How did Nepal implement?

Established vaccination funding as a budgetary priority.

In 2016, the Immunization Act¹ was established to enhance the stability and structure of the vaccine delivery system in Nepal. The legislation on immunization allowed for the country’s national immunization program to be more financially sustainable, especially as new vaccines were being introduced.² The Public Health Service Act³ of 2018 further made vaccination a priority by making health services for citizens a right by the Constitution of Nepal.⁴

Nepal’s financing for immunization reflects the importance of the program. Over the 2006–2016 study period, government financing for immunization remained stable and was higher than the average spending of other low-income countries (Figure 9). In 2021, the government contributed about three-fifths to the health funding budget for immunization, while other funders included Gavi, UNICEF, and WHO, demonstrating strong commitment and budgetary priority for immunization.⁵

Development assistance for immunization increased during the study period (Figure 9), due primarily to growth in Gavi funding for new vaccine introductions and health systems strengthening. In addition to the government, Gavi was the second largest source of funding for immunization in 2021, with one-third of resource requirements being fulfilled for Nepal.⁵ Nepal’s contribution to the purchase and delivery of Gavi-supported vaccines will require additional resources in coming years as Nepal becomes classified as a middle-income country by the World Bank; the government is exploring ways to fill these gaps.⁵ One potential consideration is the involvement of the private sector in financing the national immunization program, which was included as part of the 2016 Immunization Act. A spike in development assistance funding in 2015 was a result of the 7.6 magnitude earthquake.⁵

To efficiently disburse donor funding, Nepal adopted the sector-wide approach (SWAp) to ensure aid is used in the most effective way. With the application of SWAp, funds from development partners are pooled and managed by the Ministry of Health and Population (MoHP).⁶

This mechanism was mandated by the government starting in 2004.⁶ After all funding from partners has been allocated, the government determines the budget for each program. This fund is entirely under government control, but officials in the government are guided by partners on its use.⁶ However, there are some challenges with this approach including a weak financial management system, especially at subnational levels, leading to delays in the disbursement of funds.

Built and sustained close technical partnerships to allow for an efficient division of work.

The MoHP has fostered close partnerships over the past several decades, including with WHO and UNICEF. Informants from all levels reported that these partnerships enjoyed high levels of mutual trust, open and consistent communication among partners, and overall agreement about the division of labor.

Nepal’s polio vaccination campaigns were a turning point for the country’s technical partnerships for routine immunization. These partnerships, with entities such as UNICEF, WHO, and other external partners, evolved to be long-lasting and sustained connections dedicated to supporting the routine immunization system as a whole. Historically, a large proportion of infectious disease funding is provided to countries for the elimination of a specific disease, such as polio and measles.^7,8 Yet the organizational partnerships from polio campaigns, for example, remain and have continued to shape the nation’s routine immunization programs, even when funding is specific to vaccine-preventable diseases and not the entire routine immunization system.

Interviewees consistently mentioned that the impact of polio eradication programs—and the associated funding that followed—enabled improved delivery structures for routine immunization, including technical direction. Eradication efforts brought “new funds, new attention, new energy” along with additional support. According to one official, “the funds kept flowing,” leading to improvements in the routine immunization system.

The structure from polio vaccination campaigns and programming in Nepal were directly transferrable to overall routine immunization programming—in fact, capacity for all vaccine-preventable disease activities increased because the same routine immunization health care workers involved in polio eradication initiatives are also involved in other routine immunization service delivery. A 2014 study found that 60 polio staff from WHO and 14 staff from UNICEF supported overall routine immunization in Nepal in some capacity.⁹

Furthermore, a 2017 study found that the expansion of polio vaccination activities increased coverage of other vaccine-preventable diseases, and that polio campaign staff working in coordination with both government agencies and global organizations helped strengthen the overall routine immunization system.¹⁰

One manifestation of the collaboration with the polio campaign was the strong disease surveillance system that the government developed through a partnership with WHO and the Global Polio Eradication Initiative (GPEI). In 2005, this disease surveillance system was transformed to support the elimination of and consistent monitoring for neonatal tetanus, and to plan for the introduction of the Japanese encephalitis vaccination campaign the subsequent year.¹⁰ Ultimately, the surveillance system was strengthened gradually in a stepwise fashion, starting with polio surveillance and expanding to support all vaccine-preventable diseases, including diphtheria, tetanus, and pertussis (DTP). New disease indicators were added to the existing surveillance system, building on the preexisting infrastructure.

Commitment from GPEI was crucial to the growth of a national vaccine-preventable disease surveillance system in Nepal. While GPEI provided the bulk of the funding for this programming, in 2023, GPEI started to scale back its support and the country worked toward finalizing a Polio Transition Plan (PTP).^11,12 The objective of the PTP is for the Nepali government to take responsibility for key functions previously supported by the GPEI network, including the national vaccine-preventable disease surveillance system.¹²

There is some concern that with GPEI funding shifting toward other polio-endemic or high-risk countries, Nepal faces a unique challenge to ensure the sustainability of its surveillance system.¹² During a consultative meeting to finalize the PTP, the government of Nepal acknowledged the importance of sustaining the surveillance system and related activities. WHO also expressed commitment to continue its support of monitoring polio transition activities and to help identify sustainable financial resources for Nepal.

GPEI currently provides surveillance support to Burkina Faso, Eritrea, Ethiopia, Guinea-Bissau, Liberia, Senegal, Sierra Leone, South Sudan, Tajikistan, and Uganda.¹³ Funds are not siloed, and no distinction is made between polio activities or routine immunization activities.

Collected and used data effectively for policy and program management.

Several interviewees mentioned the value of using available data to strengthen decision making at the national and local levels. Nepal uses the District Health Information Software 2 (DHIS2) health information management system, which provides a basis for planning, monitoring, and evaluating health indicators, including immunization, for all levels of the health system.¹⁴ In addition to the DHIS2, other information systems include the Logistics Management Information System, Financial Management Information System, Human Resource Management Information System, Drug Information Network, and Ayurveda Reporting System.¹⁴

Community health workers and vaccinators use paper-based vaccine registers to record the vaccination of children during outreach and static clinics. The health post supervisor reports this data to the district each month. Data are entered into the DHIS2 at the district level and reported to regional and national levels on a monthly basis.

At the health facility level, the health post supervisor holds monthly review meetings with staff, vaccinators, and female community health volunteers (FCHVs), to monitor immunization indicators, understand local challenges, and plan for upcoming vaccination sessions. By reviewing the vaccine register at the end of each month, health facility staff identify children who missed vaccinations. Then FCHVs and health workers follow up to determine the reasons for the missed doses and remind families of the next appointment. This approach to data review and microplanning is based on the Reaching Every Child (REC) Strategy.

Districts analyze the aggregated health facility data to plan outreach events, mobilize vaccinators, and manage vaccination supplies. Districts also conduct monthly review meetings with health facility supervisors, cold chain officers, statisticians, and district health officers. In these meetings, attendees identify priority areas and develop action plans to address any gaps.

Provincial health officers review immunization data every four months and the national government conducts annual reviews. During these reviews, all districts present progress reports for the previous three years and are ranked based on their performance and health indicators. Data are analyzed to identify problems and needs, and to develop strategies at the central level.

External partner organizations also present their findings, progress, achievements, and recommendations in the annual review meeting. Lessons learned and recommendations from the annual review meeting are used guide the development of policies and national guidelines. For example, the 2011–2016 Comprehensive Multi-Year Plan¹⁵ was developed after extensive discussions with district and regional stakeholders during the annual review meetings and was subsequently renewed in the following years.

These data inform supportive supervision at all levels including national, regional, district, health facility, and community levels. The district-level immunization supervisor is responsible for supervising health facilities using monitoring sheets, supervision checklists, and providing feedback oral and written on performance according to WHO guidelines.¹⁶ Supportive supervision visits should occur “as regular and frequent as resources allow,” which may be monthly or quarterly.⁵ Key informants stated that supervisory visits occurred “often” or on a “timely” basis.

These supportive supervision visits examine facility readiness in detail, including review and monitoring of immunization program logs, vaccine registers, supply chain logistics, and cold chain maintenance to identify areas that need support. Examiners assess facility personnel on fine points such as the opening of vials and the administration of vaccines. When health facilities are hard to reach, supportive supervision may be done remotely, via telephone.

Vaccines and commodities for the national immunization program are kept in vaccine stores, separate from health facilities or service delivery points. The Central Vaccine Store is a national-level facility responsible for both storing and dispatching vaccine supplies across the country.¹⁷ The vaccines are first stored in the Central Vaccine Store when they arrive in country and then are subsequently distributed to provincial and district vaccine stores. Service delivery posts, which include hospitals, primary health care centers, and health posts, receive and store vaccines for short-term use in a vaccine cold box or carrier before service delivery.¹⁸

Nepal uses an electronic logistic management information system (eLMIS) to manage vaccine stock and prevent stockouts. This system supports replenishment, inventory management, release and dispatch, and the handling of returns, damaged, and expired stock.

In a 2021 assessment of stock management effectiveness, the Central Vaccine Store scored 93% in stock management.^17,18 The assessment highlighted strong performance in the release and dispatch of vaccines and managing returns and damaged or expired stock, but it also identified weaknesses in stock replenishment, which received a score of only 50%.

At the provincial level, the seven provincial stores averaged a 90% score in stock management, with most criteria scoring above 80%.¹⁸ However, the management of returns and damaged or expired vaccines scored lower, at 57%, indicating a need for improvement in alignment with proposed Expanded Programme on Immunization waste management guidelines. Additionally, the eLMIS is not yet fully implemented across all levels of the vaccine supply chain, but there is a mitigation plan to develop a comprehensive online vaccine management system in the coming years as of 2021.

The LMIS unit, part of the Logistics Management Division under the MoHP, collects quarterly reports from all health facilities nationwide to analyze and support decision making. Since its introduction, the LMIS has improved the way information is shared and used across the country, with MoHP recognizing it as one of its primary information systems. The LMIS data is effectively used for logistics decision making, forecasting, procurement, and distribution of health commodities, including childhood vaccines, allowing Nepal to effectively track its supply chain commodities and equipment.¹⁹

A readiness assessment of health facilities in Nepal was conducted. For this assessment, facilities were categorized into two groups: (1) facilities offering routine immunization services, such as hospitals, primary health care centers, and health posts that receive and store vaccines for short-term use before delivery; and (2) cold chain storage facilities that are responsible for housing vaccines prior to distribution to routine immunization service points.¹⁸

As shown in Figure 10, between the 2015 and 2021 SPA surveys, the readiness scores for facilities offering RI services remained relatively stable.^20,21 The highest scores in both years were observed in the category of non-cold chain equipment and supplies. According to the 2021 SPA survey, Bagmati Pradesh, Gandaki Pradesh, and Lumbini Pradesh had the highest facility readiness scores for RI services.²¹

While there is a need for improvements in service availability may be influenced by the structure of Nepal’s vaccination services, which are typically provided on a monthly basis. During the 2020–2021 fiscal year, the national immunization program held over 16,000 institutional and outreach sessions each month, reaching many communities across Nepal, especially in geographically hard-to-reach areas. These services were provided at district hospitals, primary health care centers, health posts, and through FCHVs during campaigns.^22,23 Given that services occur monthly, there may be opportunities to further increase vaccination rates by offering services or campaigns more frequently.

In contrast, cold chain storage facilities showed higher overall readiness scores, with significant improvements between 2015 and 2021.^20,21 By 2021, nearly all assessed cold chain facilities had functional fridges, maintained appropriate fridge temperatures, and had pentavalent vaccines in stock.²¹ Despite these improvements, challenges remained in areas such as monitoring systems, meeting cold chain minimum requirements, and ensuring reliable power supply. However, power supply saw the most significant improvement within this category. As of the 2021 SPA survey, Lumbini Pradesh, Madhesh Pradesh, Koshi Pradesh, and Bagmati Pradesh had the highest readiness scores for cold chain storage facilities, with Koshi, Madhesh, and Lumbini Pradesh experiencing the largest improvements between 2015 and 2021.^20,21

To ensure routine data quality, Nepal implemented and adapted the data quality self-assessment (DQSA) as a means to determine the accuracy and quality of reported data.²⁴ Many districts conduct DQSA routinely, according to interviewees. Data are verified by looking at the vaccine register and through household visits to cross-check vaccination cards. If the data are of low quality, the health office provides written feedback to health facilities on how they might improve. The data quality is also checked by comparing the past year’s data related to vaccine coverage and immunization services.

The MoHP recently developed a routine DQSA and is currently piloting the tool, but as of 2019 has yet to standardize and integrate it into the national strategy.²⁵

Another tool for maximizing the value of data is the social audit, in which an organization commissions a thorough review of its progress toward stated social objectives. These social audits aim to improve the governance of the health facilities and improve access, accountability, transparency, and quality of health services at the local level.

The second Nepal Health Sector Programme (2010–2015) mandated annual social audits in all health facilities, and in 2013 the MoHP adopted a social auditing tool based on lessons learned from other South Asian countries.²⁶ Funding for social audits is included in the health budget (20 million rupees for social auditing in fiscal years 2014–2015 and 2015–2016), which indicates a commitment to improving transparency and community engagement. As of 2016, social audits had been implemented in about 30% of Nepal’s health facilities.²⁷

Guidance states that each health facility and district should conduct a social audit and submit the report to the Primary Health Care Revitalization Division every year. During these audits, independent facilitators conduct five days of investigation, analysis, and reporting. Results are presented at a public meeting where community members monitor services and participate in forming an action plan.

Key informants described the purpose of the social audits as a means of informing community members about the progress of health indicators. “The number of households with access to immunization services” is one of the key indicators evaluated by the social audit, along with other benchmarks of public health and organizational performance.

Generated demand for vaccinations through community engagement, media, and school outreach.

The MoHP recognized that different approaches were needed to reach different facets of the population. For example, school outreach targets children and adolescents, FCHVs target mothers and grandmothers, media targets younger parents and fathers, and community leaders target hard-to-reach communities.

Women were important audiences because they are considered primary decision makers for child health. Previous studies have shown that the education and empowerment of women and girls are associated with boosts in immunization coverage, especially when coupled with antenatal services.^28,29

Across the study provinces, demand generation approaches relied on a core set of basic strategies. In addition, interviewees highlighted specific approaches that contributed to demand in their provinces, as shown in the table below.

Table. Examples of demand generation approaches in study provinces

Community engagement

Public awareness regarding vaccines is sustained through extensive community engagement. Community-led committees and groups were formed in response to increases in child mortality and continue to function at the village, municipality, and district levels. These committees and groups involve traditional leaders, government officials, volunteers, mothers, teachers, and other local opinion leaders.

These community-led groups are involved with immunization programming, including promotion, service delivery, and targeted outreach.³⁰ Committees also support equity and inclusivity by involving members from a variety of religious, ethnic, and socioeconomic groups to connect with hard-to-reach communities and address rumors and misinformation about vaccines. These community groups meet with district-level health officers to discuss any challenges and solutions for immunization programming.³¹

Messaging about the benefits of vaccinations has shifted over time. Initially, messaging emphasized a potential decrease in child and maternal mortality that would result from immunization services. In recent years, messages have focused on other benefits of vaccinations, referring to longer-term health benefits that influence quality of life.

Training for these community-led committees and groups is provided by health officers at national, provincial, and district levels to promote community ownership of the vaccination coverage.

Community leaders across all provinces demonstrated a strong commitment to improving their communities’ health by conducting extensive household visits, reminding parents to bring their children for vaccinations, and sometimes even providing transport to vaccination sites. They also tailored their messaging in ways that were easy for constituents to understand, recognizing the importance of building trust within their communities.

School engagement

The school outreach program has facilitated and enhanced public awareness of immunization in Nepal. Public schools, among other venues, are used to provide infrastructure and space for immunization. ³² Schools are at the heart of most communities and provide an ideal venue for basic health service delivery.

In addition, schools are a good place to educate children—and, indirectly, their families—about public health. The education system plan of 1971 made health a compulsory subject for all grade levels and was created to influence the health knowledge, attitudes, and practices of students and their families.^33,34

The Ministry of Education has developed a standard curriculum for health education, which is taught in all schools. The curriculum covers a variety of health topics including communicable diseases; vaccinations; personal hygiene, water, and sanitation; nutrition; safety; and first aid.^35,36

Teachers were mobilized to strengthen immunization and have been actively involved in immunization activities.³⁷ Teachers have also been involved in checking the immunization status of at-risk populations to improve immunization coverage.³⁸ Additionally, teachers inform their students about the date and place of immunization sessions in their respective village development committees. These actions are especially valuable because teachers are regarded as trustworthy messengers on immunization.

Media engagement

Most interviewees, including health workers and parents, stated that media—especially newspapers and radio—are a trusted source of information in Nepal. The government of Nepal engages the media for health-related messaging through newspapers, radio, television, social media, and an online news portal. Notably, the MoHP established a government agency, the National Health Education Information and Communication Center (NHEICC), that coordinates with external partners and media agencies to produce health-related messaging.³¹ Media is used to relay information about immunizations, vaccination days, national immunization days, and the introduction of new vaccines.

The majority of MoHP-led media engagement is conducted at the national level, but NHEICC also provides funds and materials to outreach offices at the municipality level. Additionally, municipality-level health workers mentioned agreements between the community and media outlets to regularly announce routine vaccine days.

The media typically spreads positive messages about vaccines through coordination with the government and local nonprofit organizations. The government at the national level is responsible for providing accurate and timely information for media message development, and also verifies and corrects the media’s messaging as needed.

Furthermore, there is a unit within the Child Health Division focused on responding to adverse effects following immunization and addressing misinformation. These responses involve investigative journalists who target rumors and misinformation. The government recruits an external organization to investigate adverse effects and respond to misinformation. Generally, these investigations were appreciated by the public and generated further trust in the government.

Trust in the media may not be true across all communities. Previous research states that communities in the Terai zone are less likely to trust messaging from the media and more likely to trust other community members, including FCHVs. ³⁹

Intent to vaccinate

Through tailored engagement with the community, schools, and media, Nepal made significant progress in improving overall intent to vaccinate. Most regions showed relatively high levels of caregivers who agreed that vaccines are important, according to a post-campaign measles coverage survey in 2021, reflecting the success of Nepal’s efforts to boost vaccine confidence.⁴⁰

The survey found that Bagmati Pradesh, Gandaki Pradesh, and Koshi Pradesh had the highest rates of caregivers who agreed that vaccines are important, at 97%, 94%, and 94%, respectively.⁴⁰ In contrast, Madhesh Pradesh and Karnali Pradesh had lower percentages, at 89% and 88%. At the district level, the average agreement on the importance of vaccines was 93%. However, Rautahat District in Madhesh Pradesh had the lowest rate, with only 69% of caregivers agreeing that vaccines are important, suggesting a need for more targeted interventions in that area.⁴⁰

The “5C” or “psychological antecedents of vaccination” scale is used to assess individual thoughts and behaviors concerning vaccination, and provides a measure of vaccine hesitancy or confidence.⁴¹ We applied the 5C scale retrospectively to the experiences described in our qualitative research and found strong enabling factors as well as weak barriers to vaccine demand in the table below. These findings are consistent with strong intent to vaccinate in Nepal.

Table. Intent to vaccinate in Nepal, seen through the 5Cs of vaccination

Leveraging vaccine drivers to tailor provincial-level interventions

Nepal has implemented various strategies to improve vaccination coverage over the years, including efforts to generate demand, increase caregivers’ intent to vaccinate, expand access to routine immunization facilities, reduce travel time, and improve facility readiness in both routine immunization service centers and cold chain storage facilities. By assessing the three domains influencing vaccination coverage—intent, access, and readiness—alongside DTP coverage levels at the provincial level, interventions can be better tailored to specific regions to aid in coverage improvements.

Throughout Nepal, readiness at facilities offering routine immunization services (non-cold chain facilities) remains a challenge, with only minimal improvements between 2015 and 2021. The limited availability of vaccine services—typically offered less than once a week—significantly impacts readiness scores, making improvements to facility readiness critical for increasing vaccine coverage.