Challenges

Nepal continues to face challenges in sustaining and improving immunization coverage. In its 2017–2021 Comprehensive Multi-Year Plan¹ for immunization, the Ministry of Health and Population highlighted these top-level concerns:

• Human resources – Retirement, frequent movement of staff, and inadequate skills and training have affected system performance. Motivating health workers and FCHVs remains a challenge.
• Demographic change – Rapid urbanization and new, highly mobile urban populations are creating new challenges for the delivery of health services. Ensuring sufficient health workers in urban areas has been difficult.
• Infrastructure – Procurement procedures for vaccines and related materials have faced frequent challenges, leading to poor timeliness in vaccine purchasing. Cold chain capacity for new vaccines is very limited, especially at the district level.
• Access – Strategies to find and vaccinate zero-dose children (those who have not received any routine immunization) are limited, and high coverage for the second dose of the measles-rubella vaccine has not yet been achieved.

More broadly, Nepal must address challenges in the following vital areas.

Increased local governance and autonomy

The transfer of responsibilities from the national government to district and local levels in Nepal aimed to enhance accountability and improve service provision across the country. Reforms in 1990 promoted increased local governance and autonomy, and the 2015 constitution created seven provinces from five development regions. This federalization has been implemented progressively, with powers and functions shifting from the national level to district and local authorities.

However, this increased autonomy has introduced changes in institutional roles and coordination, requiring greater local capacity, particularly in financial management. As decision making shifts to the local level, competing priorities may divert attention and resources away from immunization efforts. If not carefully managed, these changes could compromise program performance. For example, stakeholders have reported a decline in FCHV training and incentives, and local authorities have expressed uncertainty about their roles, responsibilities, and concerns regarding funding and accountability.

Emergencies

Nepal encountered several national crises during the 2000–2016 study period, including civil unrest and earthquakes, that affected vaccination programming. Several interviewees praised the resilience of the vaccination program in the aftermath of the earthquake. Even as the country was rebuilding after the 2015 earthquake, demand for vaccines remained high; for example, although infrastructure was severely damaged in many areas, families would still travel to get their children vaccinated. Their active demand and expectations for vaccines did not diminish following this natural disaster. Therefore, according to key informants at all levels, vaccination coverage remained relatively stable considering the circumstances.

This resilience is now being put to the test by the COVID-19 pandemic. As of May 2021, cases and deaths are surging in Nepal, overwhelming the health care system. Less than 10% of the population has been vaccinated against COVID-19 and vaccination has been suspended due to lack of supply. Immunization has been disrupted for all antigens in the routine schedule.^2,3

Climate change presents further threats. According to the World Health Organization, “Significant threats of climate change in Nepal include rising atmospheric temperature, changes in rainfall cycle and the impact of glacial lake outburst floods and landslides triggered by climatic extremes. Millions of Nepalese are estimated to be at risk from the impacts of climate change including reductions in agricultural production, food insecurity, strained water resources, loss of forests and biodiversity, reduced tourism and damaged infrastructure and their associated impacts on health.”⁴ As the number of vulnerable people grows, resilient health systems and high vaccination coverage will be essential to sustain the benefits of vaccination for the people of Nepal.

Ongoing equity challenges in vaccine coverage

Although significant progress has been made in narrowing equity gaps, particularly in coverage of the third dose of the combined diphtheria, tetanus, and pertussis vaccine (DTP3) between 2000 and 2010 in Nepal, disparities in vaccination coverage between urban and rural areas have widened since 2010. Despite recent efforts, especially following the 2015 earthquake, challenges remain in maintaining high vaccine coverage and further reducing these gaps.

Since 2011, dropout rates for the first and third doses of DTP (DTP1 and DTP3) have increased, with a notable spike in 2015 following the earthquake. Although efforts as of 2019 have helped reduce dropout rates, the country has not yet returned to the lower levels seen since 2011. For districts moving away from the 10% dropout rate zone, such as Bara and Rautahat, there have been increases in DTP1 coverage without corresponding increases in DTP3 coverage, meaning that while more children are receiving the first dose of DTP, many are not completing the full series.

Although progress has been made in many districts since 2015, some districts continue to struggle, often showing increases in DTP1 coverage without similar improvements in DTP3. To return to pre-2015 levels and sustain high vaccine coverage, Nepal may need to focus on improving facility readiness, increasing the availability and frequency of RI services, and tailoring interventions to the specific needs of provinces and districts. In 2011, only one district was outside the dropout range. By 2015, this number had increased to 20 districts, and by 2019, only 9 districts remained outside the 0-10% dropout zone. Prioritizing efforts to reduce dropout rates and target the no-DTP population will be critical to addressing ongoing challenges in vaccine coverage.