In Nepal, a ‘womb to tomb’ approach to community care, powered by the Community Health Toolkit, is supporting Community Health Nurses to uncover hidden health risks. Here, Medic’s Bhishan KC and Dr. Nitin Nischal Bhandari, and Ms Hira Kumari Niraula, Director of Nursing and Social Security Division (NSSD), and Ms Bala Rai, NSSD Senior Hospital Nursing Administrator, share how this program is transforming care at the doorstep.
A nurse, an app, and the patient who almost missed the care they needed.
It should have been a routine home visit.
But Community Health Nurse Sanchita Bohora noticed that something didn’t feel quite right.
As she gently spoke with a woman in the household in Nepal’s Gandaki Province and recorded her details in her Community Health Toolkit (CHT)-powered app, subtle signs began to emerge—signs that pointed toward a possible mental health condition. It wasn’t obvious, and it wasn’t easy to talk about. But instead of moving on, Sanchita chose to pause, listen more closely, and care more deeply.
She provided counseling on the spot and encouraged the woman to visit the nearest health facility.
Instead, life got in the way.
Days turned into weeks, and the woman missed not one, but two follow-up visits. Family restrictions, daily responsibilities, and perhaps even fear kept her from seeking help.
For many, that might have been the end of the story. But not this time.
Each time Sanchita opened the CHT app, the pending follow-up remained. It was a quiet, yet persistent, reminder. On the third visit, she returned with renewed determination. This time, she went beyond simple advice. With empathy, patience, and honesty, she spoke about the reality of living with an untreated condition—the silent burden it carries, and the hope that treatment can offer.
Sanchita didn’t rush, or judge. She simply stayed.
And something shifted.
The woman finally agreed to visit the health facility. There, she was diagnosed with an anxiety disorder and began treatment.
What changed her path wasn’t just one visit or one conversation. It was the steady presence of someone who refused to give up. Behind this story is more than a diagnosis—it is dignity restored, a burden shared, and a life gently guided back on track.
Nepal’s growing health burden: The 'Iceberg Phenomenon'
This is not an isolated case.
Nepal is experiencing rapid demographic and health transitions, including a rise in chronic and non-communicable diseases (NCDs), increasing mental health concerns, changing lifestyles, and a growing demand for equitable and accessible basic health services. While maternal health in the country has improved, the lack of systematic follow-up in place means many women still miss critical antenatal care (ANC), postnatal care (PNC), and early pregnancy screenings.
Beyond maternal health, many chronic conditions and mental health issues remain under the surface. It’s known as an “iceberg phenomenon”, where only severe cases reach health facilities while early-stage illnesses go undetected within communities. This challenge is further compounded by traditional paper-based reporting systems, which delay data reaching local health officers and limit their ability to identify emerging health trends or allocate resources effectively. As a result, primary healthcare often remains reactive rather than proactive.
From womb to tomb: Nepal’s lifelong approach to community health
To address these gaps, in 2022 the Nursing and Social Security Division (NSSD) of the Ministry of Health and Population launched a life-course approach to case management in five municipalities across five different districts. Through the ‘womb to tomb’ program, trained Community Health Nurses (CHN) like Sanchita provide doorstep, family-centered care across all life stages, including Reproductive, Maternal, Newborn, and Child Health (RMNCH) services as well as geriatric care. The program focuses on proactive home visits, guided by a digital health system built with the CHT, that identify hidden cases and address the “iceberg phenomenon” through screening, assessment, referral, and follow-up using the CHT.
This approach is aligned with national policies which emphasize integrated, community-based health service delivery and recognize the role of local-level health systems in ensuring continuous care across the life course.
How it works: Family-centered, doorstep care across every life stage
Each nurse like Sanchita gathers detailed demographic and health data for every family member in their catchment area. Once the profile is complete, the CHNs provide comprehensive care including RMNCH services; screening for NCDs such as hypertension and diabetes, breast and cervical cancer, and mental health; and counseling and referrals to health facilities.
This is not a vertical or disease-specific program. Rather, it is a digitally powered and holistic community care model that enables continuity of care across different health needs and stages of life.
How the CHT supports smarter care
The Community Health Toolkit (CHT) plays a critical role in strengthening the effectiveness of the nurses’ work. The platform has been specifically designed to create household and family profiles, support protocol guided service delivery, follow-up, and reporting, while improving data quality and closing the loop on care. This turns paper-based primary care outreach into an efficient and highly impactful digital system powering a range of deployments. Here’s how:
Follow-up alerts: In-app reminders alert CHNs to pending visits, referrals, and screenings. This helps CHNs maximize their time, by planning out household visits and prioritizing high-risk cases.
Data accuracy: A built-in validation process prevents contact duplication and typos, ensuring that data is accurate and to a high standard.
Smart workflows: Only relevant workflows appear based on the family member’s age and gender
Structured counseling notes: Clear and standardized prompts help CHNs provide consistent, high-quality counseling during every home visit.
Digital referrals: Referral notes improve coordination and communication between CHNs and health facilities, ensuring clients receive timely and appropriate care.
Diagnostic support: These notes assist CHNs in identifying potential health risks early for referral or follow-up.
Real-time analytics for health leaders
A key element of the program’s success is the municipality-level analytics dashboard, which has transformed service flow, data management, monitoring, and community-level coordination. It enables local health leaders to guide and proactively supervise CHNs, monitor program progress, identify emerging health issues, and plan targeted health campaigns based on real-time data. It also supports municipalities to own and understand their own data, advancing local data sovereignty.
With analytics dashboards, Community Health Officers (CHOs) can access all the essential indicators they need at a glance and effectively plan, supervise, monitor, and report.
Pilot Results: 96% Facility Deliveries, for Just USD $0.74
A pilot revealed the program to be highly cost effective, costing just NPR 107 (USD 0.74) per person per year. This amounts to just 3% of the municipal health budget, demonstrating that the model is not just financially sustainable but also scalable for local governments.
And, most importantly, it’s made critical improvements to health outcomes. The amount of facility-based deliveries rose from 75% to 96% in three years, ensuring safer births for more women.
There was also a tangible increase in pregnancy registrations and household visits, with the number of women receiving postnatal care (PNC) appointments at home rising from 66.2% to 75.7% in the final year of the program.