How did Nepal implement?

Nepal has made neonatal and maternal mortality reduction a key goal of its public health agenda in recent decades, as highlighted by several key policies that target vulnerable communities and focus on expanding access to care. This section of the narrative briefly summarizes Nepal’s health care system for context, then highlights selected programs that have been instrumental in reducing neonatal and maternal mortality in the country. A more complete policy timeline can be found in the Milestones section.

Health system organization

Nepal’s health system is divided into federal, provincial, and local levels with distinct responsibilities over policymaking, financing, and facilities. The health system’s structure has changed over the last 20 years, alongside political shifts and efforts to localize decision-making. Today, the system has a variety of services led by the public sector, private sector, and nongovernmental organizations (NGOs). Public health care services are used by most of the population, while wealthier residents and those in urban areas access private services more frequently.¹ Services are delivered at levels ranging from large central hospitals to basic health care centers, as shown in Figure 25. Most aspects of maternal and newborn care have been incorporated in a basic health care package, which has been available free of charge at public facilities for all Nepali citizens since 2007.² This package is discussed further in the health insurance sub-section in the How did Nepal implement? section. A 2019 budget analysis of the health sector shows that Nepal spent 43% percent of its budget for free care and treatment on maternal and child health.³

Both federal and provincial levels are responsible for policymaking and lawmaking, quality and standards, and management of health services. At the federal level, Nepal’s Ministry of Health and Population (MOHP) is split into five divisions, 16 sections, and three departments: the Department of Ayurveda (traditional medicine) and Alternative Medicine, the Department of Drug Administration, and the Department of Health Services. The Department of Health Services is split into seven divisions and five centers, as shown in Figure 21. Child health, immunization, maternal health, neonatal health, family planning, reproductive health, and nutrition fall under the Family Welfare Division. This division is supported by other MOHP divisions that coordinate training, set standards, develop communication strategies, and improve infrastructure, supplies, and human resource availability. The federal government is responsible for managing medical college hospitals, specialized hospitals, and six district, zonal, subregional, and regional hospitals not managed by provincial governments.²

Provincial health authorities are split up into two divisions to reflect their responsibilities: a division leading hospital development and curative services, and a division leading policy, law, standards, planning, and public health.⁴ Within each division are multiple departments: a provincial health directorate, logistics management centers, training centers, public health laboratories, and an emergency operations center. The provincial health directorates oversee more localized district-level health offices, as well as nearly all existing district, zonal, regional, and subregional hospitals, which provide more advanced care than facilities at the local level.² These levels of care are linked by a coordinated referral system, which remains a challenge but is being strengthened at all levels.²

Since the ratification of the 2015 constitution, Nepal’s health system has trended toward putting more management and financing responsibility on the local government.² At the local level, municipal authorities are responsible for infrastructure, medical products and equipment, and staffing for community and local hospitals with fewer than 15 beds, primary health care centers (PHCCs), health posts, and other similar health facilities. Staff at the community level, such as female community health volunteers (FCHVs), are also coordinated by the municipal level of government.⁴ This level of the health system is the primary point of access for most citizens and serves as an entry point for referral to advanced care.

Nepal’s health system also has many local and international NGOs working alongside the government to strengthen healthcare systems, especially to reach vulnerable populations. NGOs have made significant contributions to Nepal’s healthcare system in capacity building activities and health promotion activities, among many other areas.⁵

Throughout the past few decades, Nepal’s health system has demonstrated a learning approach to policy and program development and health system strengthening.⁶ The system’s commitment to learning was shown through gathering and reflecting on data, using pilot programs, and acting on local and global evidence. These adaptive learning and implementation processes were fostered by collaborative efforts between the MoHP and a variety of partners including professional organizations, NGOs, researchers, and international agencies – and ultimately helped improve MNCH outcomes.

Access to care

Access to health facilities in Nepal has improved greatly over the past 20 years. Travel times to a health facility have decreased overall: in 2011, 86% of the population could access any health facility in 30 minutes, compared with 45% in 1995, according to the Nepal Living Standards Survey for those years.^7,8 A separate 2021 analysis mapping out all public health facilities in the Nepal Health Facility Registry also found that 95% of the population could access a public health facility within a 60-minute walk and 93% could access a public health facility within 15 minutes using a motor vehicle.⁹ Travel times were longest in the northern mountainous parts of Karnali and Sudurpashchim.⁹

Overall, substantial reductions in time to access health facilities, especially in rural areas, are an achievement given the mountainous terrain in parts of the country. The trend of improved access to health facilities is also consistent across all wealth quintiles, as shown in Figure 25. These improvements in facility access are driven by an increase in facilities, improvements in road infrastructure, increased vehicle ownership, and urbanization. Specific road infrastructure improvements include an increased total road length from approximately 15,000 kilometers in 2000 to approximately 77,000 kilometers in 2022 and an increased percentage of vehicle-passable roads from 58% in 1996 to 80% in 2011.^7,8,10,11

Emergency medical transport in Nepal is operated by a variety of stakeholders, including trusts, nonprofits, and private hospitals, each with varying levels of equipment and staffing. Nepal established its first organized ambulance service in 2011, called the Nepal Ambulance Service (NAS).¹² NAS is a private nonprofit with government support. It operates fully equipped ambulances with trained emergency medical technicians. NAS launched in the greater Kathmandu area with five ambulances and grew to a fleet of 40 by 2020.¹² As of 2020, NAS was beginning to expand to surrounding hill areas.

Nepal also uses a helicopter-based emergency service, with both private and army helicopters, for women in rural and remote settings who need referral due to complications.¹² However, the cost of a helicopter rescue is high, especially for private services. In 2018, the government built on smaller-scale initiatives to launch the President’s Women Upliftment Programme, providing free helicopter rescue for delivery emergencies in remote parts of Nepal.^12,13,14 Women are airlifted to the nearest hospital and can be accompanied by some family members or caretakers. The program has a dedicated annual budget (50 million Nepali rupees, or NPR) and is accessible to women and their families via a hotline number.¹⁵ By 2022, this program had provided helicopter referrals to 304 women.¹⁴ Women must live in one of 19 remote districts or remote parts of 29 additional districts to be eligible for this program.¹⁵ They must also meet one of the program’s eligibility criteria: prolonged labor, stillbirth, complicated pregnancy, or postpartum hemorrhage (PPH).¹⁵ Although this program is limited to high-risk women in remote settings and helicopter response times can vary, this initiative highlights Nepal’s commitment to reaching women in areas that are difficult to reach and often have challenging topography.

Health facilities

In the Nepal Safe Motherhood and Newborn Health Road Map 2030, the MOHP encourages women to deliver at comprehensive emergency obstetric and newborn care (CEmONC) and basic emergency obstetric and newborn care (BEmONC) sites if these facilities are within 2 hours of travel.² By 2018, every district in the country had at least one hospital; the MOHP suggested in the Nepal Safe Motherhood and Newborn Health Road Map 2030 that each municipality should have at least one BEmONC health facility.² Nepal has substantially expanded the number of birthing centers and BEmONC sites, from 291 sites in 2008 to 2,296 sites in 2018.² Alongside increasing the number of facilities, Nepal also systematically improved the range of services provided at facilities.² Figure 26 below shows the number and type of key facilities providing maternal, neonatal, and reproductive health services according to the 2021 Nepal Health Facility Survey.¹⁶

Facility expansion has enabled Nepal to shift a large percentage of deliveries to hospitals. From 2001 to 2022, hospital deliveries increased from 7.3% of deliveries to 61.6% of deliveries.¹⁷ Deliveries at lower-level facilities, such as PHCCs and basic health care centers, also increased from 1.8% of deliveries to 15.7% of deliveries over this same time period.¹⁷ Delivering in a hospital instead of a lower-level facility confers access to more advanced forms of care in case of complications during birth.¹⁶ For example, all essential medicines for delivery were available in 2022 at 84.4% of federal- and provincial-level hospitals, 42.1% of local-level hospitals, and 54.5% of private hospitals, as compared with only 12.2% of basic health care centers.¹⁶ C-section delivery was available in 2022 at 81.9% of federal- and provincial-level hospitals, 24.3% of local-level hospitals, 48.3% of private hospitals, and 0.5% of PHCCs.¹⁶

Currently, Nepal is focusing on upgrading existing facilities and improving referral and emergency transport networks between facilities. One example underway in 2021 was the scaling up of midwife-led obstetric units next to large hospitals to avoid overcrowding in facilities.² In 2010, Nepal also initiated provision of referral funds to hospitals where CEmONC services were not available to support transport of women in need of higher-level care.² Focusing on quality of care improvements in hospitals will also help ensure that all women and newborns receive the care they need.¹⁶ In terms of further facility expansion, new facilities are only built where there are large access challenges, such as creating birthing centers in areas that are more than 2 hours of travel from a PHCC or district hospital.²

Health insurance

Prior to the turn of the 21st century, Nepal had a handful of small community-based health insurance (CBHI) programs, based in a facility or local area.^{18 ,19} In 2007, the government introduced an initiative to broadly remove fees from health care services, called the Free Health Care program.¹⁸ The Free Health Care program covered outpatient and inpatient services at health posts, sub-health posts, and PHCCs for the whole population.¹⁸ It also covered a list of approximately 30 medicines provided at these three facility types as well as district hospitals.17 Additionally, this program covered the cost of services provided by district hospitals for disadvantaged groups.¹⁸ The MOHP conducted a rapid assessment of the program in late 2008, finding substantial increases in service use across various facility types after the program was implemented.²⁰ Nepal’s adjustments to the policy were informed by these assessments, showing another example of adaptive learning at the system level.

Momentum around health insurance continued to build as the new constitution was being developed in the years leading up to 2015; all political parties were advocating for the creation of an expanded health insurance system to reduce out-of-pocket costs for households.²¹ Various policies, legal frameworks, governance acts, and regulations were endorsed between 2013 and 2019 to set up the National Health Insurance Program (NHIP).^21,22 The NHIP pilot occurred in three districts in 2016 and was rolled out nationally starting in 2017.²³

As of 2023, all citizens, governmental employees, migrant workers, and their families were eligible for coverage by the NHIP.²¹ Included services were all preventive, diagnostic, and curative services, including outpatient and inpatient treatment, medicines, and equipment.²¹

According to a 2023 assessment, the NHIP expansion made admirable progress from 2016 to 2022: the NHIP had been expanded into all 77 districts and 745 local governments. In July 2022, 5.66 million people from 1.74 million households were enrolled in the NHIP, representing 21.4% of the population.²¹ Usage rates had increased since the program’s inception, with approximately 28% of the insured population using NHIP services in the year.²¹ However, challenges remain in implementation as the program grows: The government’s goal was to enroll 100% of the population in the NHIP. The annual dropout rate in 2022 was 25.5%, with beneficiaries citing reasons such as health service underuse, poor health care services, and insufficient benefit packages.²¹

Maternal and perinatal death surveillance

Nepal started to track maternal and perinatal deaths in recent years by establishing the Maternal and Perinatal Death Surveillance and Response (MPDSR) system in 2015.²⁴ This system was built on existing processes that were established in hospitals starting in 1990 when a maternal death review process was implemented at Paropakar Maternity and Women’s Hospital.²⁴ Doctors and nurses in public hospitals were trained for maternal death review in 2002 and 2003. The process was revised in 2003 to include perinatal deaths, and it was expanded to more hospitals over the following decade. In 2015, the MOHP released a national guideline outlining maternal death surveillance and response at the community and hospital levels, as well as MPDSR at the district, regional, and national levels.²⁴ The 2015 guideline sets up the infrastructure for a continuous surveillance system that links mortality information and quality improvement processes from local to national levels.²⁴ By 2019, 77 hospitals were implementing facility-based MPDSR and 11 districts were implementing community-based maternal death surveillance and response.²⁵ As of 2021, 27 out of 77 districts were using the MPDSR system, as well as 94 hospitals; expansion to more districts and hospitals will continue.²⁶ In 2024, the MOHP has been working to expand the MPDSR system to a total of 55 districts.²⁷

Death reporting was made mandatory at all health facilities and local levels during the COVID-19 pandemic, improving the tracking of causes of death and enabling the formulation of action plans to prevent similar deaths in the future.²⁸ PPH was identified as a leading cause of maternal death in 2020 from the MPDSR data. In response, the national government developed a PPH management package, ensuring the availability of drugs and commodities in hospitals, as well as staff preparedness. The Family Welfare Division of the MOHP will continue to strengthen the MPDSR, develop action plans, and implement those plans for quality improvement.^28,29

Female community health volunteers program

The female community health volunteers (FCHV) policy was introduced in 1988 and was scaled up nationally by 1992. In 1991, there were 20,000 FCHVs, and by 2020, the cadre had grown substantially to over 51,000.^30,31 Commonly known as mahila swoyemsewika, FCHVs are typically local women over 25 years of age who receive 18 days of training in various primary health care topics, including maternal and child health care services.³² FCHVs usually work part time, averaging approximately 7 hours per week, but this number can vary depending on the location in which they serve.³³ FCHVs are also discussed as an integral component of providing community-based health care in the Exemplars in Global Health research about under-five mortality reduction in Nepal.

FCHVs work at the community level, making door-to-door visits and providing services to clients in their homes to offer promotive and preventive health services. For the first four years of the FCHV program, FCHVs provided family planning commodities such as condoms and pills, counseling on maternal health and antenatal care (ANC), control of acute respiratory diseases, promotion of immunization services, and referrals to primary care facilities.³³ As time went on, the roles of FCHVs were expanded to include supporting diarrhea prevention, provisioning oral rehydration solution packets, and distributing vitamin A. Over time, FCHVs’ roles were further expanded to include deworming, conduct of polio campaigns, zinc therapy distribution, integrated management of childhood illnesses, and collection and reporting of demographic data to an intermediary in the community.³⁴ Specific responsibilities varied by region as the program was tailored at the regional level.

Some specific years for FCHV program broadening are as follows:

• Vitamin A distribution in 1993
• Deworming and treatment of other neonatal and childhood illnesses in 1999
• Iron folate distribution for pregnant women in 2003
• Zinc therapy distribution for diarrhea in 2006
• Provision of community-based newborn care package in 2007
• Misoprostol distribution in 2010
• Implementation of additional newborn care interventions from 2008 to 2011

FCHVs help bridge health facilities and communities, motivating women and their families to access health services. Though their role and responsibilities varied by region, they are widely recognized as playing an important role in creating awareness, referring clients to health care services, and ultimately contributing to improved health outcomes in Nepal.

Additionally, FCHVs used to lead participatory mothers’ groups in the community. These were groups of women who met monthly to discuss and address local health issues, especially reducing maternal and perinatal mortality in their communities. These interactions were an important part of disseminating health information in communities. However, FCHV roles have been shifting as access to other forms of media and information have increased and institutional delivery has become more of a norm in many areas.

FCHVs are widely acknowledged as playing a key role in expanding health services in communities, as described by one individual who works at a health care provider organization:

A qualitative study in 2023 suggests that FCHVs also played a key role in maintaining access to essential health services after the 2015 earthquake, despite being victims of the disaster themselves.³⁵ FCHVs roles expanded to include treating the injured, providing psychosocial support, empowering and mobilizing communities, providing supplies, guiding medical teams, and monitoring and preventing outbreaks of infectious disease.³⁵ This cadre of active and dedicated women is acknowledged in the study as helping build resilience in Nepal’s health system.

Figure 27 shows some of the key attributes of the FCHV profile and program characteristics, as outlined in a government- and NGO-run program assessment in 2014 administered to 4,302 FCHVs.³³

Legalization of abortion and expansion of abortion services

Abortion was formally legalized in Nepal in 2002; it had been prohibited prior to this date. Data from the 1998 National Maternal Mortality and Morbidity Study from the Nepal MOHP suggest that approximately half of gynecologic and obstetric hospital admissions were related to unsafe abortion.^36,37 The decision to provide safe abortion services in Nepal was catalyzed by advocacy work by civil society, women’s rights activists, and the Nepal Society of Obstetricians and Gynaecologists. Safe abortion services, including postabortion provision of contraception, were introduced in 2004 and scaled up across the nation over several years. Other key milestones are described in Figure 28.

From 1990 to 2004, maternal abortion- and miscarriage-related deaths constituted a large part of Nepal’s maternal mortality, accounting for 14% of overall maternal mortality in 1990 and 6% of overall maternal mortality in 2004.³⁷ Seventeen years after the first legal abortion was performed in the country, abortion- and miscarriage-related maternal mortality was estimated to have decreased by 59%, accounting for only 4% of overall maternal mortality in 2021.³⁸ More information about maternal causes of death is explored in the Why Is Nepal an Exemplar? section.

To improve access to abortions across Nepal’s diverse geographic terrain, Nepal started to train healthcare providers in safe abortion services. Surgical abortions were introduced in 2003, and medical abortions were introduced in 2009. The type of abortion and the timing at which it can be performed vary by the provider’s qualification.³⁹ Auxiliary nurse-midwives (ANMs) can provide medical abortion up to 10 weeks gestation; staff nurses can perform surgical and medical abortion up to 10 weeks gestation; MBBS doctors can perform both services up to 12 weeks gestation.³⁹ Abortions from 13 to 28 weeks gestation can only be provided by obstetrician-gynecologists and general practitioners.³⁹

Training midlevel providers, such as nurses and ANMs, to deliver abortion services has enabled broader access of abortion care services in rural and remote areas, especially medical abortions. Task shifting has increased the number of qualified providers: as of 2021, the number of trained providers was 4,500 clinicians, with 57% of this group being ANMs and nurses.³⁹ A government official shared their thoughts about the importance of legalizing abortion for women’s health and about how Nepal scaled up services:

Nepal has been able to successfully scale up abortion access: Data from the 2021 Health Facility Survey suggest that of the facilities that provide normal vaginal delivery services, 95.5% of federal- and provincial-level hospitals, 53.6% of local-level hospitals, 75.4% of private hospitals, and 65.2% of PHCCs provide medical abortion services.¹⁶ Approximately 19.9% of health posts are also able to offer this service to clients. Furthermore, comprehensive abortion care is available at 93.3% of federal- and provincial-level hospitals, 39.7% of local-level hospitals, and 69.5% of private hospitals, and 31.5% of PHCCs.

Despite this notable progress in service expansion and access, comprehensive abortion care facilities are mostly located in terai and hill ecological zones, which tend to have higher population densities. Some challenges also remain with awareness about abortion legality in Nepal and compliance with service standards: the 2016 Demographic and Health Survey suggests that only 41% of women knew that abortion was legal and only 51% of abortions were carried out at authorized sites.⁴⁰ The Nepal Safe Motherhood and Newborn Health Road Map 2030 proposed a plan to increase the number of certified sites and ensure comprehensive abortion care is available at all health facilities that provide BEmONC services.²

Safe motherhood plans

Nepal has established several safe motherhood (aama surakshya) plans: the first plan spanning from 1993 to 1997, the second plan from 2002 to 2017, and the most recent plan from 2019 to 2030. The goals of safe motherhood plans are to ensure a healthy life for all mothers and newborns and improve their overall well-being.⁴¹ Figure 29 shows highlights in the safe motherhood plans from 2005 to 2018 and articulates how the policy has evolved over the years, including how incentives were introduced for a larger range of services, in a larger number of districts, across the continuum of care.⁴¹ This section discusses components of the safe motherhood plans, including various incentive programs and the policy on skilled birth attendance.

Incentive programs

Several types of incentives were introduced over time as part of the safe motherhood plans. The Maternity Incentive Scheme was a key policy introduced in 2005 to decrease financial barriers to accessing maternal and newborn care services.⁴¹ This program made cash payments directly to all women who delivered in a government health institution. Shortly after it was established, it introduced incentives for health workers and health facilities. The payment to women varied according to geography—NPR 1,500 in the mountains, NPR 1,000 in the hills, and NPR 500 in the terai—to reflect the higher travel costs in mountainous areas.⁴¹ The payment was meant to contribute to the transport costs of reaching a health institution, not to fully compensate women for all travel expenditures they incur. Since the introduction of the Maternity Incentive Scheme, transport costs have been part of all subsequent programs.

In 2006, the Maternity Incentive Scheme was renamed the Safe Delivery Incentive Programme. User fees were removed for women, and free delivery care was introduced in 25 districts with the lowest Human Development Index.⁴¹ All 17 mountain ecological zone districts were among the 25 districts with the lowest Human Development Index, plus 8 hill ecological zone districts.⁴¹ Government health facilities were also paid NPR 1,000 for every delivery performed regardless of the complexity of the delivery or the length of stay.⁴¹ Additionally, health workers in these 25 Safe Delivery Incentive Programme districts received a payment of NPR 300 for each delivery conducted regardless of whether the delivery was in a health institution or at home.⁴¹

User fees were removed for all districts in 2009, making delivery care available free of charge to all Nepali women. The program was also expanded from government health facilities to additionally cover some certified NGO-run and private health facilities. Facilities that could not provide CEmONC services were given funds to support referral costs. The payment for health workers’ conduct of home-based delivery was also gradually reduced and eventually removed in 2009.⁴¹ Additionally, the government introduced the incentive program that paid women NPR 400 when they completed four ANC visits as well as delivery in a health facility and one postnatal care visit.

The Safe Delivery Incentive Programme policy to abolish user fees was implemented in response to concerns about the level of out-of-pocket expenditures in the National Health Accounts, as well as the belief that it was key for Nepal to achieve the Millennium Development Goals related to increasing in-facility births. This policy also reflected global evidence suggesting that the abolition of user fees was a key strategy for encouraging institutional delivery.

Nepal’s actions to develop the Safe Motherhood policies are one example of adaptive learning and implementation processes in the health sector.⁶ Over time, these policies were evaluated with local assessments, and adapted based on the evidence so that challenges could be addressed. For example, an evaluation of financial incentives for maternal health, published in 2012, suggested that many women did not know about the Safe Delivery Incentive Programme or did not receive payments even if they attended facilities.⁴² Following the report, the Family Welfare Division of the MOHP commissioned 10 rounds of rapid cross-sectional, mixed-method studies to appraise the program. The 10th rapid assessment was conducted in 2017 across 11 districts and 69 health facilities, gathering data about usage of the delivery, transport, and ANC incentives; budgeting; quality of care; and other topics.⁴³ In each round, discussions took place both at national and district levels about how to address and resolve identified problems. This resulted in adjustments to policies, funding amounts, management structures, and training programs, such as an increase in the incentive amounts in 2018, as reflected in Figure 29.⁴¹

Overall, the government in Nepal has prioritized access to maternal and newborn health via the safe motherhood plans, ultimately contributing to reductions in maternal mortality and neonatal mortality. A senior public health official shared their view:

National policy on skilled birth attendants/h4>

Nepal introduced its National Policy on Skilled Birth Attendants⁴⁴ in 2006 to improve the skill quality of maternal, newborn, and child health (MNCH) staff; the policy recommendations for doing so are outlined in Figure 30. A subsequent HRH strategy draft, produced in 2012, has also contributed greatly to the broader growth of HRH in Nepal. A range of improvements in quality of care across ANC, family planning interventions, and institutional delivery (described in the What Did Nepal Do? section) suggests that investments in human resources for health are paying off.⁴⁵

Skilled birth attendance has also increased since this policy was enacted, from 26.0% in 2006 to 81.5% in 2022.¹⁷ Data from the 2021 Health Facility Survey¹³ found that higher percentages of delivery care staff have undergone structured delivery care training: 53.2% of staff in federal and provincial hospitals, 53.4% of staff in local-level hospitals, 25.2% of staff in private hospitals, and 48.2% of staff in PHCCs. In 2020, the National Health Training Center recorded the training of 9,489 skilled birth attendants (SBAs) via actions introduced in this policy.⁴⁶

Nepal has developed a range of MNCH-specific trainings for various cadres to upgrade the skills of existing cadres. Some of these trainings are described by a senior nursing official as follows:

Upskilled staff are especially crucial to improve the quality of care in remote areas where human resources for health can be scarcer. This is emphasized by a senior nurse:

While upgrading existing cadres, Nepal is also in the process of training a new professional midwife cadre for skilled MNCH care. Several universities have established a bachelor's degree program in midwifery, and the first few years of graduates have completed the program as of 2023. Over the long-term, Nepal plans to transition to midwives as the frontline providers of maternal and newborn health services.

Evidence suggests that several challenges still remain in terms of reaching full coverage of skilled birth attendance, especially when implementing the policy in rural areas. An evaluation of the SBA policy, administered to 502 staff across 15 districts, was commissioned by the MOHP in 2018.⁴⁷ It found that some staff scored poorly on clinical skills assessments. One key explanation was that only 7% of SBAs—and even lower in the mountain ecological zone—met the World Health Organization bar of conducting 15 deliveries a month to maintain minimal competencies.⁴⁷ Nepal then initiated programs to address these issues, such as a follow-up and enhancement program for SBAs, which provided supportive supervision and in-service training.⁴⁸ As of 2021, this program had been implemented in 47 districts throughout Nepal.⁴⁸ Women are now encouraged to deliver in facilities with higher volumes of deliveries, where they will be cared for by better-trained staff who see a larger number of deliveries and thus able to maintain their skills for both normal and complicated deliveries. Gaps in geographic distribution of HRH in Nepal remain in rural and remote areas, with recent policies aiming to mitigate shortages of health professionals.

Nepal also released a new strategy for 2020 to 2025 for skilled health personnel and SBAs, as well as the national HRH strategy from 2021 to 2030.⁴⁶ These strategies build on the 2006 policy and previous HRH initiatives, recognizing the need to improve the skills, training, and deployment of SBAs. Actions to take include improving the modular training package for maternal and newborn health service providers, strengthening the guidelines for continuous professional development, improving opportunities for on-site mentorship, and deploying skilled health personnel to roles that match their skills.⁴⁶ The broader strategy continues to improve strategies to recruit, motivate, and retain HRH in Nepal.

Postpartum hemorrhage prevention program

Nepal had high maternal mortality due to PPH at 211 deaths per 100,000 live births in 1990. Uterotonic availability during delivery was very low, approximately 3.2% of births in 1996.¹⁷ In 2009, Nepal’s MOHP launched a program targeted at preventing PPH in home births, using distribution of misoprostol to mothers during ANC visits.⁴⁹ The ministry also started improving uterotonic availability at health facilities.

For home births in certain regions, Nepal increased the availability of uterotonics by using FCHVs as a distribution channel, via the advance distribution program, or Matri Surakshya Chakki.⁵⁰ FCHVs preemptively distribute 600 micrograms of misoprostol to women during their eighth month of pregnancy and educate women about usage of the pills during home births. By 2017, this program was operating in 27 of 75 districts, often those in more mountainous areas.⁵⁰ The Nepali government and NGOs led an assessment of the advance distribution program in 2013, interviewing 2,070 women and 270 FCHVs. This assessment suggested that 96% of FCHVs provided advance misoprostol for PPH prevention and 87% of women who received misoprostol from FCHVs and gave birth at home used it for PPH prevention.⁵⁰

Both the facility-based and the FCHV-based programs have resulted in significant increases in misoprostol availability and contributed to maternal mortality reduction. From 2009 to 2020, the availability of uterotonics at in-facility deliveries increased from 20.0% to 76.6%.⁵⁰ Maternal mortality due to PPH decreased 53%, from 111.5 deaths per 100,000 live births in 2009 to 52.7 deaths per 100,000 live births in 2021, 12 years after implementation of the new program. More information about maternal causes of death is explored in the Why Is Nepal an Exemplar? section. According to the lives saved analysis described in the What Did Nepal Do? section, an estimated 2332 additional maternal lives were saved from 2000 to 2022 due to increased availability of uterotonics. In this model, increased availability of uterotonics accounted for 19.7% of additional maternal lives saved over this time period.

However, PPH still remains a leading cause of maternal death in Nepal overall—17% of deaths in hospitals and 23% of deaths at the community level.² Health administration is continuing to address this maternal cause of death by ensuring misoprostol availability in facilities and improving staff training, as discussed in the maternal and perinatal death surveillance sub-section in the How did Nepal Implement? section.