- Nepal is a country with a wide range of ethnic, cultural, religious, linguistic, economic, social, and political identities. Despite rapid urbanization, it remains largely rural, with ~30 million people spread out over a mountainous, varied landscape.
- A decade-long Maoist insurgency, which killed or displaced over two million people, began in 1996. While the civil war disrupted the function of most social programs, the health system remained unscathed and even improved during this time period.
- Until 1990, Nepal was ruled by an absolute monarchy. Since then, constitutional reforms and revisions and conflict have led to political instability. Foreign donors and NGOs have stepped in to fill resulting gaps in economic and social development, especially in the areas of education, health, and transportation.
- Nepal’s economy has grown steadily since the late 1990s, but income levels remain substantially lower than the average in South Asia.
|Nepal at a glance||U5MR1
Per 1,000 live births
Per 100,000 live births
|Total fertility rate3
|GDP per capita7
PPP, constant 2011 int’l $
Percent of adults
|49 (2001)||60 (2011)|
|Poverty headcount ratio at $1.90/day9
|46 (2003)||15 (2010)|
Nepal’s recent history is full of challenges, from decades of autocracy through a bloody Maoist insurgency and a period of extreme political instability to the devastating 2015 earthquake. Despite this string of difficulties, Nepal has demonstrated resilience, accelerating both economic growth and progress on most key development indicators in recent years.
Demographics and Topography
Bordered on all sides by the two most populous nations in the world, Nepal is a land apart - a distinctive and diverse country of 30 million people representing a wide range of ethnic, cultural, religious, linguistic, economic, social, and political identities.
A 2011 census found that Nepal’s population includes members of 125 different castes and ethnic groups speaking 123 separate languages. 63 marginalized indigenous peoples make up more than a third of the population; the rest is organized into 59 castes, 15 of them Dalit or “untouchable.”10While the caste system was officially abolished in 1963, it is informally still in effect, particularly in the marginalization of some groups such as the Chamars, Musahars, and Tatma.11
The people of Nepal overwhelmingly live in rural areas, but in recent years, the country has become one of the most rapidly urbanizing in South Asia, with an average urban population growth of six percent since 1970. Many recent migrants to cities have clustered in informal settlements, and slumdwellers are among the populations most at risk of stunting.12
Urban population (percent of total)
Nepal’s diversity is also reflected in the terrain itself. The country is divided into three geographic zones. The remote mountainous region, which includes not only Mount Everest but also seven other peaks above 8,000 meters, constitutes about a third of the nation’s land area but has less than seven percent of its population. A hill zone comprises approximately 40 percent of Nepal’s land and population, including the approximately five million living in the Kathmandu Valley. The terai, or low-lying flatlands, make up less than a quarter of Nepal’s landmass but are home to half of its people.13
Nepal ecological regions
Ruled for almost 200 years first by a king and then by a hereditary prime minister, the Kingdom of Nepal tended to spend little money outside Kathmandu except on the military and the police. Eventually, a pro-democracy movement developed in response to the impoverished, undemocratic condition of the country. Under pressure, the king agreed to a new constitution whereby the government became a multi-party constitutional monarchy in 1990. Although a long period of instability was just beginning, from this moment on, the Government of Nepal pursued a variety of pro-poor investments and policies.
A ten-year-long Maoist insurgency began in 1996, killing over 12,000 people, internally displacing another 200,000, and sending approximately 2 million people across the border into India.14
Surprisingly, the health system continued to improve during the insurgency. Certainly, the violence and destruction it caused were impediments, but since the monarchy’s lack of concern for the rural poor was a major factor in the insurgency, there was pressure on both sides of the conflict to invest in the health system. The Maoist insurgents fought for a more egalitarian health agenda, and the government responded by trying to show that they were already pursuing one. During the conflict, health infrastructure and health workers were rarely targeted.
The insurgency came to an end in 2006 with the signing of a peace deal and the declaration of Nepal as a federal democratic republic; however, the new government was unable to agree on a permanent constitution until 2015. Between 2000 and 2015, there were ten different prime ministers.15
Development and Economy
During these years of political instability, especially those following 1990, foreign donors and NGOs came to play a large role in policymaking and program design and implementation, especially in the areas of education, health, and transportation. For example, the World Bank has funded 12 roads projects in Nepal since the early 1970s, when the country’s road network totaled 2,700 kilometers. Now, it spans over 42,000 kilometers, half the population enjoys access to paved roads, and travel time has dropped nearly 80 percent on average.16
Just under 40,000 NGOs were registered in Nepal between 1977 and 2014, the vast majority after 1990.17 Total donor spending increased from $420 million in 2000 to $1.07 billion in 2015.18
Alongside assistance from external partners, the economy has continued to grow at a steady if unspectacular pace, despite the political instability. GDP per capita grew at about 3 percent per year from 2000 to 2015. As of 2016, it stood at approximately $2,302, still well below the South Asia average of $5,625.7
GDP per capita
Precondition for success
Nepal has made significant progress despite facing imposing barriers. Its terrain is forbidding, making it difficult to build infrastructure and even more difficult for people to access what exists. Moreover, the country is subject to frequent natural disasters, most recently the devastating earthquake in 2015 that destroyed much of the infrastructure built up in previous years. Politically, Nepal ended decades of an autocratic monarchy in 1990, only to witness a decade of a violent insurgency followed by almost a decade of instability and turmoil, with frequent turnover in government and no constitution.
It is important to note that the insurgency in Nepal had less impact on health than many other insurgencies in other countries, because both sides in the conflict were trying to make the point that they could best provide for the health of the people in the wake of the monarchy. In Nepal, the health system and health workers were singled out as safe from the violence, and health indicators did not decline as much as might be expected.
The country’s success in the past two decades has built upon two foundations that have been in place since the 1970s and 1980s.
First, the Female Community Health Volunteers, launched formally in 1988, continued an older tradition of relying on community-based health workers-and they have been a linchpin of Nepal’s health system. They give informed advice and basic care at the community level, and they also provide a key link to the formal health system, bringing information into the community from the center and referring patients in need of specialized care to the appropriate facility. The FCHVs’ responsibilities have expanded along with Nepal’s ambitions for its health system, and the country would not have been able to achieve the results it has without the platform of more than 50,000 volunteers in place.
Second, the donor and NGO landscape has been very active since the 1970s, and donors and NGOs have been critical partners with the government in health, education, and sanitation, not to mention infrastructure, especially road construction. Since 1977, 39,759 NGOs and 189 international non-governmental organizations have been registered in Nepal in various sectors.17 The role of external development partners picked up after 1990, with the creation of the constitutional monarchy, so by the turn of the millennium, many of the most active partners were equipped with a firm understanding of the on-the-ground realities of Nepal.
Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare. Accessed 22 February 2019.
Maternal mortality ratio (national estimate, per 100,000 live births). UNICEF, State of the World's Children, Childinfo, and Demographic and Health Surveys. https://data.worldbank.org/indicator/SH.STA.MMRT.NE. Accessed 19 February 2019.
Nepal Demographic and Health Survey 2001. DHS Program. Kathmandu, Nepal; 2012; Nepal Demographic and Health Survey 2016. DHS Program. Kathmandu, Nepal; 2017
Joint Malnutrition Estimates. UNICEF/WHO/World Bank joint child malnutrition estimates [Internet]. 2018. p. Wasting (national and disaggregated). Available from: https://data.unicef.org/topic/nutrition/malnutrition/.
WHO-UNICEF estimates of DTP3 coverage. WHO vaccine-preventable diseases: monitoring system 2018 global summary. http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tswucoveragemcv1.html. Updated 15 July 2018. Accessed 19 February 2019.
People practicing open defecation (% of population). WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. https://washdata.org/. Accessed 19 February 2019.
GDP per capita, PPP (constant 2011 international $). World Bank, International Comparison Program database. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD. Accessed 19 February 2019.
Literacy rate, adult total (% of people ages 15 and above). UNESCO Institute for Statistics. https://data.worldbank.org/indicator/SE.ADT.LITR.ZS. Accessed 19 February 2019.
Poverty headcount ratio at $1.90 a day (2011 PPP) (% of population). World Bank, Development Research Group. http://iresearch.worldbank.org/PovcalNet/home.aspx. Updated 7 February 2019. Accessed 19 February 2019.
Indigenous peoples in Nepal. International Work Group for Indigenous Affairs. https://www.iwgia.org/en/nepal. Updated 29 May 2018. Accessed 19 February 2019.
Maternal and Child Health in Nepal: The Effects of Caste, Ethnicity, and Regional Identity Further Analysis of the 2011 Nepal Demographic and Health Survey (DHS). DHS Program. 2011. https://www.dhsprogram.com/pubs/pdf/FA73/FA73.pdf. Accessed December 11, 2017.
Mugambwa J, Katusiimeh MW. IGI Global. Handbook of Research on Urban Governance and Management in the Developing World. http://www.sias-southasia.org/wp-content/uploads/2018/07/Challenges-of-Urbanization-in-Nepal-pdf.pdf. Published 2018. Accessed 19 February 2019.
Nepal Population Report 2016. Population Education and Health Research Center (as submitted to the Government of Nepal M of P& E. Kathmandu, Nepal; 2016. http://www.mope.gov.np/downloadfile/Nepal%20Population%20Report%202016_1481259851.pdf. Population Report 2016_1481259851.pdf. Accessed December 12, 2018.
Devkota B, Van Teijlingen ER. Understanding effects of armed conflict on health outcomes: the case of Nepal. Conflict and Health. 2010; 4:20
Nepal gets new Communist prime minister after landmark polls. Agence France-Presse (AFP). https://www.nst.com.my/world/2018/02/335840/nepal-gets-new-communist-prime-minister-after-landmark-polls. Updated February 15, 2018. Accessed February 1, 2019.
Strengthening Connectivity in Nepal. World Bank. http://www.worldbank.org/en/news/feature/2016/02/17/strengthening-rural-connectivity-in-nepal. Published 17 February 2016. Accessed 19 February 2019.
Karkee R, Comfort J. NGOs, Foreign Aid, and Development in Nepal. Front Public Health. 2016;4:177. Published 2016 Aug 24. doi:10.3389/fpubh.2016.00177
The World Bank. World Bank Indicator [Internet]. [cited 2018 Aug 29]. Available from: https://data.worldbank.org/indicator.