But progress at the two ends of the journey - pregnancy care once conception has already happened, and child health once the baby has already arrived - has left a critical middle section almost entirely unaddressed. There is no organised, national programme to prepare couples for a safer pregnancy before conception. There is no systemic screening programme for the major categories of birth defects: structural and neural tube defects, hearing and vision impairments, congenital heart disease, and neurodevelopmental conditions
Every year in Nepal, a family celebrates a pregnancy with hope, follows the antenatal visits they are told to attend, and delivers their baby in a health facility - doing everything right, by the book. And yet, for a significant number of these families, that child will grow up with a disability that could have been prevented. Not because anyone failed them individually, but because Nepal's health system has a structural blind spot that almost no one is talking about.
I have spent the past 20 years working in maternal and child health, disability prevention, and community-based rehabilitation at Karuna Foundation Nepal. In that time, I have watched Nepal make genuine, measurable progress. Institutional deliveries have risen from just 8 percent in 1996 to 79 percent today. Immunisation programmes reach the vast majority of our children. These are real achievements, and they deserve recognition.
But progress at the two ends of the journey - pregnancy care once conception has already happened, and child health once the baby has already arrived - has left a critical middle section almost entirely unaddressed. There is no organised, national programme to prepare couples for a safer pregnancy before conception. There is no systemic screening programme for the major categories of birth defects: structural and neural tube defects, hearing and vision impairments, congenital heart disease, and neurodevelopmental conditions.
And there is no routine pathway for foetal screening of conditions like Down syndrome, which families elsewhere in the world are able to know about, and prepare for, well before birth.
The consequences of this gap are not abstract. One-third of neonatal deaths in Nepal are attributed to congenital anomalies - one of the least addressed causes in our national newborn health response.
Despite folic acid's proven ability to reduce neural tube defects by up to 70 percent, only 21 percent of pregnant women in Nepal take it adequately. Only one in four of our birthing centres is properly equipped for emergency obstetric and newborn care. And our neonatal mortality rate has been stuck at 21 per 1,000 live births for years, even as institutional delivery coverage has climbed.
This stagnation is not a mystery - it is what public health experts recognise elsewhere as an epidemiological transition, and Nepal is living through its own version of it.
We have done the harder, more visible work of getting mothers to a skilled attendant and a facility bed. What remains stuck is a different category of problem entirely: congenital and non-communicable conditions present at or before birth, which do not respond to more access alone.
Expanding institutional delivery got us this far. It cannot, on its own, take us further. The children we are still losing, and the disabilities we are still failing to catch early, are being driven not by a lack of facilities, but by a lack of planning, screening, and early detection - a fundamentally different kind of intervention than the one that got Nepal from 8 percent institutional delivery to 79.
One consequence I have seen repeatedly in my own career deserves particular attention: a substantial share of children living with cerebral palsy in Nepal acquired it not from any prenatal condition, but from prolonged or poorly managed delivery - something that, with the right emergency obstetric capacity in place, is often preventable.
There is also a challenge on the horizon that Nepal is not yet prepared for. Autism and other neurodevelopmental conditions are being diagnosed at rising rates worldwide, and there is every reason to expect Nepal will see the same trend, whether or not our health system is ready to recognise it.
Early identification - ideally by age three - makes an enormous difference to a child's long-term development. Right now, Nepal has no structured system to make that early identification happen.
Nepal got mothers to health facilities. Nepal got children immunised. Those were the right first battles, and they were won. The next one is harder, because it cannot be solved by access alone - it requires catching what can be caught, preventing what can be prevented, and giving every child, not just the fortunate ones, the healthiest possible start in life.
That is not only a health question. It is one of the most cost-effective investments Nepal could make in its own future - because a disability prevented is a lifetime of care, dignity, and opportunity given back to a child and their family, at a fraction of the cost of managing that disability for decades to come.
Nepal has already shown, twice now, that it knows how to close a health gap when it decides to. The question is whether we recognise this one before another generation of children pays the cost of our not looking.
Sapkota is executive director of Karuna Foundation Nepal