among the world’s strictest), bans on smoking in public places, and restrictions on tobacco advertising. This reflected growing policy attention to NCD risk factors in the 2010s.
2014 – National Health Policy 2014: The government updated its national health policy (after 23 years) to address new health challenges and commit to universal health coverage. NHP 2014 aimed to “improve access to quality and equitable health services for all” and explicitly set UHC as a goal ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). It recognized the rising burden of NCDs and injuries, and the need to strengthen governance and multi-sectoral action (for example, through a Multi-Sectoral Nutrition Plan and NCD action plan). Policies for decentralization and social health insurance were included, anticipating the coming federal restructuring.
2015 – Constitution of Nepal 2015: Nepal’s new Constitution reinforced health rights, guaranteeing every citizen the right to free basic health services and emergency care, and specific rights to reproductive health and clean drinking water. It mandated a three-tier federal structure (federal, provincial, local governments) with devolved responsibilities in health ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). This set the stage for a major health system restructuring to implement federalism (which formally began after local elections in 2017).
2016 – National Immunization Act 2016: This law was enacted to ensure sustainability of immunization achievements. It established every child’s right to free immunizations and secured a government funding stream for vaccines (Critical success factors for high routine immunization performance). Nepal’s immunization program, which had already eliminated polio and neonatal tetanus, benefited from this legal backing to continue introducing new vaccines (such as pneumococcal vaccine in 2015 and rotavirus vaccine in 2018) and maintain high coverage.
2016 – Social Health Insurance Program Launch: Following a 2014 Health Insurance Policy, Nepal piloted a National Health Insurance Program in three districts in 2016 (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). The Health Insurance Act 2017 then created the national Health Insurance Board to expand the program (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). This social health security scheme aimed to reduce out-of-pocket payments by covering a package of services for enrolled households, moving toward UHC through pre-paid pooling of funds.
2017 – Federalization of Health Governance: With elections and new laws in 2017, Nepal transitioned to federalism. Local governments (municipalities) took over managing local health facilities, human resources, and budgets, while provincial governments assumed regional hospitals and coordination. The Local Government Operation Act 2017 and Intergovernmental Fiscal Arrangement Act 2017 operationalized these changes. This devolution was intended to make health services more responsive but came with challenges of capacity-building and coordination in the transition ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ).
2018 – Public Health Service Act 2018: To implement the constitutional health rights, this Act clarified federal, provincial, and local roles in health service delivery and regulated standards. It also guaranteed free basic health services in law and outlined citizen’s rights to quality care, informed consent, and non-discrimination. Additionally, the Safe Motherhood and Reproductive Health Rights Act 2018 was passed, further ensuring maternal and newborn health services (skilled birth attendance, emergency obstetric care, etc.) are provided free and setting penalties for denial of such services.
2019 – National Health Policy 2019 (NHP 2076): The latest national health policy (replacing the 2014 policy) was approved to guide the health sector in the federal context and toward the Sustainable Development Goals (SDGs). It reinforced commitments to universal health coverage, quality of care, and multi-sectoral collaboration. NHP 2019 put forward strategies to strengthen primary health care, integrate province and local level health plans with national priorities, and address emerging issues like urban health and climate change impacts on health. (Note: The English version of NHP 2019 is available via MoHP.)
2020 – COVID-19 Pandemic Response: The COVID-19 crisis in 2020–21 forced Nepal to rapidly activate public health emergency systems. The government formed a high-level coordination committee and implemented nationwide lockdowns, risk communication, and a scaling-up of testing and treatment capacities. Despite limited resources, Nepal rolled out a national COVID-19 vaccination campaign by 2021, achieving vaccination of a large share of the adult population (over 70% received a full course by 2022). The pandemic stressed the health system but also spurred reforms such as investments in oxygen plants, disease surveillance, and telemedicine services. It highlighted gaps in health emergency preparedness and the importance of a robust primary care system.
2022–2025 – Ongoing Initiatives: In recent years, Nepal has been developing the next Health Sector Strategic Plan (2022–2027) to align with SDG targets for 2030. The country remains committed to eliminating diseases like malaria by 2026/2030 (although the original 2025–26 target is being reconsidered) (Nepal set to miss 2026 malaria elimination goal as indigenous and …) (Nepal to push malaria elimination goal to 2030 as 2026 proves …) and to ending TB as a public health problem by 2030. New policies are under discussion for mental health (including a draft Mental Health Act) and for strengthening the quality of health care through accreditation and regulation. The period up to 2025 is thus focused on consolidating gains of past reforms while addressing the unfinished agenda of equitable access and quality.

(Table 1 below summarizes Nepal’s progress on key health indicators over this period.)

Health Indicator	Early 1990s	Recent (~2015–2020)
Life Expectancy at Birth	~54 years (1990) (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies)	71.5 years (2018) (Health in Nepal – Wikipedia)
Maternal Mortality Ratio (per 100,000 live births)	~850 (1990) (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies)	186 (2017) (Health in Nepal – Wikipedia)
Under-5 Mortality Rate (per 1,000 live births)	~142 (1990 estimate) (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies) (≈14%)	32 (2018) (Health in Nepal – Wikipedia)
Immunization Coverage (DPT3)	~43% (1990) (WHO estimate)	90% (2019) (WHO/UNICEF est.)
Facilities – Health Posts	~200 health posts (1990)	3800+ health posts (2020) ([Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?
Skilled Birth Attendance	<10% (1991)	58% (2016) ([What did Nepal do?
Population with Health Insurance	~0% (1990s)	~20% enrolled (2022) ([Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

Table 1: Selected health indicators in Nepal, showing improvements from the 1990s to recent years. Maternal and child mortality have fallen sharply, life expectancy has risen, immunization now reaches the vast majority of children, and health facility infrastructure has expanded nationwide. However, coverage of health insurance remains a work in progress. Sources: Government of Nepal and WHO/UN reports as cited.

Below, we delve into the major policy areas, analyzing the intent and impact of key policies, along with successes achieved and challenges that persist.

Maternal and Child Health Policies: Saving Mothers and Children

Improving maternal and child health has been at the heart of Nepal’s health policies since 1990. The commitment has paid off in many ways – Nepal is often cited as a success story for reducing maternal and child mortality. National policies provided direction, while grassroots innovations and global partnerships supported implementation. Here we review the major maternal and child health (MCH) initiatives and their outcomes.

Safe Motherhood and Newborn Health: The 1991 National Health Policy explicitly made “Safe Motherhood” a priority, setting the first ever targets to reduce maternal deaths (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies). This commitment was in response to Nepal’s extremely high maternal mortality (among the world’s highest in 1990). The National Safe Motherhood Policy of 1998 translated that commitment into a focused strategy. Its intent was to ensure women have access to skilled care during pregnancy and childbirth and to emergency obstetric care when complications arise. Under this policy, the government expanded birthing facilities and launched training programs for nurses and midwives as Skilled Birth Attendants (SBAs). The Skilled Birth Attendant Strategy 2006 further defined SBAs and aimed to deploy them in all health posts and primary health centers. As a result, the rate of deliveries attended by a skilled provider rose steadily (from under 10% in the early 1990s to 58% by 2016) (What did Nepal do? | Exemplars in Global Health). The impact on maternal mortality has been significant – Nepal’s MMR declined from about 850 per 100,000 live births in 1990 to around 190 by 2013 (Abortion and Unintended Pregnancy in Nepal | Guttmacher Institute), a drop of almost 80%. This was one of the fastest declines in the world, attributed to increased facility births, better management of obstetric emergencies, and reductions in unsafe abortion.

Despite this progress, gaps remain. Many rural municipalities still lack 24/7 surgical obstetric services (Comprehensive Emergency Obstetric Care), contributing to persistent maternal deaths from complications like hemorrhage. Geographical disparities are notable – for example, mountainous districts have lower rates of facility delivery compared to the lowlands. Implementation challenges have included retaining skilled staff in remote areas and ensuring consistent supplies (for example, blood for transfusion and essential medicines). Moreover, quality of care is an issue – maternal deaths increasingly occur not from lack of access, but from suboptimal care (e.g. delayed referrals, inadequate treatment of complications) at health facilities. Key recent policies like the Safe Motherhood and Reproductive Health Rights Act 2018 try to address these gaps by making high-quality maternity care a legal right, but enforcement and quality improvement on the ground are ongoing challenges.

Safe Abortion Policy: Perhaps one of the most impactful reforms was the legalization of abortion in 2002. Prior to this, unsafe abortions were a leading cause of maternal mortality (studies in the 1990s found over half of maternal deaths in some hospitals were due to abortion complications (Abortion Law in Nepal: The Road to Reform)). The policy change – allowing abortion on request in the first trimester and in specific circumstances later – was driven by evidence and advocacy that unsafe abortion was killing women (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies). After legalization, the government trained providers and authorized facilities for safe abortion services (medical and surgical), integrating them into the public health system. The results were dramatic: complication rates and abortion-related deaths dropped precipitously. Maternal mortality fell in part because the contribution of unsafe abortion plummeted. For example, by 2015 Nepal’s MMR was roughly one-third of what it was in 1990, and experts agree the availability of safe abortion was an important factor (Abortion and Unintended Pregnancy in Nepal | Guttmacher Institute). The success of this policy is evident in lives saved, but there are still challenges in ensuring equitable access – rural and poor women may still resort to unsafe methods if they cannot reach licensed providers or afford services. Ongoing efforts focus on improving awareness that abortion is legal and available, expanding services to all districts, and reducing stigma.

Incentives for Safe Motherhood: To complement service delivery improvements, Nepal introduced innovative demand-side incentives. In 2005, the government launched the Maternity Incentive Scheme, paying women a small cash sum (e.g. NRs. 500–1,500) to offset travel costs if they delivered in a health facility. This was one of the earliest conditional cash transfer programs for maternal health in the region (Contribution of Nepal’s Free Delivery Care Policies in Improving …). In 2009, it evolved into the Aama Suraksha (“Safe Motherhood”) Program, which made all childbirth services free of charge nationwide and continued the transport incentive. Under Aama, hospitals are reimbursed for delivery costs so that women pay nothing, and women still receive the cash incentive upon discharge. These policies have been successful in boosting institutional deliveries, especially among the poor ( Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants – PMC ) ( Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants – PMC ). Facility birth rates rose from around 18% in 2006 to 57% by 2016 (DHS data), indicating that cost was a significant barrier that Aama helped remove. The increased utilization no doubt contributed to improved maternal-newborn outcomes. However, the surge in utilization also strained health facilities, revealing gaps in staffing, infrastructure and quality. Some studies found that while free delivery care increased coverage, it did not fully address issues like respectful maternity care or availability of C-section capability in every district. The government has had to increase funding to hospitals to keep the program sustainable. Ensuring that “free” services are truly free (no informal fees) and high-quality is an ongoing challenge noted by policy monitors.

Child Survival and Immunization: On the child health front, Nepal’s policies have led to dramatic gains in child survival. Under-five mortality fell from an estimated ~142 per 1,000 live births in 1990 to just 32 per 1,000 by 2018 (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies) (Health in Nepal – Wikipedia). Key to this success has been the National Immunization Program and community-based child health interventions. Nepal’s immunization program, which started in the 1980s, was strengthened through policies that ensured high coverage of vaccines against the major killers (measles, polio, diphtheria, pertussis, tetanus, TB). By the mid-1990s Nepal had already achieved >70% routine immunization coverage, and it continued to introduce new vaccines with donor support (Hepatitis B, Haemophilus influenzae B in the 2000s, pneumococcal and inactivated polio vaccine in the 2010s). The Immunization Act 2016 was a policy milestone that made immunization a right and secured domestic funding (Critical success factors for high routine immunization performance), reducing dependence on external funds. As a result of sustained immunization policy, Nepal eliminated polio (no wild polio cases since 2010) and eliminated maternal and neonatal tetanus by 2005, and has maintained measles vaccination coverage high enough to drastically reduce measles deaths ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). The country is now pursuing measles elimination.

Beyond vaccines, Nepal adopted the Integrated Management of Childhood Illness (IMCI) strategy in the late 1990s, training health workers to diagnose and treat common childhood illnesses (pneumonia, diarrhea, malaria) according to standard protocols. Complementing this facility-based IMCI, the government scaled up community-based programs: distributing oral rehydration solution and zinc for diarrhea, antibiotics for pneumonia, and long-lasting insecticidal nets in malaria areas. One flagship was the Vitamin A supplementation program, launched in 1993 through a policy that empowered Female Community Health Volunteers (FCHVs) to give high-dose vitamin A capsules to children under five nationwide. This program, cited as an exemplar in public health, achieved universal coverage and significantly reduced child mortality from measles and diarrhea (Vitamin A deficiency was virtually eliminated as a cause of child death) (What did Nepal do? | Exemplars in Global Health) (What did Nepal do? | Exemplars in Global Health).

Female Community Health Volunteers (FCHVs): A distinctive aspect of Nepal’s MCH success is the use of community health volunteers, mainly local women, to extend reach into villages. The FCHV program was initiated in 1988 and expanded nationally by 1992 with an early policy push for community participation (What did Nepal do? | Exemplars in Global Health). By 2017, over 50,000 FCHVs were active across Nepal (What did Nepal do? | Exemplars in Global Health). These volunteers, supported by government policy and minimal incentives, became the backbone of many child and maternal health interventions – from distributing Vitamin A and deworming tablets to promoting birth preparedness and newborn care. Policies in the 2000s (like the National Nutrition Policy and Safe Motherhood plans) increasingly formally recognized FCHVs’ role and provided them with training and supplies. The impact of FCHVs has been widely lauded: they contributed to increases in contraception use and awareness (helping drop fertility from 4.6 to 2.3 between 1996 and 2016) (What did Nepal do? | Exemplars in Global Health), improved breastfeeding practices (What did Nepal do? | Exemplars in Global Health), and facilitated community-level management of pneumonia and diarrheal disease. A government analysis found that communities with strong FCHV networks saw better uptake of antenatal care and immunizations. The challenge going forward is maintaining volunteer motivation (as they are essentially unpaid) and integrating them into the formal health system under federalism. Nonetheless, Nepal’s experience showed that engaging communities through volunteer health workers is a powerful policy tool for improving MCH outcomes.

Child Nutrition: Nutrition has been another focus of policy because malnutrition underlies many child deaths. In 2002, Nepal enacted a National Nutrition Policy and Strategy, and later a Multi-Sector Nutrition Plan (MSNP) in 2012, recognizing that nutrition improvement needs actions in agriculture, education, sanitation, and women’s empowerment. Through interventions like breastfeeding promotion, vitamin supplementation, and treatment of severe acute malnutrition, Nepal substantially reduced child undernutrition. Stunting in under-fives declined from ~57% in 2001 to 32% by 2019. Still, one in three Nepali children is stunted (Health in Nepal – Wikipedia), indicating remaining gaps in food security and maternal nutrition that policies must tackle. The MSNP I (2013–2017) and II (2018–2022) have been positive steps, fostering coordinated efforts (for instance, integrating nutrition in school curricula and agriculture extension). The success of these efforts is tied to high-level political support and decentralized implementation – both of which the current policies are trying to sustain.

Successes and Ongoing Challenges: Overall, Nepal’s maternal and child health policies have saved tens of thousands of lives. Maternal health initiatives, safe abortion, free delivery, immunization, and community-based child health have together led to Nepal achieving many of its Millennium Development Goal (MDG) targets by 2015 ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). For example, Nepal met the MDG target for reducing child mortality, and came close for maternal mortality. These successes demonstrate strong policy intent matched by effective program delivery (often with donor partnership, e.g. UNICEF and USAID were key supporters of child health programs, while DFID and GIZ supported safe motherhood and free care programs).

However, the unfinished agenda in MCH remains significant. Maternal mortality has plateaued in recent years – progress stagnated after 2015, partly coinciding with the disruption of the health system restructuring and the 2015 earthquakes ( Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants – PMC ) ( Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants – PMC ). Neonatal mortality (deaths in the first month) now constitutes the majority of under-five deaths, and has been harder to reduce (neonatal mortality was 33 per 1000 in 2000 and about 21 in 2018 (Health in Nepal – Wikipedia)). This calls for enhanced focus on quality of newborn care, management of neonatal infections, and addressing prematurity – areas that past policies did not fully cover. Equity is another challenge: remote rural districts, poor households, and certain castes/ethnic groups still have worse MCH outcomes, reflecting barriers in access and social determinants. For instance, the Terai Dalit communities have higher child mortality and lower nutrition indicators. Policies now emphasize reaching the unreached (through programs like Expanded Community Health Clinics in hard-to-reach areas), but these need robust implementation.

In summary, Nepal’s MCH journey from 1990–2025 is one of significant achievement through well-crafted policies – prioritizing safe motherhood, empowering community health workers, removing financial barriers, and integrating services. To sustain and build on these gains, current efforts are directed at improving quality of care (not just quantity), addressing residual inequalities, and adapting MCH services to the decentralized governance structure. The intent to save mothers and children is clearly evident in Nepal’s policies; the task ahead is to refine implementation so that no woman or child is left behind in enjoying the health improvements that so many have already benefited from.

Combating Infectious Diseases: Policy Efforts and Epidemiological Transition

Nepal in 1990 faced a heavy burden of communicable diseases – respiratory infections, diarrheal diseases, tuberculosis, malaria, and leprosy were among the leading causes of illness and death. Over 70% of the disease burden was communicable. Consequently, national policies in the 1990s and 2000s placed strong emphasis on infectious disease control through both vertical programs and integrated primary care. By 2025, the landscape has shifted dramatically: communicable diseases have declined and non-communicable diseases now account for over two-thirds of total mortality (Health in Nepal – Wikipedia) (Health in Nepal – Wikipedia). This section reviews Nepal’s major infectious disease control initiatives, their impact, and remaining challenges – essentially tracing Nepal’s epidemiological transition and how policy responded.

Routine Infectious Disease Control through Primary Health Care: The foundation of Nepal’s infectious disease strategy has been its network of primary health care facilities (health posts and primary health centers) established per the 1991 policy. These centers deliver immunizations, diagnose and treat common infections, and carry out health education on hygiene and disease prevention. As noted, the expansion of health posts to every village was a key aim of NHP 1991 ( Health System Development in Nepal – PMC ). By 2020, Nepal had over 4,000 health posts and urban health clinics providing basic services, which greatly improved access to care for communicable diseases. This was complemented by community-level efforts (FCHVs and outreach clinics) extending services like immunization and case-finding for TB and leprosy. The intent was to integrate disease control into the primary health system rather than rely solely on standalone vertical projects.

Tuberculosis (TB) Control: Nepal’s National Tuberculosis Control Programme (NTP) is one of the success stories of the post-1990 period. In 1996, Nepal adopted the WHO-recommended DOTS (Directly Observed Treatment, Short-course) strategy via a policy commitment to make TB treatment accessible in all districts. DOTS was rapidly scaled up – from covering just 1.7% of the population in 1996 to all 75 districts by 2001 ([PDF] tuberculosis patients opinion for directly observed treatment short …). By 2003, 100% of the population had access to DOTS services ([PDF] tuberculosis patients opinion for directly observed treatment short …). The policy provided free TB diagnosis and treatment through the government network, with support from NGOs and external partners channeled into the unified program. As a result, treatment success rates climbed above 85% and TB prevalence and mortality steadily declined. Nepal met the MDG target of halting and reversing TB incidence well before 2015 ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ).

Today, TB remains a concern (around 32,000 people develop TB annually in Nepal), but the nature of the challenge has shifted to case finding and drug-resistant TB. Policy efforts in the 2010s introduced community-based TB care and incentives for patients (and even mobilized FCHVs for sputum collection in remote areas). The NTP also established a network of GeneXpert machines for rapid diagnosis of multi-drug-resistant TB (MDR-TB) and introduced new drugs for MDR-TB treatment. Challenges include reaching “missing” cases (it’s estimated a significant percentage of TB cases are not diagnosed or notified) and ensuring adherence among migrant populations. Furthermore, the rise of MDR-TB requires costly treatment – Nepal’s policies, supported by the Global Fund, now cover MDR-TB treatment free of cost, but ensuring quality and preventing further resistance is an ongoing battle. The government has committed to the global End TB Strategy, aiming for TB elimination by 2035, and is updating policies accordingly (focusing on active case finding, social support for patients, and integration of TB services in primary care). High-level political commitment was demonstrated in 2018 when Nepal’s Prime Minister publicly committed to ending TB and tobacco use as dual health priorities (Nepal’s Prime Minister commits to end TB and tobacco | The Union).

Malaria and Vector-Borne Diseases: Historically, malaria was a major public health problem in Nepal’s southern plains (Terai). Control efforts date back to the 1950s. By 1990, malaria incidence had been greatly reduced compared to the pre-1970 era, but it persisted in pockets. National policy in the 90s and 2000s maintained a Malaria Control Program with indoor residual spraying, distribution of bed nets, and case management as core strategies. In 2011, Nepal aligned with the Asia Pacific goal of malaria elimination by 2030, and accordingly the National Malaria Strategic Plan 2014–2025 set the target of zero indigenous cases by 2025. Significant progress was achieved: annual malaria cases dropped from over 30,000 in 2010 to under 4,000 by 2017 (P. vivax malaria in Nepal | PVIVAX), a testament to intensified control in high-risk districts and improved surveillance. Indigenous malaria is now rare and mostly confined to a few southern districts; the majority of cases are imported (Nepalese working abroad in India/Africa returning with malaria) (Nepal set to miss 2026 malaria elimination goal as indigenous and …).

As of 2024, Nepal was close to eliminating Plasmodium falciparum malaria (the deadliest form) but saw an uptick in P. vivax cases, largely imported, which threatened to derail the 2026 elimination target (Nepal set to miss 2026 malaria elimination goal as indigenous and …) (Nepal to push malaria elimination goal to 2030 as 2026 proves …). Policy adjustments are being made – the government is considering extending the elimination target to 2030 in line with WHO’s global strategy (Nepal to push malaria elimination goal to 2030 as 2026 proves …). Key challenges include maintaining funding and vigilance as cases decline (the classic “near-elimination” challenge of not losing focus), and addressing new threats like insecticide resistance in mosquitoes and climate change potentially expanding malaria risk areas. Additionally, other vector-borne diseases have surged: dengue fever, once unknown in Nepal, has caused major outbreaks since the 2010s (with thousands of cases in 2019 and 2022). The health system had to adapt policies for dengue surveillance, community mosquito control, and clinical management without a vertical program like malaria’s. Similarly, kala-azar (visceral leishmaniasis) remains in the Terai, though its incidence has come down with concerted efforts. Nepal’s experience underscores that even as legacy diseases like malaria recede, emerging vector-borne diseases require policy attention and resources.

HIV/AIDS: Nepal confronted a growing HIV epidemic in the 1990s, primarily affecting injecting drug users, sex workers, and migrants. The government formed the National AIDS Control Program and a National AIDS Council in 1992, and by mid-2000s had developed a series of National HIV/AIDS Strategic Plans (e.g. 2002–2006, 2006–2011, etc.). A pivotal policy move was the adoption of harm reduction approaches – Nepal was an early adopter in South Asia of needle exchange programs (around 2002) and opioid substitution therapy (OST) for people who inject drugs, reflecting a pragmatic public health policy rather than a punitive approach. This helped contain HIV among drug users. Similarly, the government collaborated with NGOs for targeted interventions among female sex workers and migrants, guided by policies that recognized the need for focused prevention in key populations. Free antiretroviral therapy (ART) was introduced in 2004 at a few hospitals as a pilot and expanded nationwide by 2010 as policy commitment grew under the global “3 by 5” and later “90-90-90” initiatives. By making ART free and decentralizing its delivery to district hospitals, Nepal achieved relatively good treatment coverage – by 2020, over 18,000 people living with HIV were on ART (around two-thirds of those estimated in need).

The impact of these policies is that Nepal’s HIV prevalence has remained low (<0.2% in adults) and the epidemic has not generalized into the wider population. New HIV infections and AIDS deaths have both declined from their peaks in the early 2000s. The success in controlling HIV owes much to policy openness to NGO partnerships and harm reduction, as well as support from the Global Fund which financed HIV programs from 2003 onward. Nonetheless, challenges persist: infections continue among key groups (for instance, HIV prevalence among people who inject drugs is still >5%), and stigma/discrimination often hinders people from accessing services. With decentralization, ensuring local governments prioritize HIV prevention for marginalized groups is also a concern. The policy focus now is on achieving the UNAIDS 95-95-95 targets (percent of people with HIV diagnosed, on treatment, and virally suppressed) by 2025. This entails integrating HIV services into general health services (for sustainability) while protecting the targeted outreach approach. In summary, Nepal’s HIV policy response has been relatively successful in preventing a major epidemic, demonstrating the value of evidence-based and inclusive strategies.

Leprosy: Leprosy was once a significant public health problem in Nepal. The National Leprosy Control Program, with free multi-drug therapy and community case-finding, made huge strides in the 1990s and 2000s. By 2010, Nepal achieved the elimination of leprosy as a public health issue (defined as prevalence <1 case per 10,000 population) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). This met a long-standing national and WHO goal. The policy challenge after elimination status was declared has been to integrate leprosy services into primary care and sustain surveillance to prevent resurgence. Nepal still detects a few hundred new cases annually, and combating stigma for those affected remains important (Nepal enacted in 2018 a law to end discrimination against persons affected by leprosy). Overall, leprosy elimination is a notable success of sustained policy attention since the 1960s, culminating in post-1990 achievements.

Polio and Vaccine-Preventable Diseases: As part of the global polio eradication initiative, Nepal was very active in the 1990s–2000s, conducting National Immunization Days and acute flaccid paralysis surveillance. The last indigenous polio case in Nepal was seen in 2000, and importations from India occurred until 2010. After that, no polio – wild or vaccine-derived – has been detected. In 2014, the WHO certified Nepal (and the entire South-East Asia region) as polio-free ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). This is a clear example of successful infectious disease policy – combining routine immunization strengthening with mass campaigns and cross-border collaboration. Likewise, maternal and neonatal tetanus was eliminated by 2005 through focused immunization of women and clean delivery practices ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). Measles remains endemic but deaths from measles have dropped by >95% due to high vaccine coverage and periodic catch-up campaigns; Nepal aims for measles-rubella elimination by 2023, and introduced rubella vaccine in 2015.

One current challenge in vaccine-preventable disease policy is maintaining high coverage in the face of anti-vaccine rumors or complacency. Nepal has had pockets of lower immunization in certain communities (e.g. some religious groups or remote nomadic populations). The Immunization Act and strong community engagement have helped keep coverage high overall (>90% for DPT3 in recent years), but COVID-19 disruptions caused slight declines in 2020. The government has initiated an “Fully Immunized District” approach, certifying districts that achieve >95% coverage, to encourage local accountability. As a result, many districts have achieved that status.

Integrated Disease Surveillance: Recognizing the need for timely detection of outbreaks, Nepal’s policies supported establishing an Integrated Disease Surveillance and Response (IDSR) system in the 2000s. Sentinel sites and weekly reporting for diseases like cholera, dengue, encephalitis, etc., have been set up. However, surveillance capacity is still developing; for example, the large dengue outbreak in 2019 revealed gaps in early warning. The COVID-19 pandemic further underscored the importance of strengthening laboratory networks and real-time surveillance. In late 2020, Nepal approved a National Action Plan for Health Security to comply with the International Health Regulations (IHR), aiming to bolster pandemic preparedness.

WASH (Water, Sanitation, Hygiene) and Diarrheal Disease: Many infectious disease gains also came from improvements outside the health sector, supported by national campaigns. Access to clean water and sanitation has improved markedly (the percentage of population with access to improved sanitation rose from 6% in 1990 to >45% by 2015). Government-led Open Defecation Free (ODF) campaigns and sanitation policies in the 2010s led most districts to declare ODF status. These efforts, combined with oral rehydration therapy dissemination, drove down deaths from diarrhea among children. Cholera outbreaks still occur, but less frequently, and typically in smaller scales than before. A current policy step is the introduction of rotavirus vaccine (in 2020) to further reduce diarrheal disease burden in infants.

Successes and the Road Ahead: In summary, Nepal’s infectious disease control policies have been broadly effective, transforming a country plagued by communicable diseases into one where most traditional infectious scourges are under control or eliminated. As noted in a 2019 analysis, Nepal managed to “halt and reverse the trends of tuberculosis, HIV and malaria with elimination of polio, maternal and neonatal tetanus and leprosy” ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). This is a tremendous achievement attributable to sustained policies, global partnerships, and community health systems. The successes include:

High vaccine coverage and disease elimination: Polio gone, no tetanus in newborns, measles mortality greatly reduced.
Tuberculosis contained: A functioning TB program integrated into primary care with good outcomes.
Malaria pushed back: Now close to elimination with only sporadic cases.
HIV kept low prevalence: Through proactive harm reduction and treatment policies.
Integration of services: Immunization, TB, leprosy, etc., are delivered through the same health infrastructure, increasing efficiency.
Community engagement: Use of volunteers and local health committees to support disease control efforts.

However, Nepal also faces the typical “dual burden” of disease now – while communicable diseases are relatively controlled, they are not gone, and new diseases (like COVID-19, dengue, scrub typhus) are emerging, even as non-communicable conditions rise. For infectious diseases, remaining challenges include:

Finishing the job on unfinished targets: e.g., eliminating measles and malaria by or before 2030, eliminating mother-to-child transmission of HIV and syphilis.
Sustaining political and financial commitment: As disease burdens fall, ensuring the programs (especially those reliant on donor funds, like TB/HIV) are sustained and domestic financing increases.
Health security: Building robust systems to detect and respond to outbreaks (the pandemic revealed gaps to fix).
Antimicrobial resistance (AMR): Overuse of antibiotics has led to resistant infections (for TB, typhoid, etc.). Nepal’s 2016 AMR National Action Plan needs full implementation across human and animal health.
Cross-border collaboration: Many infectious diseases (polio, malaria, kala-azar, even COVID-19) involve cross-border issues with India and China. Policies that enhance surveillance and response cooperation with neighbors are vital.
Urban environments: Rapid urbanization has created pockets of poor sanitation in city slums, leading to diseases like cholera and dengue. Urban public health policy is still evolving in Nepal.

In conclusion, Nepal’s national policies from 1990 to 2025 in communicable disease control have yielded significant success, altering the country’s health profile. The focus now is to consolidate these gains while transitioning the health system to tackle a new set of challenges – an increasing dominance of chronic diseases, without losing sight of the communicable diseases that still affect the most disadvantaged communities.

Addressing Non-Communicable Diseases (NCDs) and Health Promotion

As Nepal brought infections under control and life expectancy rose, non-communicable diseases emerged as the next great challenge. By the 2010s, diseases like heart disease, stroke, diabetes, chronic lung disease, and cancer were causing over 60% of deaths in Nepal (Health in Nepal – Wikipedia) (Health in Nepal – Wikipedia). In addition, mental health issues and injuries (from accidents and disasters) became more prominent. The shift towards NCDs is a classic epidemiological transition, but one accelerated in Nepal by changes in lifestyle, urbanization, and aging population. National health policy, which had until the early 2000s been preoccupied with communicable diseases, had to adapt to this new reality. Here we examine how Nepal’s policies have tackled NCDs and what progress and gaps exist.

Initial Neglect and Policy Shifts: For a long time, NCDs did not feature prominently in Nepal’s health plans – the health system was oriented towards acute and infectious care. The 1991 National Health Policy did not explicitly mention non-communicable diseases, though it did acknowledge the need for some specialized services. In fact, the few early initiatives were the establishment of specialized centers: e.g., the BP Koirala Memorial Cancer Hospital (est. 1995) and the Shahid Gangalal National Heart Center (est. 2001) came about through individual projects and external assistance. These hospitals improved tertiary care for cancer and cardiac patients and were products of policy decisions to invest in specialized care as Nepal’s burden of cancer/heart disease became apparent in the 1990s ( Health System Development in Nepal – PMC ) ( Health System Development in Nepal – PMC ). Still, there was no overarching NCD policy at the time.

A turning point came in the 2010s under the influence of global NCD targets and local epidemiology. The National Health Policy 2014 for the first time emphasized prevention and control of NCDs and mental health at the primary care level ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). It advocated integrating NCD screening and management into basic health services and improving the capacity of district hospitals to treat chronic diseases. Another significant step was the formulation of the Multi-Sectoral Action Plan (MSAP) for the Prevention and Control of NCDs (2014–2020), endorsed by the government. This plan brought together ministries of health, education, agriculture, urban development, etc., to address risk factors like tobacco use, unhealthy diet, physical inactivity, and alcohol abuse. It set targets aligned with WHO’s 25×25 goals (25% reduction in premature NCD mortality by 2025) and initiated activities such as raising public awareness, piloting NCD screening camps, and introducing WHO’s PEN (Package of Essential NCD interventions) protocols in primary health care.

Tobacco and Alcohol Control: Tobacco control has been a flagship area where Nepal made bold policy moves. After ratifying the WHO Framework Convention on Tobacco Control (FCTC) in 2006, Nepal passed comprehensive tobacco control legislation in 2011. This law banned smoking in public places, outlawed all tobacco advertising, and mandated large graphic health warnings on tobacco packages. By 2015, Nepal required graphic warnings to cover 90% of the cigarette pack front and back – one of the largest such requirements globally – reflecting a strong anti-tobacco stance (National Health Policy 2014 | Notes, Videos, QA and Tests – Saralmind). The government also levied high taxes on tobacco products (over 30% of retail price as excise tax). The impact has been gradual declines in tobacco use: smoking rates among adults dropped and youth smoking initiation slowed. The Global Adult Tobacco Survey showed a significant decrease in tobacco consumption between 2007 and 2016 in Nepal, attributable to these measures and public awareness campaigns. However, smokeless tobacco remains popular in some communities and needs continued attention.

For alcohol, Nepal introduced restrictions on advertisement and sales hours, but policies are less stringent than for tobacco. Rising alcohol consumption is contributing to NCDs and injuries, and while the 2017 Alcohol Control Policy was drafted, it has yet to be fully implemented or enforced.

Diet and Lifestyle: Changing diets (more salt, sugar, processed foods) and sedentary lifestyles have led to a surge in hypertension and diabetes in Nepal. The MSAP on NCDs encouraged inter-ministerial programs like healthier school meals, urban walking trails, and regulating transfats in foods. Implementation has been patchy. There have been some local successes – for example, a few municipalities started “open street” events to promote physical activity, and the government set guidelines to limit sugar in school cafeterias. In health facilities, screening for hypertension and diabetes is now part of the basic package: many primary health centers measure blood pressure and test for diabetes in adults thanks to training under WHO PEN. Consequently, more people are being diagnosed earlier, though ensuring they receive continuous treatment is challenging due to medication costs and health system constraints.

Health System Response to NCDs: One of the biggest challenges is that managing chronic NCDs requires a different health system model – one that emphasizes long-term follow-up, a strong referral chain, and a continuum of care from community to specialized centers. Nepal’s health system is in transition to accommodate this. Some steps taken include: developing a roster of “Chronic Disease Nurses” at district level, expanding the availability of essential NCD drugs in primary care (e.g., medicines for diabetes, blood pressure, asthma are now on the free essential drug list), and setting up NCD clinics in some district hospitals. The Nepal Health Sector Strategy 2015–2020 explicitly included NCD-related outcome goals and quality of care improvements (National health policy 2071 | PPT) (National health policy 2071 | PPT). Telemedicine has also been piloted to link rural clinics with specialists in cities for NCD management.

Despite these efforts, there are significant gaps: a large proportion of people with hypertension or diabetes remain undiagnosed or untreated. For instance, a STEPS survey in 2019 showed over one-fourth of Nepali adults had hypertension, but among them, more than half were not aware of it. Even among those diagnosed, control rates were low. Thus, implementation of NCD policies at scale is still in early stages. Reasons include limited trained human resources (e.g., few dieticians or physiotherapists in rural areas), lack of equipment (some health posts still lack functional blood glucose meters or ECG machines), and the need for greater health education to improve medication adherence.

Mental Health: Nepal’s mental health policy trajectory exemplifies the neglect and nascent progress of NCD-related conditions. A National Mental Health Policy was formulated in 1996, aiming to integrate mental health into general health services and ensure availability of essential psychiatric drugs (Health in Nepal – Wikipedia). However, this policy saw little implementation – mental health remained a low priority with <1% of the health budget and no specific legislation for decades (Health in Nepal – Wikipedia). There were only a few public psychiatric hospitals, all in urban centers, and a severe shortage of psychiatrists (almost all based in Kathmandu). The decade-long civil conflict (1996–2006) and the 2015 earthquake both raised awareness of mental health needs (due to trauma and psychosocial issues), prompting calls for better services. In recent years, mental health has slowly gained policy attention: the new federal structure actually helped some provinces to start their own mental health initiatives, and the MoHP with WHO support launched the mental health Gap Action Program (mhGAP) training to enable general doctors and nurses to handle common mental illnesses. A draft Mental Health Bill (to replace the outdated colonial-era laws on mental illness) is under discussion to protect the rights of people with mental disorders and streamline services.

The challenge in mental health policy is overcoming stigma and establishing services in primary care. A few pilot projects integrating mental health in primary health centers (e.g., in Chitwan and Jhapa districts) showed that even basic training of health workers can increase identification of depression, anxiety, and epilepsy (often considered a mental health issue in health policy) and improve treatment. Yet scaling this nationwide requires clear policy directives and resources. As of 2025, Nepal has not yet passed a comprehensive Mental Health Act, but the intent is visible in policy circles to do so, especially after COVID-19, which saw increased mental health problems and the need for psychosocial support.

Injury and Disaster Health Management: The rise in road traffic accidents and injuries has been noted in policies as well. Road traffic injuries and deaths have been increasing with more vehicles and difficult terrain; by 2018, they were a leading cause of hospital death in young males. Nepal’s health policies have started to incorporate trauma care – for example, establishing a Trauma Center in Kathmandu (opened 2014) and trauma units along the highways. The National Health Sector Strategy includes improving emergency referral systems for accidents ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). Occupational health and safety regulations exist but enforcement is modest. Meanwhile, natural disasters (like the 2015 earthquakes) prompted development of emergency preparedness and disaster response plans. After the 2015 quakes, a National Reconstruction Plan included rebuilding safer hospitals and strengthening emergency medicine. By 2025, Nepal has more paramedics trained in mass-casualty management and conducts annual disaster drills. These efforts, albeit reactive, indicate a policy shift toward broader concepts of public health that include injury prevention and disaster resilience.

Achievements and Future Directions: The achievements in NCD policy so far are incremental but notable. Tobacco use is declining, which will pay dividends in future NCD rates. The legislative and multi-sector framework for NCD prevention (e.g. taxes on sugary drinks are being discussed, a ban on trans-fats is in the works) is gradually taking shape. Public awareness of NCD risk factors is improving – today it’s common to hear radio messages about healthy eating or see anti-tobacco signage in villages, which was not the case in 1990. The health system is slowly adapting, with primary care workers now more likely to check blood pressure or counsel on diet and exercise. Nepal has also leveraged international support by aligning with global NCD targets; for example, the WHO PEN pilot and World Bank projects on NCDs have brought in technical resources.

However, the NCD challenge is immense and many gaps remain:

Resource allocation: NCDs still receive a disproportionately small share of health funding. Out-of-pocket costs for chronic disease medications push many families into poverty (e.g., lifelong diabetes care or cancer treatment can be catastrophic without insurance).
Health insurance and NCDs: The national health insurance program, if expanded, could greatly aid NCD patients by covering expensive treatments. Currently, insurance enrollment is low and coverage limits are modest (cap of NPR 100,000, which a cancer patient can exceed easily) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). Policy needs to expand both enrollment and benefit packages for NCD care in insurance.
Human resources: There’s a lack of specialists outside cities – e.g., no cardiologist in many provinces, and very few oncologists nationwide. Training more general physicians in NCD care and deploying specialist visiting teams to remote areas are potential strategies under discussion.
Data for NCDs: Unlike infectious diseases, NCD surveillance is weak. The policy goal is to establish a disease registry (like a cancer registry) and integrate NCD indicators into the Health Management Information System (HMIS) for regular monitoring. This is nascent but necessary for informed policy.
Community engagement: Just as FCHVs helped with MCH, a community approach for NCDs could help (for example, peer support groups for hypertension or village health volunteers screening for vision or dental problems). Policy hasn’t fully tapped into community-based NCD interventions yet.

In conclusion, Nepal’s experience with NCDs is at a relatively early stage, akin to where it was with infectious diseases perhaps in the 1960s. The intent to combat NCDs has been clearly expressed in policies from 2014 onward, and some building blocks are in place (like tobacco control laws and NCD action plans). The impact on the ground is slowly emerging – fewer smokers, slightly better early detection of diabetes, etc. But major successes (like dramatic reductions in NCD mortality) are still aspirations for the future. The country must navigate through obstacles of limited funding, low health literacy about chronic diseases, and competing health priorities. Encouragingly, Nepal’s government recognizes that without tackling NCDs, the health gains of past decades could be undermined. As such, the 2019 National Health Policy and current 15th National Plan (2020–2025) both stress NCD prevention and management as key to improving life expectancy and quality of life. The next years will be critical in translating these policy commitments into concrete outcomes – much as Nepal impressively did for maternal health and infectious diseases in earlier decades.

Health Systems Strengthening and Universal Health Coverage

Underpinning all specific health programs is the strength of the health system itself – its infrastructure, workforce, financing, governance, and information systems. From 1990 to 2025, Nepal’s health system has transformed from a highly centralized, publicly funded model into a more decentralized system with a mix of public and private providers, aiming for Universal Health Coverage (UHC). The journey of health systems strengthening in Nepal is closely intertwined with the political and administrative changes in the country, as well as global paradigms like primary health care and sector-wide approaches. This section reviews how health system reforms and financing policies have supported (or sometimes hindered) Nepal’s health goals.

Infrastructure Expansion and Service Delivery: A cornerstone of Nepal’s health policy has been to bring services closer to the people. The 1991 National Health Policy’s primary objective was “to upgrade the health standards of the majority of the rural population by strengthening the primary health care system” (National Health Policy (Nepal) | PPT – SlideShare). In practice, this meant building many more local health facilities. In the early 1990s, Nepal created two new tiers of rural facilities: sub-health posts (the lowest-level clinic, typically staffed by a midwife or community health worker) and primary health care centres (PHCCs) at the sub-district level (staffed with a doctor or senior health officer). The goal was one health post or sub-health post per Village Development Committee and one PHCC per electoral constituency ( Health System Development in Nepal – PMC ). Over the 1990s, thousands of sub-health posts were established, and by 2015 all sub-health posts were upgraded to full Health Posts with expanded services ( Health System Development in Nepal – PMC ). As a result, by 2020 Nepal had 3,800+ health posts and ~200 PHCCs across the country ( Health System Development in Nepal – PMC ) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text), in addition to hospitals at district and central levels. This vast expansion brought basic services (immunization, antenatal care, minor illness treatment) within a one-hour walk for most of the population. It is a major success in terms of physical access.

In parallel, the private sector grew after economic liberalization in 1991 ( Health System Development in Nepal – PMC ). Private hospitals and clinics proliferated, especially in urban areas. By 2020, the private sector accounted for an estimated 60–70% of total health expenditures (mostly out-of-pocket spending at private facilities) ( Health System Development in Nepal – PMC ) ( Health System Development in Nepal – PMC ). Recognizing this, government policies gradually started engaging the private sector – e.g., by regulating private medical colleges (which helped produce more doctors) and contracting private providers for certain public health services (like family planning or TB dots centers run by NGOs). However, regulation of quality in the private sector remains a challenge.

Decentralization and Governance: Nepal’s governance reforms significantly affected the health sector. In 1999, the Local Self-Governance Act gave local bodies (District Development Committees and Village Development Committees) some responsibility for health facilities and encouraged community management. Some pilot projects in the 2000s devolved primary care facility management to Health Facility Management Committees with community representation ( Health System Development in Nepal – PMC ). Where implemented, this led to local innovations (for instance, communities raising funds to upgrade their health post). Full devolution stalled during the conflict years, but the concept was revived after 2006.

Federalism since 2017 has been the biggest governance shift. Now, local governments employ the frontline health workers, manage health posts, and have budgetary authority for local health programs ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). This brings decision-making closer to communities, theoretically allowing health services to be tailored to local needs. For example, some municipalities have started local ambulance services or nutrition programs from their budgets. Provinces oversee provincial hospitals and coordinate more specialized services. The federal Ministry of Health and Population sets national policy, standards, and provides funding and technical support. This transition is still ongoing, and challenges have emerged: initially there were disruptions in drug supply and staff salaries as roles shifted, and many local governments lacked the technical capacity for health planning ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ) ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ). The central government responded with capacity-building programs and by enacting the Public Health Service Act 2018 to clarify responsibilities. Federalism brings opportunity (local accountability, innovation) but also requires strong coordination mechanisms between levels – something Nepal is building through joint forums and guidelines.

Health Workforce: A critical component of health system strengthening is human resources. Nepal’s policies have consistently acknowledged health workforce issues. The expansion of services meant training and deploying thousands of new health workers. Throughout the 1990s and 2000s, the Ministry of Health expanded training institutions for nurses, paramedics (health assistants, auxiliary nurse midwives), and recruited many paramedics to staff new health posts. The rise of private medical and nursing colleges (encouraged in the 1990s) increased the production of doctors and nurses substantially. For example, there were only a few hundred doctors in Nepal in 1990; by 2020 there were over 20,000 registered doctors (though many emigrated or worked in cities). Still, distribution remains skewed – rural and remote areas struggle to retain skilled staff. The government has used policies like bonding schemes (requiring new medical graduates who studied on government scholarship to serve in rural posts for 2–3 years) and incentives (hardship allowances, career points for remote service). These have met with mixed success; turnover in remote posts is high, and many sanctioned posts remain vacant in mountain districts. The Human Resources for Health Strategic Plan (2011–2015) and updates in NHSS (2015–2020) emphasize training mid-level providers and task-sharing (e.g., allowing nurses to prescribe certain medications) to mitigate the shortage of doctors in rural areas.

Community health volunteers (FCHVs) have been discussed earlier; they effectively extend the workforce with unpaid labor. The government provides them some incentives (annual stipend, priority in community development programs) and supplies, acknowledging their role in policy documents.

A new challenge is to develop specialized expertise at the provincial level – such as public health officers, health statisticians, and hospital administrators – because under federalism each province and municipality needs such capacity. Policies now focus on creating provincial public health training centers (one reason the National Health Training Center was decentralized) and sharing technical staff between governments.

Health Information and Monitoring: Since 1994, Nepal has run a Health Management Information System (HMIS) that collects data from all public health facilities ( Health System Development in Nepal – PMC ). Over time, it has improved and is now an electronic reporting system (DHS2 platform) with monthly data on service utilization, morbidity, etc. This has greatly aided policy monitoring – for instance, tracking the uptake of free health care or the number of institutional deliveries. The Ministry publishes an Annual Health Report using HMIS data. Still, there are issues with data quality and completeness (especially from private sector, which often doesn’t report). Another achievement was conducting periodic Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), which provided independent outcome measures (e.g., maternal mortality, malnutrition rates) that guided policies and allowed evaluation of progress (like the dramatic drops in under-five mortality). Moving forward, integrating various information systems (HMIS, logistics, HR, financial data) and strengthening vital registration are policy aims for better decision-making.

Sector-Wide Approach (SWAp) and Aid Coordination: In the early 2000s, Nepal pioneered a SWAp in health – the Nepal Health Sector Program – to coordinate donor funding under government leadership. This was a policy shift from donors running separate projects to pooling funds and aligning with the government’s plan (National health policy 2071 | PPT). The NHSP-IP 2004–2009 was supported by a pool of donors (World Bank, DFID, etc.) and set common targets. The SWAp improved harmonization and reduced duplication, enabling more efficient use of resources for health system strengthening (like pooled procurement of essential drugs, joint annual reviews of sector performance). This approach continued with NHSP-II and NHSP-III. By having one sector plan, the Ministry could direct investments into priority areas (e.g., rolling out free care, expanding immunization) with donor backing. One can argue that Nepal’s ability to scale up interventions rapidly owes partly to this coordinated planning. A downside, however, is heavy reliance on external funding for some areas (e.g., family planning commodities, immunization vaccines via Gavi, TB/HIV via Global Fund). The policy challenge as Nepal approaches middle-income status is to increase domestic health financing to sustain these programs.

Health Financing and Universal Health Coverage: Financing is a core aspect of UHC. Historically, Nepal’s health spending from government sources was low (typically around 5-7% of the total government budget and <2% of GDP) (Health in Nepal – Wikipedia). Out-of-pocket spending by households made up the bulk of health expenditures (over 60% in 2012). This meant many faced financial hardship when falling ill. Recognizing this, Nepal’s policies over the past 15 years have made incremental moves toward UHC:

The Free Essential Health Care Policy (2007–2009) dramatically reduced user fees at the point of service for a range of basic services. As described, by 2009 all primary-level services and district hospital emergency/inpatient services were free for all (Fed_Draft-01_19Apr09) (Fed_Draft-01_19Apr09). This was a huge step towards UHC in terms of service coverage. It led to big increases in utilization (OPD visits jumped by 50-100% in many facilities after fees were removed) (Fed_Draft-01_19Apr09). Importantly, it improved equity – the poorest benefited the most from free services, as evidenced by more equal service usage stats after 2009. However, free services strained government budgets and logistics (to supply free drugs, etc.). The policy intent was noble and aligned with the constitutional right to health, but implementation challenges included frequent drug stock-outs (because demand increased without commensurate supply increase) and quality concerns (shorter consultation times due to patient load). Over time, the government refined the free care package and increased the list of free essential drugs to 70 items. Still, by mid-2010s, surveys showed many patients were technically going to “free” public facilities but still paying out of pocket – either buying medicines outside or seeking care in private clinics due to perceived low quality. So, free care, while a foundation of UHC, needs parallel improvements in quality and availability.
The Social Health Insurance (SHI) scheme (also called National Health Insurance) was introduced to tackle costs beyond primary care and to cover the growing burden of chronic diseases. Piloted in 2016 and legally mandated in 2017 (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text), the program offers households coverage of up to NPR 100,000 per year for a range of services in exchange for an annual premium (NPR 3,500 for family of five, with government subsidies for poor and vulnerable groups). The intent is to protect families from catastrophic expenses and to pool risk nationally. By 2022, the insurance was rolled out to all 77 districts (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text), and about 21% of Nepal’s population had enrolled (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). While this is progress, enrollment has lagged behind the 100% target (the goal was universal enrollment by 2022) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). Reasons include limited awareness, inability to pay premiums for some, and dissatisfaction with the scheme’s perceived benefits (some join, use it once, then drop out if they feel it’s not worth the cost). Hospitals have had issues with delayed reimbursements, causing a few to temporarily stop accepting insurance patients (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). The challenges at policy and implementation levels – as studies note – include high dropout rates, concern among providers about low payment rates, and the administrative capacity of the Health Insurance Board (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). Despite these issues, SHI has provided financial relief to tens of thousands of families for surgeries, inpatient care, and chronic disease treatments. For instance, dialysis for kidney failure, which is expensive, is now covered for insured patients, and the government separately funds it free for all as a commitment. The sustainability of SHI will depend on increasing the enrollment of healthy individuals (to balance the risk pool), possibly raising government subsidies, and improving scheme management.
Healthcare financing reforms also included increasing government health budgets gradually and seeking innovative financing. By 2021, health received about 9-10% of the national budget – an increase in absolute terms, but still below the 10-15% recommended for low-income countries. The Economic Survey 2021 highlighted the need for more investment to meet constitutional guarantees (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). Nepal has also tried performance-based grants to provinces, and some local governments levy local taxes that partly fund health activities (like ambulance services).
Importantly, the constitution and laws have institutionalized the right to health. This means citizens can hold the government accountable legally if basic services or emergency care are denied. While practical enforcement is evolving, it puts pressure on authorities to allocate resources to health. For example, a court case in 2019 forced the government to supply life-saving drugs for children with certain rare diseases, citing the right to health.

Quality of Care: As coverage expanded, quality emerged as a central issue. The 2018 Lancet Global Health Commission on High-Quality Health Systems included a case study on Nepal, noting that improving quality (effectiveness, patient-centeredness, safety) is essential for UHC – “if not now, when?” (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). The government responded by developing a National Quality Assurance Policy and establishing a Quality Improvement division in the Ministry. Some hospitals have begun accreditation processes, and provinces are tasked with monitoring quality in facilities. Still, quality regulation is in infancy: e.g., no nationwide hospital accreditation system yet, and patient feedback mechanisms are weak. Addressing this will be key in the next phase of health system strengthening so that expanded coverage translates into better health outcomes.

Community Participation and Accountability: Nepal’s policies often stress community engagement – from village health committees to hospital development boards – to ensure the health system is accountable and culturally appropriate. The experience has been mixed. Where communities are active (e.g., managing birthing centers or raising funds for health post buildings), services tend to be more responsive. The challenge is keeping communities engaged beyond specific programs like FCHVs. The federal structure actually gives local elected leaders a direct stake in health services, which is promising for accountability. Early signs show some mayors are very invested in improving local clinics (seeing it as a deliverable to voters). The health sector needs to harness this political will with proper technical support.

Key Outcomes and Looking Ahead: By 2025, Nepal’s health system has made major strides: It is more accessible, somewhat more affordable, and backed by stronger policies and laws than ever before. Notably, Nepal has extended basic health services to virtually all its population (geographic coverage), removed primary-level user fees, and initiated social health protection – components that many low-income countries struggle with. These efforts are reflected in improved utilization and health outcomes (as described in earlier sections).

However, as Nepal chases UHC by 2030, the health system must tackle next-generation issues: quality, equity, and resilience. There are still gaps between policy and practice – for example, the persisting high out-of-pocket expenditure (around 50% of total health spending) indicates many services or medications are not yet affordably accessible despite free care and insurance (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text) (Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? | Health Research Policy and Systems | Full Text). Perhaps those are costs for outpatient specialist care or diagnostics not covered by current policies. Bringing those under financial protection will be important.

Another future focus is digital health – Nepal’s draft Digital Health Strategy envisions using telemedicine, e-health records, and mobile health solutions to overcome physical barriers and improve efficiency. The pandemic accelerated some of this (teleconsultations grew when lockdowns stopped travel).

Finally, health systems resilience – climate change is causing more floods/landslides, and emerging diseases pose new threats. The health system’s ability to absorb shocks (like COVID or earthquakes) and continue essential services is now a policy priority. Investments in emergency preparedness, supply chain reforms (e.g., building buffer stocks of medicines and regional logistic centers), and flexible financing are part of current plans.

In summary, Nepal’s health system in 1990 was under-developed but uncomplicated (limited services but low usage). By 2025 it has become far more complex, with multiple layers of government, public-private mix, and diverse health needs. The reforms and policies implemented over 35 years have generally strengthened the system – evidenced by more health workers, facilities, and service outputs – yet they also uncovered new issues to address. The quest for Universal Health Coverage is ongoing, guided by the principle laid in 1991 and constitutionally mandated in 2015, that every Nepali deserves access to health care without financial hardship. With strong foundational policies in place, Nepal is poised to continue making strides towards that goal, provided it maintains commitment and adapts to the lessons learned from past implementation challenges.

Conclusion

From 1990 to 2025, Nepal’s health sector journey has been one of remarkable progress, guided by an evolving policy landscape that consistently pushed for broader access, better quality, and greater equity in health care. Starting from a period when health indicators were among the poorest in the world, Nepal’s national health policies – spanning safe motherhood, infectious disease control, nutrition, health financing, and systemic reforms – have contributed to transformative gains. Child mortality plummeted, maternal deaths sharply declined, and life expectancy jumped by nearly 20 years (Nepal’s story: Understanding improvements in maternal health – – Research reports and studies) (Health in Nepal – Wikipedia). Communicable diseases that once raged have been tamed: polio, leprosy, and neonatal tetanus were eliminated as public health problems ( Implementing Federalism in the Health System of Nepal: Opportunities and Challenges – PMC ), and HIV contained to a low-level epidemic. These successes are a testament to sound policies like the 1991 National Health Policy focusing on primary care, the bold Free Health Care policy ensuring basic services for all (Fed_Draft-01_19Apr09), and targeted programs that leveraged community engagement (e.g., FCHVs) and international support in a coordinated way.

At the same time, Nepal’s health policy story is also about addressing new challenges and learning from setbacks. The rise of NCDs and the transition to federal governance tested the system in recent years, revealing gaps in quality and access that policies are only beginning to tackle. Implementation has not always kept pace with policy ambition – for example, enacting a right to health is easier than making it a reality in the most remote village. Many reforms, such as health insurance, are works in progress that require persistence and mid-course adjustments in response to evidence (like simplifying enrollment processes or increasing provider payment rates). The stagnation of maternal mortality in the last half-decade shows that constant effort is needed to avoid complacency ( Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants – PMC ). Moreover, equity remains a concern: averages have improved, but not all population groups have benefited equally. The poorest, certain rural residents, and some marginalized communities still face hurdles in obtaining quality care. Future policies must explicitly target these gaps, possibly through more refined pro-poor strategies or area-specific interventions (e.g., special programs for the mountainous regions).

A few cross-cutting lessons emerge from Nepal’s experience for health policy and systems:

Political commitment and continuity: The dramatic improvements in health wouldn’t have happened without sustained political will. Across changing governments and even through conflict, core health programs (like immunization, safe motherhood) were maintained and scaled up. The constitutional enshrinement of health rights in 2015 was a pinnacle of this commitment, creating a non-reversible mandate for health investment.
Community-based approaches: Many of Nepal’s gains were achieved by empowering communities – be it volunteer health workers distributing remedies, mothers’ groups promoting health practices, or local health management committees overseeing clinics. National policies that created space for community engagement proved very effective in increasing coverage and uptake of services.
Integrated and sector-wide planning: Nepal’s use of a unified sector strategy (NHSP) aligned government and donor efforts behind common goals (National health policy 2071 | PPT). This ensured that health system strengthening (training, HMIS, drug supply) underpinned specific disease programs. The integration of services at the point of delivery (e.g., one health post provides MCH, TB, family planning, etc.) made it easier and more efficient for people to receive care – a hallmark of a primary health care approach.
Evidence-informed policy and innovation: Nepal often piloted new ideas (cash incentives for births, insurance models, telemedicine, etc.) and used data from DHS surveys and research to inform decisions. For instance, recognizing unsafe abortion’s toll led to law change, and seeing the financial barrier to care led to free services policy (Fed_Draft-01_19Apr09). Willingness to innovate – and to adapt global best practices to local context – has been an asset.
Challenges of implementation and the importance of strengthening institutions: Good policies alone are not enough; Nepal’s struggles with staffing remote clinics or managing the health insurance fund highlight the need to build robust institutions and administrative capacity. Decentralization offers opportunities for more responsive services, but only if local institutions are strong. Ongoing reforms in public financial management, procurement systems (to avoid stock-outs), and accountability mechanisms are crucial to translate policy into performance.

Looking ahead, Nepal’s aim is to achieve the Sustainable Development Goals (SDGs) for health, including Universal Health Coverage by 2030. The period from 2025 to 2030 will likely focus on consolidating the UHC pillars: ensuring quality of care, expanding financial protection (perhaps by fully institutionalizing the insurance and increasing the government funding share), and reaching the hard-to-reach populations. Additionally, emerging issues like climate change impacts on health, air pollution in cities, and an aging population will demand policy attention (for example, geriatric health services and air quality regulations as health measures). The groundwork laid by national health policies over 1990–2025 puts Nepal in a strong position to tackle these challenges. As a lower-middle-income country now, Nepal has more domestic resources to invest in health than before, and the experience of what worked (and what didn’t) in the past 35 years to guide future strategies.

In conclusion, Nepal’s health policy evolution from 1990 to 2025 is an inspiring narrative of commitment to public health and social justice. It exemplifies how a poor, landlocked country can, through wise policy choices and community-centric approaches, make great strides in health outcomes. Maternal health, once a dire situation, has improved such that tens of thousands of women’s lives have been saved. Children born today in Nepal are far more likely to survive and thrive than those born a generation ago, thanks to immunization and nutrition policies. And people in remote villages now have basic health services at their doorstep, reflecting the fulfillment of the primary health care promise. The road was not easy – fraught with political instability, conflict, natural disasters, and limited resources – but Nepali health workers, communities, and policymakers demonstrated resilience and innovation. The successes achieved provide valuable lessons for other countries and a strong foundation upon which Nepal can continue to build a healthier, more equitable future for all its citizens.