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Nepal

Last Updated: February 27, 2012

Senior Program Officer:

Devendra Gnawali, MSc, PhD

  • Program Activities
  • Health Sector Architecture
  • Health Financing
  • Budgeting
  • Budget Flows and Reporting
  • Budget Performance
  • Parliamentary Notes
  • Immunization Performance Indicators
  • Disease Burden
  • Useful Links

    • Program Activities:

    • December 2008: Mike McQuestion and Devendra Gnawali met with MoH officials (including the NIP manager), MoF officials and representatives of the World Bank, UNICEF and WHO in Kathmandu.
    • February, May 2009: Devendra Gnawali attended meetings of the Inter-agency Coordinating Committee for NIP.
    • May 2009: Devendra Gnawali and Mike McQuestion met with parliamentarians, business leaders and MoH, WHO, UNICEF, World Bank and Rotary counterparts.
    • September 2009- January 2010: Devendra Gnawali organized a series of three SVI-sponsored parliamentary briefings ("Talk Program on Immunization"), held in Kathmandu.
    • February 2010: Devendra Gnawali and Mike McQuestion, with UNICEF/Nepal and the Nepali Parliament, co-hosted a sub-regional "Parliamentary briefing on child health and sustainable immunization financing" in Kathmandu. Attending were 150 participants, including 12 parliamentarians and government counterparts from both Cambodia and Sri Lanka.
    • March 2010: SIF Sabin and WHO co-sponsor the 15th Congress of Nepal Paediatric Society's (NEPAS) special session on "Social Determinants of Neonatal Health" in Kathmandu, Nepal.
    • April 2010: The Women, Children and Social Welfare Committee (WCSWC) of the Legislature Parliament of Nepal endorses the "Kathmandu Declaration" on April 8. Advocacy and Parliamentary briefing activities were inserted in the annual plan of action to ensure the implementation of sustainable immunization financing.
    • May 2010: Devendra Gnawali held a series of meetings with the Secretary of the WCSWC to plan the implementation of the “Kathmandu Declaration”. A meeting was also held with the Development Bankers’ Association.
    • June 2010: Sabin, with Rotary Club of Nepal North and UNICEF Nepal, organized the “Countdown to 2015 and Sustainable Immunization Financing: Role of Civil Society Organization” colloquium in Kathmandu, Nepal.
    • July 2010: On 15-16 July, a nine-person delegation, including four parliamentarians, Director General of Department of Health Services and other Government officials, attended the Sabin sponsored “Second Sub-regional Symposium for Parliamentarians on Sustainable Immunization Financing” in Colombo.
    • August 2010: The WCSWC met to discuss immunization and other public health issues. More than 30 parliamentarians were briefed by officials from the Ministry of Health and Ministry of Finance. The committee encouraged the Ministry of Health and Finance to take necessary steps to ensure the establishment of the “Immunization Act” and “National Immunization Trust Fund”.
    • October 2010: Seven Nepali peer exchangers attend the "Third Sub-Regional Symposium for Parliamentarians on Sustainable Immunization Financing”, held on 21-22 October in Phnom Penh, Cambodia.
    • January 2011: SIF Sabin, UNICEF, government and parliamentary counterparts insert the national immunization trust fund and National Immunization Act into Nepal's 2012-2016 cMYP.
    • March 2011: Five Nepali delegates attend the Addis Ababa Colloquium on SIF.
    • October 2011: A government Immunization Drafting Committee began writing vaccination legislation. Included are Policy, Planning and International Cooperation Division of MoH; Child Health Division; EPI Manager; Legal Officer; Director of Primary Health care Revitalization Division. Also participating are WHO and Sabin SIF.
    • November 2011: Sabin and UNICEF sponsor a workshop in Kathmandu for Nepal's Rotary and Lions Club leaders.
    • January 2012: Health Committee of Legislature Parliament of Nepal convened a briefing on immunization financing attended by Ministry of Health and Ministry of Finance officials.

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    Health Sector Architecture:

    • The Ministry for Health and Population coordinates its work through a National Health Sector Coordination Committee. A Health Sector Development Partners Forum was established in 2004. All external donor activities are coordinated through this body.
    • The MoHP adopted a SWAp approach in 2006. In 2007 DFID and the World Bank were pooling their funds with government health sector funds. The Government of Nepal provides trimestral Implementation Progress Reports to the SWAp partners. Semiannual Joint Reviews happen in October/November and May/June.
    • Nepal became a fully-inaugurated member of IHP+ in 2008. Its country compact was signed in February 2009. Overseeing the IHP+ compact is the Nepal Health Development Partner’s Forum, which meets quarterly.
      Read more here.
    • The National Immunization Program is located in the Immunization Section, Child Health Division, Department of Health Services, Ministry of Health and Population.
    • An Interagency Coordinating Committee for the NIP has been operational since 2001 and meets regularly.
    • External partners channel project support to the MoHP/NIP through a network of eleven WHO and UNICEF field offices (Programme for Immunization Preventable Diseases).
    • Numerous non-governmental organizations provide immunizations in many of Nepal's 75 districts.
    • Devolution of health services to Nepal's 75 districts and 58 municipalities was proposed in the Local Self-Governance Act of 1999. The plan calls for Village Development Committees to actively administer 3,129 local health posts. Political instability has delayed the process. The 2007 cMYP reported that only 43 of the districts were sufficiently equipped to manage immunization services.

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    Health Financing:

    • In 2007, Nepalis spent US$53 per capita on health. Health accounted for 11% of recurrent government expenditures. (Source: Countdown to 2015 Report, 2010)
    • In 2008, Nepal received US$81.7m in Official Development Assistance for health, up from US$29.3m in 2007. (Source: OECD Creditor Reporting System)
    • In FY 2008/09, health represented more than 7% of the government budget, compared to 4.9% in FY2004/05. That year the new government announced that all Nepalis could utilize primary health care services free of charge.
    • For FY 2009/10 the Government allocated 6.5% of the national budget for health, a decrease relative to 2008/09.
    • Highly Indebted Poor Countries (HIPC) Debt Relief:
      Although eligible, Nepal does not participate in the HIPC Initiative.
    • National Immunization Program (NIP)
      • In 2001, prior to GAVI funding, Nepal spent US$17.4m on its immunization program, of which the government provided $14.4m (83%). In 2003 the figures were $16.7m total, with the government providing $12.6m (76%).
      • According to the 2007-2011 cMYP, $9.4m were spent in 2005 specifically on the routine NIP ($13 per infant born that year). Adding in shared health services expenditures to support the NIP increases this to $16.8m ($22 per infant). The government financed $4.2m of the specific routine expenditures (45%), about $6 per infant.
      • According to the WHO/UNICEF Joint Reporting Form, the Nepali Government spent US$ 2.1m to immunize about 560,000 infants in 2009, an investment of around $4/infant. The $2.1m represented 15% of the total 2009 routine EPI budget. In 2010, routine government immunization expenditures fell to $1.1m- around $2/infant. For 2006, 2007 and 2008, routine EPI government expenditures were, respectively, $8.3m, $2.0m and $3.9m.
      • External donors provide most of the balance of immunization funding, principally UNICEF and GAVI. Other donors directly fund NIP activities through the MoHP. These external donor inputs are off of the government budget.
      • The overall pattern since 2005 suggests a substitution effect.
      • Nepal began making co-payments to GAVI for newer vaccines in 2009 and was up-to-date on those co-payments through 2011.

        • < In 2011, Nepal's Rotary and Lions clubs began capitalizing a private fund to support routine immunization capacity building. As of December 2011, the fund had received over US$4,000.

    • Amount spent (USD) by the government of Nepal on routine immunization per infant (2000-2010)
      Nepal routine imm spending 2000 2010.jpg
    • Note: the lighter blue columns show recreated data (trends), since no official data was available for these years. Data for 2010 consists of unofficial figures reported by national EPI managers to SIF program officers.

    • Source:
      1. WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Nepal. All data derived from the WHO/UNICEF Joint Reporting Form as follows:
      a: C_6450. This % excludes any external financing from donors.
      b: C_6490. This % includes all recurrent, immunization-specific spending financed solely with government funds. This includes vaccines, injection supplies, salaries, and per diems of health staff working full-time on immunization, transport, vehicles, and cold chain maintenance, training, social mobilization, and monitoring and surveillance.
      "NA" indicates data not available.

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Budgeting:

  • The National Health Sector Program Implementation Plan 2004-09 links health policy with the national health budget. The Plan includes inputs from eleven major external partners.
  • A cMYP for the NIP was prepared in 2007, covering the period 2007-11. In 2011 the cMYP was updated to cover 2012-2016.
  • The Immunization Section of the Child Health Division develops an annual operational plan with budget. After approval by the ICC, the MoHP incorporates this document into the annual MoHP plan and budget.
    The MoHP submits this plan to National Planning Commission. The latter then submits the health sectoral plan to the Ministry of Finance for budget allocation.
    The MoF then sends the annual health plan to parliament for approval.
    Once the national health plan and budget are approved they are entered into the Government's annual consolidated plan (the “Red Book”).
    Nepal's budget cycle begins on 15 July. Before that date the MoHP (Department of Health Services) authorizes the DoHS to inform the district health offices of their approved budgets. For immunization, the MoHP sends annual line item budgets to each district.

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    Budget Flows and Reporting:

  • Funding and reporting for Nepal’s health sector involve several institutions. Following approval from Parliament, the Ministry of Finance authorizes the Financial General Control Office (FGCO), an autonomous national agency, to make quarterly disbursements for health services.
  • Separate disbursements go to the central MoHP, Regional Offices (n=5) and to district health offices (n=75). The latter go through District Accounting Offices (DAO) (n=75). The funds are used for both secondary (hospital) and primary curative and preventive services.
  • The MoHP accounts for its expenditures through an autonomous FGCO unit located within the MoHP. District health offices provide monthly expenditure reports to the DAOs. The DAOs, in turn, report expenditures to the central FGCO. The MoHP generates program reports (coverage, surveillance, other technical indicators) through its Health Management Information System. The District Health Offices send monthly/quarterly reports to the central MoHS through the HMIS network. The MoHS also uses the HMIS to generate raw data reports to the MoHP and to the National Planning Commission (NPC).
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    Budget Performance:

    • In 2007, Nepal's routine EPI Program immunized 630,718 children with DTP3 and spent around US$13 per DTP3 immunized child (US$8,011,615 total). (Source: GAVI Annual Progress Report, 2008)
    • Country Policy and Institutional Assessment:
      The World Bank 2007 CPIA gave Nepal's budget and financial management systems (Indicator #13) a score of 3.5, equal to its 2005 score. (mean 2007 score for all IDA countries: 3.2) Read more here.
    • Open Budget Index: Nepal scored 43% out of 100% on the Open Budget Index 2008, indicating that the government makes public "some, albeit incomplete" budgetary information. Read more about the 2008 Index here. Nepal's score has increased since the Open Budget Index 2006, in which it scored a 36%. Read more on Nepal's performance in the 2006 Index here.
  • The MoHP and its external donors perform joint semi-annual health sector assessments.
  • 81% of the health sector budget was used in 2006/07 compared to 73% in 2003/04.
  • Current routine health expenditure data are available through the the Fiscal Management Information System located in the MoHP.

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Parliamentary Notes:

  • Nepal's newest government consists of a President (head of state), a prime minister (head of government) and a Constituent Assembly. The latter, elected in April 2008, acts as a unicameral parliament and replaces its predecessor Legislature- Parliament.
  • As of December 2011, a new constitution was still in preparation.
  • The coalition government formed in August 2008 fell in April 2009. The Constituent Assembly was briefly blocked but resumed meeting in May 2009 and was to form a new government.
  • In parliament, the 63-member Women, Children and Social Welfare Committee looks after health issues and budgets.
  • In May 2009, the Constituent Assembly Secretariat had a staff of 337.
  • Most recent parliamentary elections were held 10 April 2008 (Source: ElectionGuide).
  • In December 2010, Nepal’s Parliament requested the Government to prepare draft legislation to create a national immunization trust fund and a national Immunization Act supporting the National Immunization Program.

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    Immunization Performance Indicators:*

    Percent of districts reporting at least 80% coverage (DPT3), 2008*: 44%

    = 80% DPT3 Coverage" />

    *Source:
    WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Nepal. Data derived from the WHO/UNICEF Joint Reporting Form, Indicator GSA17ap. "NA" indicates data not available.

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    Disease Burden:

    Population (2008): 28,810,000
    Births (2008): 732,000
    U5 Deaths (2008):
    - total 37,000
    - preventable by routine EPI: 5,1801
    - preventable by routine EPI and new vaccines: 9,2502

    (Source: UNICEF "State of the World's Children" 2009 )

    1 Assumes use of BCG, DPT, polio, and measles vaccines prevent 14% of U5 deaths.
    2 Assumes use of BCG, DPT, polio, measles, HepB, Hib, yellow fever, and pneumococcal antigen-containing vaccines prevent 25% of U5 deaths.

    Note: Vaccine preventable death estimates assume that force of infections, individual susceptibility, and probability of exposure are constant at all mortality levels.

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    Useful Links:

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