Why is Nepal an Exemplar?

For the purposes of this study, we define Exemplar countries as those that have proven to be positive outliers in increasing immunization coverage (using the first dose of diphtheria, tetanus, and pertussis vaccine [DTP1] and the third dose [DTP3] as proxy indicators).¹ Their success cannot be statistically attributed to economic growth, as reflected by Figure 1 below.

Nepal was selected to represent Asia as an Exemplar country due to its success in achieving high DTP3 coverage compared with its economic peers. In Figure 1, the relationship between the sociodemographic index (a composite measure identifying countries on a scale of development using education, total fertility rate, and income per capita) and DTP3 coverage in low- and middle-income countries can be seen.^2,3 The observed sociodemographic index and DTP3 coverage estimates for each country are shown underlaid in light gray.

Nepal’s trajectory, shown in the blue dots along with the other Exemplar countries in vaccine delivery, shows consistently high performance in DTP3 coverage that outpaces other countries in similar settings.

During the 2000–2016 study period, Nepal’s total health spending per capita was similar to or lower than that of peer low-income countries that did not achieve comparable vaccination coverage. As of 2019, Nepal’s government health expenditure, as a share of total expenditure, was low relative to other countries in the region, with only Bangladesh and Pakistan spending less.⁴ This suggests that total health spending and global domestic product (GDP) per capita alone do not sufficiently explain Nepal’s vaccination success.

According to annual World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) estimates of national immunization coverage (WUENIC) coverage data, Nepal has maintained consistently high coverage of DTP1, while narrowing the gap between DTP1 and DTP3 from 2000 to 2006 (Figure 2). A slight decline in immunization coverage occurred in the years following the 2015 earthquake (see Context section for further details). Relative to the disruption caused by the earthquake, coverage declined only slightly, which is a testament to the resilience of Nepal’s vaccine delivery system. In this analysis, we used data from both the Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease⁵ and WUENIC because they have different strengths and limitations. However, it is worth noting that they use different approaches to estimate coverage of DTP1 and DTP3.

DTP3 coverage levels improved nationwide in Nepal from 2000 to 2019. However, as with other Exemplar countries in vaccine delivery, there were variations at the subnational level, as shown in Figure 3. Most provinces saw increases in coverage over the years, particularly those in the mountain and Hill regions. The provinces that experienced the most improvement in vaccination coverage overall were Sudurpashchim Pradesh, Madhesh Pradesh, and Karnali Pradesh, whereas Bagmati Pradesh and Koshi Pradesh saw less progress. Notably, the most significant decline in no-DTP cases occurred in Sudurpashchim Pradesh, where coverage dropped. However, as of 2019, there were still pockets within southeastern provinces in the Terai, or low-lying flatland zone, region with the lowest vaccination rates.

Similarly, equity in immunization improved from 2001 to 2016, according to sociodemographic measures of wealth and maternal education as seen in Figure 4. Nepal closed the gap in DTP3 coverage by wealth quintile, with the poorest 20% of the population achieving similar or better coverage rates as wealthier populations. The country also narrowed the gap in DTP3 coverage by maternal education. In 2016, infants born to mothers with no education were more likely to be fully immunized than they would have been in 2001, with DTP3 coverage for this group increasing by almost 15%.

How did Nepal achieve these improvements? In our research, we used both a qualitative and quantitative approach to generate hypotheses on the key drivers of success related to health facility readiness, intent to vaccinate, and community access within the context of governance and finance, health systems, and past and present interventions (Figure 5).⁶

This narrative builds on an extensive body of knowledge about the essential components of an effective vaccine delivery system. We used the following two guidelines to synthesize this knowledge: the Global Routine Immunization Strategies and Practices³ describes a comprehensive framework of strategies and practices for routine immunization, and the Reaching Every District (RED) approach⁷ defines five strategies to equitably increase immunization coverage rates: (1) planning and management of resources, (2) reaching all eligible populations, (3) engaging with communities, (4) conducting supportive supervision, and (5) monitoring and using data for action. In addition, evaluations such as the Africa Routine Immunization System Essentials project⁸ and the full country evaluations⁹ conducted for Gavi, the Vaccine Alliance, documented factors contributing to coverage improvements. These assessments also shed light on how vaccination programs are being implemented and the various obstacles to immunization.