Context

Geography, demographics, and economics

Bordered on all sides by India and China, the two most populous nations in the world, Nepal is a distinctive and diverse country of 30 million people with a wide range of ethnic, cultural, religious, linguistic, economic, social, and political identities.

According to the census in 2021,¹ Nepal’s population includes members of 142 castes/ethnicities, an increase from 125 according to the 2011 census. In 2021, Nepal was also home to ethnic groups speaking 124 distinct languages. Religious identities are less heterogeneous—just over 80% of the population was Hindu, with smaller segments practicing Buddhism and Islam (8% and 5%, respectively).

Nepal is divided into three geographic zones.² The mountainous zone—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 less than 7% of its population. A larger hilly zone comprises 42% of Nepal’s land, and a roughly equivalent share of its population. The Terai, or low-lying flatlands, make up less than a quarter of Nepal’s landmass but are home to half of its people.

Nepal’s varied geography presents barriers to the delivery of health services. In addition, 80% of Nepal’s population lives in rural areas, many of which are difficult to reach by road or air.³ The nation’s transportation infrastructure is improving, but it remains underdeveloped, as does the energy grid. Persistent power shortages hinder both health care delivery and economic development.

Even with these challenges, Nepal’s economy has experienced substantial growth. Part of this is due to a population boom; as recently as 1990, Nepal had only 19 million people—a third fewer than recent years.³

GDP per capita (in purchasing power parity, constant 2017 international dollars) grew at about 4% per year from 2010 to 2019.⁴ As of 2019, it stood at approximately US$3,417, still well below the South Asia average of US $6,225.⁴ At that time Nepal was classified by the World Bank as a lower-middle-income country.⁵

The proportion of Nepalis living below the global poverty line (US$1.90 per day) declined from 50% in 2003 to 15% in 2010.⁴ Nepal’s labor force is mostly agricultural, but farming makes up only about a third of the country’s GDP. Most of the country’s reduction in poverty is attributable to nonagricultural production and remittances from Nepalis working abroad. ⁶ Remittances, worth US $8.2 billion in 2018, account for more than one-quarter of Nepal’s gross domestic product, placing it among the world’s top five nations for personal remittances received as a share of the GDP.³

Political history

Nepal was founded in 1769 and remained a monarchy until 1990 when general elections were held, and a constitution was adopted that transformed Nepal into a constitutional monarchy with a multiparty parliamentary political system.⁷

Despite making significant progress toward a more democratic form of governance, the 1990 reforms did not address fundamental issues of inequality and poverty.

In 1996, Maoist parties declared a “People’s War.” This civil war lasted a decade, killing or displacing thousands.⁸ During the conflict, King Gyanendra suspended the constitution and reestablished an absolute monarchy. In 2006, the king reinstituted the parliament and a peace accord was signed, ending the war. An interim constitution was adopted in 2007, with final agreement on a constitution coming in 2015.⁹

In April 2015, a devastating earthquake struck Kathmandu Valley, causing widespread destruction and triggering a humanitarian crisis.¹⁰ Nepal’s official constitution was approved in the aftermath of the earthquake, establishing the country as a secular, federal republic. The constitution also changed administrative borders and codified a variety of human rights—an important step for equity among minority groups.⁹

Health system

Nepal’s health system consists of both traditional medicine (Ayurveda) and modern medicine, and services are delivered through the public and private sector at the community, municipality, district, provincial, and national levels.

Community-level services (within villages, wards, or municipalities) are delivered through female community health volunteers (FCHVs), auxiliary nurse midwives, auxiliary health workers, staff nurses, health assistants, and medical officers.

According to the 2021 Nepal Health Facility Survey,¹¹ about 74% of public health facilities offered a basic health care package that included outpatient curative care for sick children, growth monitoring, child vaccinations, family planning, and antenatal care. Urban health centers and private hospitals were less likely to provide this basic package (with only 20% of private hospitals reporting that they do so, a decrease from the 25% reported in the 2015 survey¹²). Facilities in the hill region were more likely to provide the basic package (80%) than facilities in the Terai (71%) or mountain (62%) zones. Since the 2015 survey, coverage has improved, with 70% of facilities offering this basic package in the hill region, 54% and 53% for the Terai and mountain regions, respectively.¹¹ Over two thirds of facilities in the earthquake-affected districts offered all basic services.

History of the immunization program

In 1978 and 1979, Nepal launched its national immunization program, which aims to provide equitable immunization services to all communities, including those that are geographically isolated or economically marginalized. In 2016, Nepal became the first country in the region to implement a national immunization act,¹³ which ensured all children have the right to vaccines.¹⁴

Funding for immunization in Nepal comes primarily from the Nepali government and from international development assistance. The majority of external funding for immunization is channeled through Gavi, the Vaccine Alliance, which since 2002 has provided over US$150 million for immunization in Nepal.¹⁵

These funds have supported health system strengthening, cold chain equipment optimization, new vaccine introductions, and the purchase of new and underutilized vaccines. In turn, this has enabled the introduction of vaccines against hepatitis B, Haemophilus influenzae type b, Japanese encephalitis, pneumococcus, poliovirus (inactivated vaccine), rotavirus, rubella, and a second dose of measles-containing vaccine.^14,15

For more information on immunization financing in Nepal, see How did Nepal Implement?