Nepal: An exemplar in neonatal and maternal mortality reduction

Introduction to Nepal

Nepal is a nation of 30 million people, located in South Asia, nestled between northeastern India and southwestern China. Health and social progress are enshrined in the country’s identity: Nepal’s commitment to improving health for all started in 1978 after the Declaration of Alma-Ata. This commitment was reaffirmed in 1990 at the commencement of Nepal’s multi-party democracy.¹ The country underwent a series of political transitions over recent decades. In 2015, it ratified a new constitution that enshrines a right to health, mandating that the government provide basic and emergency health services for all citizens.²

Through these transitions—and challenges such as a civil war and a destructive earthquake—civil society has helped keep the country’s health system progressing, promoting an emphasis on the importance of resilience. This progress is particularly impressive considering that Nepal faces unique geographical challenges inherent to being a highly mountainous country with many hard-to-reach communities.

The maps in Figure 1 reflect Nepal’s population density across three ecological zones in 2000 and 2020, as well as relevant administrative boundaries for the country. From 1982 until 2015, Nepal was divided into five development regions: Far-Western, Mid-Western, Western, Central, and Eastern. These regional boundaries have since been phased out. They were replaced by seven provinces in 2015: Sudurpashchim, Karnali, Lumbini, Gandaki, Bagmati, Madhesh, and Koshi. Figure 1 shows the current provincial boundaries and the former development regions, as well as the ecological zones that overlap within each administrative region.

Nepal’s gross domestic product per capita was US$1,337 in 2022, a large increase from US$224 in 2000.³ Our country selection analysis found that economic progress does not entirely explain Nepal’s progress in reducing neonatal and maternal mortality in recent decades. This narrative will highlight the key policies, programs, and interventions that contributed to rapid neonatal and maternal mortality reduction in Nepal. Nepal was also identified as an Exemplar in under-five mortality reduction, stunting, and vaccine delivery, where similar policies and programs played a role in the nation’s success. Additional details about Nepal are included in the Context section.

Key Insights

Exemplars in Global Health program

The Exemplars in Global Health program aims to learn from countries that have made rapid progress in improving health outcomes and disseminate this evidence to inform health policy and funding decisions. Our aim is to research success stories from low- and middle-income countries and share findings that can be useful for leaders looking to act in comparable contexts.

In selecting Exemplar countries, we review evidence to identify countries that outperformed their peers in vital areas of public health, controlling for factors such as economic growth. In this way, we aim to provide more actionable, policy-relevant insight for stakeholders about how health progress can be made despite resource limitations.

Together with research partners and technical advisers, we conduct quantitative and qualitative analyses to validate our initial assessments and assess factors that contribute to a country’s exemplary performance.

Research in and across Exemplar countries could help ministries, nongovernmental organizations, and multinational bodies better deploy finite resources to address key public health issues in low- and middle-income countries.

By studying proven strategies to prevent disease, malnutrition, and other conditions that burden populations of low- and middle-income countries, we aim to create a list of data-driven narratives that can serve as resources for leaders looking to improve health within their own countries. The following narrative focuses on factors that contributed to rapid reductions in neonatal and maternal mortality in the Exemplar country of Nepal.