Local Governance and Maternal Health Outcomes: A Case Study of Nepal’s Decentralized Health Reforms

Nepal has made impressive gains in reducing maternal deaths in the last 25 years. The maternal mortality ratio dropped from 539 to 151 deaths per 100,000 live births between 1996 and 2022. During the same period, skilled birth attendance rose from 9% to 77% and institutional delivery from 8% to 79%. Alongside these improvements have been major reforms in the health system, especially decentralization. The Local Self-Governance Act of 1999 assigned local bodies responsibility of health facilities. In 2015, the Constitution of Nepal established a federal system with 753 local governments responsible for basic health services. This case study explores the role of decentralization in improving maternal health outcomes in Nepal. It draws on data from national demographic and health surveys, policy documents and global health estimates. The study finds that decentralization was helpful as it increased local resources, improved community participation, strengthened accountability and supported national programs such as the Aama Program. However, the challenges remain and include inadequate local capacity, lack of clarity of roles, quality gaps and disparities between rich and poor, urban and rural and between provinces. Nepal’s experience provides important lessons for other countries looking to reduce maternal mortality rates through devolved health systems.