Emergency and trauma care in Nepal: what the 2021 system assessment asks of districts and municipalities

Emergency care is where a health system's weaknesses become visible within an hour. Nepal's own assessment of that system is unusually clear about it. In 2021 the Ministry of Health and Population, through its health emergency and disaster management structures and with WHO support, published a report on Emergency Care System Assessment and consensus-based action priorities for Nepal. The process began in 2019 under WHO's Global Emergency and Trauma Care Initiative, and the assessment used the WHO Emergency Care System Assessment tool across five domains: system organisation, governance and finance; human resources; information management; health facilities and infrastructure; and quality and safety.

1. The five assessment domains, read as a work plan

2. The legal duty behind the clinical work

The Public Health Service Act, 2075 (2018) obliges providers to deliver emergency health services without demanding prior payment, and the Public Health Service Regulations 2020 set out operational standards. A facility with no triage, no stabilisation capability and no referral arrangement is therefore not just clinically weak, it is out of compliance with a statutory entitlement. This framing is useful in budget discussions: emergency readiness is not an optional quality improvement, it is the minimum condition for lawful service delivery.

3. The trauma burden and where it comes from

Road traffic injury is one of the clearest drivers of Nepal's emergency and trauma workload. WHO's Global Status Report on Road Safety 2023, published in December 2023, and its accompanying Nepal country profile released in 2024, are the appropriate primary sources for national road-death estimates; secondary media citations of those estimates circulate widely and should not be used in place of the profile itself. The operational implication for a district is predictable geography: crash clusters concentrate on specific road segments, and both prevention and pre-hospital response should be planned around those segments rather than spread evenly.

• Map crash locations from police and facility records to identify the two or three segments producing most severe trauma in your area.
• Place ambulance standby and trained first responders relative to those segments and to travel time, not to administrative boundaries.
• Agree fixed destinations by injury severity in advance, so decisions about where to send a patient are not made under pressure.
• Record pre-hospital time intervals; without them you cannot demonstrate improvement or justify investment.

4. Pre-hospital care and the referral chain

Nepal's pre-hospital layer remains the least standardised part of the chain. The 2021 assessment is the definitive national statement on the gaps; I was not able to verify a newer publicly-available national ambulance or pre-hospital referral directive in English at the time of writing, and readers planning against current rules should check the Health Emergency Operation Center's publications directly. What is not in doubt is what makes referral work at facility level, because it is the same everywhere: a phone number that is answered, a receiving facility that accepts, transport that departs within a defined window, and a written handover.

1. 01Publish a single referral contact list for the municipality, laminated and posted at every facility, reviewed twice a year.
2. 02Pre-agree transport: whether ambulance, community vehicle or contracted service, the arrangement and its cost-recovery rule must exist before the emergency.
3. 03Standardise a one-page handover form with vital signs, time of onset, interventions given and time of departure.
4. 04Close the loop: receiving facilities should report outcome back to the referring facility, which is the only way frontline staff learn whether their decisions were right.
5. 05Review three referrals per month in a short meeting — this single habit improves referral quality faster than any training event.

Emergency care systems do not fail dramatically. They fail through a phone that is not answered and a vehicle that is not fuelled.

5. Implementation research questions worth answering

My current research examines readiness and implementation determinants for emergency and trauma care pathways in rural Nepali municipalities — the practical question of why identical guidance produces functioning emergency care in one palika and not the next. Three questions are open and answerable with modest resources:

• What are the determinants of sustained triage practice at health-post level after training ends, analysed with an implementation determinant framework?
• What is the measured effect of a municipality-level referral protocol and contact list on time-to-definitive-care for severe trauma?
• How complete and usable is routine emergency-case data in DHIS2 at the facility level, and what minimal register redesign fixes it?