The ECO Strategy provides a global framework and ten-year blueprint for the WHO support structure. NSOAPs are the ministerially led, regionally coordinated implementation mechanism to operationalise global ECO priorities into national outcomes. The ECO Strategy and NSOAPs are complementary instruments that the global health architecture needs.
In May, 2026, the 79th World Health Assembly adopted the Global Strategy for Integrated Emergency, Critical, and Operative (ECO) Care 2026–2035. The Strategy states that its success depends on its integration into regional and national health policies and implementation mechanisms. A reliable, field tested mechanism for integration exists in the form of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). There is a crucial opportunity to ensure the newly adopted strategy builds on 10 years of evidence and best practice in the field.
NSOAPs are active in more than 30 countries across Africa, Asia, the Pacific Islands, and Latin America. These ministerially-authored policies are grounded in local priorities and domestically costed.1–4 NSOAPs respond to recent calls for the WHO to refine its governance structure, arguing that “streamlined regional and country structures are essential for saving money”.5 They enable health ministries to coordinate ECO Strategy implementation at a lower cost. The ECO Strategy seeks to rectify institutional fragmentation; NSOAPs can achieve this by aligning international institutions in service of national leadership.
Three objectives should be met before the end of the 2026 development window. First, the action plan should set a specific target for NSOAP adoption and mid-term review. Recent discourse argues that “…global health organisations, including the WHO, should focus on public goods that cannot be delivered by sovereign countries acting alone.”5 Countries should retain responsibility for NSOAP priority setting and costing; however, WHO is well positioned to engage its regional offices, health ministries, and non-state stakeholders to technically support NSOAP implementation.
Second, civil society should formally engage in developing the ECO Strategy action plan. Natural convening bodies, such as the Acute Care Action Network, the G4 Alliance, and the International College of Surgeons, should facilitate community input. Regional bodies and NSOAP-country ministries of health should coordinate region and country input, ensuring ECO Strategy objectives are mapped against existing NSOAP targets and vice versa, consistent with the African Union Center for Disease Control principle that “countries lead, regions coordinate, the global level supports.”
Third, the ECO Strategy should formally adopt the six Lancet Commission on Global Surgery indicators for timely access, workforce density, case volume, perioperative mortality, and protection against both impoverishing and catastrophic health expenditure. These indicators have been integrated into many national health management information systems, WHO’s Core 100 Indicators, and the World Development Indicators. Rather than creating a parallel measurement infrastructure, the ECO Strategy should build upon the Commission’s established indicators, which are the basis for a decade of existing country-level data from over 30 NSOAP-committed countries. 1
[Please note that Claude was used in the original compliation by the authors.]
Nepal Health Sector Strategic Plan (2023-2030).
This Health Sector Strategic Plan provides for the roadmap for strengthening the health system and achieving Universal Health Coverage and the Sustainable Development Goals by 2030.
It emphasizes strengthening governance across federal, provincial, and local governments, improving evidence-based planning, expanding digital health systems, enhancing disaster preparedness, and mobilizing sustainable domestic and partner financing. Regular monitoring, mid-term and final evaluations, and strong collaboration among government agencies, development partners, and local bodies are proposed to ensure effective implementation and continuous learning.
The key strategies include:
1. Strengthening health system efficiency and accountability by improving governance, health workforce management, infrastructure, medical supplies, health information systems, leadership, and emergency preparedness;
2. Addressing the broader determinants of health through multisectoral coordination and collaboration across sectors;
3. Promoting sustainable health financing and social protection by increasing investments in health, expanding health insurance, and reducing financial barriers to healthcare;
4. Ensuring equitable access to quality health services by improving availability, affordability, and quality of essential health services for all populations, particularly underserved groups; and
5. Managing population dynamics and migration by addressing demographic transitions, migration, planned settlements, and maximizing Nepal’s demographic dividend.
Key Maternal and Newborn Health Issues in Nepal (Regarding NSOAPs)
There is little change in the leading causes of maternal deaths over time: Postpartum Haemorrhage (PPH) and Hypertensive Disorders of Pregnancy (HDP) continue to be the leading causes of maternal deaths. Infection and NCDs are becoming increasingly important as causes of maternal death. One-third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to NCDs. Maternal death reviews at hospitals revealed that nearly 70 percent of maternal deaths could have been prevented.
Causes of newborn mortality have also not changed: The most common causes of newborn death are respiratory and cardiovascular disorders of the perinatal period (31%) and complications of pregnancy, labour and delivery (31%). Within respiratory and cardiovascular disorders, perinatal asphyxia accounted for more than half of the deaths. Most newborn deaths (57%) occurred within the first 24 hours of life, with 17 percent occurring within one hour and 40 percent from one hour to 23 hours. This highlights the need for continued attention to labour, delivery and immediate PNC of the newborn.
Women’s awareness about maternal health issues remains limited: Women’s low social status and inability to make decisions related to their own health, plus their poor knowledge of obstetric and newborn danger signs, are mediated by their relative wealth, caste or ethnicity, and by where they live. Targeted, context-specific interventions will be necessary rather than a blanket approach to meet the needs of different population groups. Strengthening the FCHV Programme will be of paramount importance in this regard.
Short birth-intervals persist: Short intervals between births are known to increase risks of morbidity and mortality to mothers and newborns. The proportion of babies born within a short interval (less than 24 months) in Nepal has remained constant at 21 percent since 2011. Birth intervals were shorter amongst certain groups of mothers, such as those less than 19 years of age, living in the Terai and/or in Province 2 and in rural areas, and among those who had lost a child from the previous pregnancy. Postpartum FP needs to be promoted, especially for vulnerable women.
Rate of pregnancies is high and contraceptive use is low among teenagers: Child marriage is still high, especially in Province 2. The Contraceptive Prevalence Rate (CPR) among currently married adolescents is 23 percent, against a national average of 43 percent for modern methods, resulting in high teenage pregnancy. Adolescent health programmes are few and scattered and adolescent-friendly health clinics are not functioning well.
Fertility rates reduced and FP increased, but low contraceptive prevalence continues among some groups: Use of any FP method by married women has increased from 29 percent in 1996 to 53 percent in 2016, with 43 percent using a modern method and 10 percent using a traditional method. The National Health Facility Survey (NFHS) 2015 found that 98 percent of health facilities in Nepal provide at least one modern FP method. However, only around one in five facilities where FP services are available provide Longacting Reversible Contraceptives (LARCs). There has also been a decline in exposure to information on FP among women and men over the past five years. FP is a highly effective strategy for reducing maternal and infant death and disability by lowering women’s exposure to the risks of unintended pregnancy and childbirth; the Road Map therefore recommends further strengthening the FP programme.
Overall ANC coverage has increased, but quality has been relatively weak: In 2016, 84 percent of pregnant women had at least one ANC contact with a skilled provider. There was a 25-percentage-point increase in the proportion of women receiving ANC from skilled providers from 2011 to 2016. However, 76 percent had their first ANC appointment on time and 59 percent had Four ANC Visits (4ANC). Long waiting times in antenatal clinics and poor counselling are some of the deterring factors. While access has increased, it appears that quality has not kept pace as only 76 percent receive care as per the protocol.
Institutional deliveries and skilled birth attendance increased: Between 2011 and 2016, there was a remarkable 22-percentage-point increase in the proportion of institutional deliveries (Nepal Demographic Health Survey (NDHS) 2016), with institutional birth reaching 57 percent. Despite this, high levels of disparity persist, varying according to the mother’s educational status, wealth and place of residence. Analysis of NDHS 2016 reveals that institutional deliveries are disproportionately concentrated in richer households, but the inequities are decreasing over time. Geographical barriers are prominent in the mountains, but access is relatively easy in the Terai. Despite easy access, institutional delivery is low in the Terai primarily because of sociocultural practices.
Awareness about legality of abortions and compliance with service standards is low: Abortion was legalised in 2002 and services became available in 2004, but only 40 percent of people know that abortion is legal. About 27 percent of pregnancies end in induced abortion among 35–49-year-old women. Among health facilities that provide normal delivery, 14 percent currently provide surgical and 26 percent provide medical abortions. Only fortytwo percent of abortions fully comply with service standards.
PNC is crucial for preventing maternal and newborn deaths, but current coverage levels are low: The GoN protocol on PNC includes three postnatal checks: the first at 24 hours after birth, then at three and seven days after birth. The first postnatal check is particularly important given that the majority of maternal and newborn mortality occurs within 48 hours of birth. Severe bleeding (PPH) can kill a healthy woman within hours of birth and yet only 45 percent of mothers had a postnatal check within four hours of birth at a facility and another 10 percent between four and 23 hours. In 2016, approximately half (54%) of newborns had a postnatal check within 24 hours.
Access to health services has improved but quality of care is still poor: As a result of irregular and poor-quality services, women bypass lower-level health facilities to go directly to higher centres, which, in turn, are overcrowded. Poor service readiness, long waiting times, barriers in discussing concerns/problems and inadequate explanations given by service providers are some of the challenges with regard to quality. This again is linked with health workers’ workload, availability, training and skills. A study in 2014 showed many gaps in the knowledge, skills and practices of trained SBAs with very little difference from untrained nurses.
Patient satisfaction and respectful and high-quality care are low across facilities: Observation of the client provider interaction during NHFS 2015 revealed that compliance with standard service delivery protocols was limited, especially in HPs and private hospitals. Only one-quarter (25%) of women had received all components of care, including at least one ANC visit, giving birth in a health facility and having at least one postnatal check for the mother or the newborn within two days of birth (NDHS 2016 – further analysis). The Road Map focuses on improving the quality of care around the time of birth and immediate postpartum period, which has been identified as the most impactful strategy for reducing maternal deaths, stillbirths and neonatal deaths.
Sources;
The Lancet Surgery & Anaesthesiology 2026
https://www.thelancet.com/journals/lansur/article/PIIS3117-7778(26)00001-1/fulltext?__cf_chl_rt_tk=jc4dLx4Tp1Z7cfbpK0OlOw7OXzHE9EVbWejWPO.lPR8-1790720404-1.0.1.1-SAdV3VWnmbtfTqW6OZhnKn23XcXvGF0Xqem8pD4aQJE
Nepal Safe Motherhood and Newborn Health Road Map 2030
https://leap.unep.org/en/countries/np/national-legislation/nepal-health-sector-strategic-plan-2023-2030