Transforming health in Nepal: a historical and contemporary review on disease burden, health system challenges, and innovations

Abstract

Introduction: Nepal witnessed a tumultuous journey over past two centuries, marked by significant political, social, and cultural shifts. From fighting British colonial encroachments in 1800s, the dynastic Rana regime (1846-1951), and democracy movements in the late 1950s, 1990s and 2000s, Nepal became a federal republic in 2008. The main objective of this review is to lay out an interpretative summary on Nepal's epidemiological transition (includes general trends and disease specific topics) followed by discussion on health system development over key periods: historical period (-1950s), modern period (1950-1990), post-democracy (1991-2016), and post-federalization (2016-).

Methods: We conducted a scoping review of available literature using the Arksey and O'Malley framework to synthesize the key insights. Searches were performed in PubMed (via NLM), Embase and Google Scholar using a combination of search terms related to Nepal's health system, epidemiological transition, disease burden and emerging health issues. A total of 1204 records were identified, of which 123 documents - including peer-reviewed articles, government reports and grey literature - met the inclusion criteria.

Results: Major advances in maternal and child health, nutritional health and reduction of infectious diseases have been observed in recent decades. The maternal mortality ratio (MMR) declined by 55% (1996-2016), and neonatal mortality halved (40 to 20 per 1000 live births) due to improved antenatal care, skilled birth attendance and family planning. Stunting rates fell from 66% (1996) to 25% (2022), yet rising non-communicable diseases (NCDs) pose new challenges. Communicable diseases, once dominant, have declined owing to expanded immunization and tuberculosis control. However, NCDs now account for over two thirds of deaths, driven by urbanization, ageing and lifestyle shifts. Health system gaps persist, with workforce shortages, rural-urban disparities and out-of-pocket health costs limiting access. Addressing rising health inequities, digital health innovations and service expansion is critical to achieving universal health coverage and sustaining Nepal's health gains.

Conclusions: Nepal's health care landscape has continuously evolved over the past centuries, coinciding with key demographic and political changes. Advances through innovation are necessary for the country's overstretched health system to reduce the cost of health services whilst increasing quality and access.

Keywords: Digitalization; Health system; Inequities; Innovation; Nepal; Poverty.

Fig. 1

Epidemiological transition in Nepal from 1990 to 2019 [7, 15]. The legends are ordered on the basis of descending disability-adjusted life years (DALYs) per 100 000 in 1990. The figure shows the shift in the burden of major causes of DALYs in Nepal. Dominated by maternal and neonatal disorders, and communicable disease in 1990s – the burden of disease shifted over the next 20 years (to 2019), when cardiovascular disease became the leading cause of DALYs [7]. Data for this visualization were derived from the Global Burden of Disease Study, Institute of Health Metrics and Evaluation (https://vizhub.healthdata.org/gbd-compare/)

Fig. 2

Maternal mortality ratio over 50 years in Nepal. The datapoints for this figure were obtained from the references below: WHO 1991 [36], WHO 1991 [36], NDHS 1991, NDHS 1996, NDHS 2001, NDHS 2006, NDHS 2011, NDHS 2016 and NDHS 2022 [37]

Fig. 3

Chronological development of Nepal’s health and political landscape (1800s–2020s). This is based on further expansion of the authors’ earlier work [1]. The use of // is used to show that the gaps between these milestones are not exactly proportional compared with those between other milestones. EPI expanded programme in immunization, FCHVs female community health volunteers