1. Executive Summary and Policy Call to Action

The health system of Nepal is actively engaged in strengthening its pre-hospital emergency medical services (EMS) through focused training of professionals, including Basic Emergency Medical Technicians (BEMTs) and community responders, often in coordination with international partners such as the World Health Organization (WHO).1 While these efforts are commendable, relying solely on professional capacity development fails to address the widespread issue of preventable mortality during the critical “Golden Hour.” Currently, the absence of widespread bystander competence in Basic Life Support (BLS) represents a significant systemic vulnerability.

I.1. The Public Health Crisis: Preventable Mortality in Nepal

Nepal faces a severe public health crisis defined by a high burden of accidental injuries, particularly those resulting from road traffic accidents (RTAs). National data indicate that the country records over 2,700 deaths annually due to RTAs.2 A profound challenge is the high rate of preventable death: it is estimated that up to 90% of accident-related fatalities occur due to delays in receiving timely medical care in the immediate aftermath of the incident.2 This delay underscores the critical importance of immediate, competent bystander intervention.

Survival from sudden cardiac arrest or severe traumatic bleeding hinges on rapid initiation of resuscitation or hemorrhage control by the nearest person, often a lay bystander. When the bystander lacks the necessary skills, the chain of survival is broken at its weakest link. Therefore, this report proposes a fundamental shift in national health and education policy: the transition from optional knowledge to mandatory, population-wide, practically certified BLS skills.

I.2. Key Policy Recommendations (The Tri-Pillar Mandate)

To effectively address the bystander gap and establish a resilient, population-based emergency response capability, the Government of Nepal must adopt a coordinated, three-pronged policy approach—The Tri-Pillar Mandate. The successful implementation of this mandate requires legislative action, educational restructuring, and regulatory enforcement across multiple ministries, ensuring that the entire adult population possesses the certified ability to save a life.

Pillar I (Education): Integrate mandatory, practical BLS/Hands-Only Cardiopulmonary Resuscitation (CPR) certification into the secondary school curriculum, specifically targeting students in Grade 10 and Grade 12.

Pillar II (Licensing): Make certified, NHTC-accredited BLS training a mandatory prerequisite for all new applicants seeking a motor vehicle license.

Pillar III (Legal Reform): Enact comprehensive Good Samaritan legislation to provide clear legal immunity and protection to bystanders who render reasonable emergency aid, thereby removing the pervasive culture of fear that currently deters intervention.

1. The Public Health Imperative and Institutional Framework

II.1. Justification: Bridging the Gap in Pre-Hospital Care

The necessity of mandating universal BLS competence is amplified by the observed deficiencies within Nepal’s existing healthcare workforce. While the Ministry of Health and Population (MOHP) and its partners strive to improve professional pre-hospital services 1, studies reveal that BLS knowledge and practical competency remain critically low, even among essential staff.

Research focused on Health Assistants (HAs), who play a crucial role in healthcare delivery, particularly in remote and rural areas, highlights a significant lack of practical training and limited CPR knowledge.3 Compounding this deficiency, one study observed that a startling 76% of healthcare staff surveyed had encountered a cardiac arrest situation in their clinical practice but were managing these cases with severely limited BLS knowledge.5 Furthermore, only 14% of these participants reported having received previous BLS training.5 This low competency among personnel directly responsible for health service delivery demonstrates that current training accessibility, methodology, or enforcement is fundamentally inadequate. If trained medical professionals are deficient in these foundational life-saving skills 3, the general population is entirely unprepared, confirming the urgent need for a population-wide, standardized intervention. The solution must focus on utilizing highly accessible, video-based, and cost-effective practical training methods to succeed where reliance on traditional, intermittent professional training has proven insufficient.

II.2. Institutional Capacity for Implementation: The Role of NHTC

The institutional framework necessary to implement, standardize, and monitor a national BLS mandate is already established within the Ministry of Health and Population (MOHP). The National Health Training Centre (NHTC) operates as the designated federal body responsible for the coordination and management of all health trainings in Nepal.6

NHTC’s organizational mandate is extensive, covering policy formulation, planning, curriculum design, implementation, monitoring and evaluation (M&E), and overall quality assurance related to the training system.6 NHTC currently oversees a comprehensive training network that includes seven provincial health training centers and 60 clinical training sites, catering to the needs of all MOHP departments.6 This existing infrastructure provides the necessary administrative and physical backbone for rolling out a national training initiative. The NHTC is also responsible for accrediting clinical training sites and public health-related training courses to maintain standardized quality.6

Crucially, the NHTC already manages specialized mandatory training programs within the government, such as the required training for ambulance drivers stipulated by the National Ambulance Directives, 2021.7 This precedent confirms the institutional acceptance of NHTC’s authority in certifying mandatory health and safety skills. The policy recommendation should therefore leverage this existing legal and administrative infrastructure 6 to assume command of the national BLS mandate. The core challenge is not the creation of a new bureaucracy but the scaling of NHTC’s accreditation and monitoring capacity through its established provincial network to manage the increased volume of trainees required by the school and licensing mandates.

III. Legal and Cultural Prerequisites: Enabling Bystander Action

The universal acquisition of BLS skills (Pillars I and II) is directly dependent on the successful enactment of a robust legal framework (Pillar III) that protects citizens who intervene.

III.1. The Critical Void: Absence of Good Samaritan Law in Nepal

The primary obstacle to bystander intervention in Nepal is widespread public fear. Despite the Constitution guaranteeing the right to emergency health services, citizens are profoundly hesitant to assist accident victims due to the fear of police involvement, court summons, legal complexities, and bureaucratic delays.2 This culture of fear directly contributes to preventable deaths during the crucial “Golden Hour”.2

A Good Samaritan law is a vital legal principle, common in many jurisdictions globally, designed to provide legal protection from civil liability to individuals who voluntarily offer reasonable assistance to those injured or in peril.8 Without this protection, a trained bystander performing CPR might face a civil lawsuit if the victim suffers unintentional injury (such as broken ribs, a known complication of effective chest compressions).10 If this fear of liability persists, the entire public investment in mandatory BLS training will yield minimal returns, as citizens will remain reluctant to step forward.

Immediate enactment of a dedicated Good Samaritan Law is the foundational prerequisite for the success of the BLS mandate. This law must guarantee legal immunity for laypersons who voluntarily provide aid (including CPR or bleeding control) without gross negligence, provided they act within the scope of reasonable training. It should also establish clear Standard Operating Procedures (SOPs) for police, hospitals, and emergency services to ensure that Good Samaritans are not unnecessarily dragged into investigations or legal processes.2 By urging the MOHP to lobby the Ministry of Law, Justice and Parliamentary Affairs (MOLJPA) for expedited passage of this framework, Nepal can align with neighboring countries, such as India (since 2016), which have seen bystander engagement increase significantly following such legal reforms.2

III.2. Addressing Cultural and Gender Disparities in BCPR

Beyond legal hurdles, the success of a national BLS program must account for regional socio-cultural dynamics that influence intervention rates. Studies conducted in Pan-Asian communities reveal significant gender disparities in bystander CPR (BCPR) based on location.11

Data shows that females suffering cardiac arrest in public locations are statistically less likely to receive bystander CPR (31.2%) compared to males (36.4%).12 Conversely, in private locations (such as the home), females are slightly more likely to receive BCPR.12 This disparity strongly implies that cultural norms regarding physical contact between unrelated individuals in public spaces likely contribute to bystander hesitation when the victim is female.

To mitigate this critical societal barrier, the national training program must prioritize and heavily market Hands-Only CPR as the primary public intervention for laypersons. Hands-Only CPR reduces the cultural barriers associated with mouth-to-mouth contact.11 The MOHP/NHTC curriculum design and public awareness campaigns must explicitly address gender sensitivity, utilizing culturally appropriate language and encouraging immediate, hands-on chest compressions in public emergencies. This targeted focus ensures that merely teaching the technical skill is not enough; the policy must incorporate a strategy to ensure equitable intervention rates across all segments of society, recognizing that generic training models may fail to account for regional societal constraints.12

1. Pillar I: Integration into the National Education System (The Youth Life Savers Programme)

IV.1. Curriculum Mapping and Strategic Entry Points

Integrating BLS into the national school curriculum guarantees universal saturation across the rising adult population, ensuring skill embedding and high long-term retention. Nepal’s secondary education system provides strategic entry points for this mandate. Lower secondary education (Grades 9-10) is compulsory and concludes with the Secondary Education Examination (SEE). The compulsory subjects for this stage include “health, population and environmental education”.13

The Grade 10 curriculum already addresses safety and First Aid principles, including activities that encourage the organization of First Aid training by inviting a trainer to the school.14 Upper secondary education (Grades 11-12) includes mandatory subjects such as “Life Skill”.16 The strategic requirement is not the introduction of a new subject, but a policy shift from teaching theoretical knowledge of First Aid 14 to mandating a practically assessed skill certification in BLS/Hands-Only CPR as a prerequisite for graduation.

The policy recommends making BLS/Hands-Only CPR certification a required component of the Grade 10 curriculum, leveraging the existing Health, Population, and Environmental Education framework.13 A mandatory, standardized refresher course should be integrated into the Grade 12 “Life Skill” module 16 to ensure skill retention prior to entering adulthood. By aligning the mandate with these existing mandatory subjects, the administrative and infrastructural burden on the Ministry of Education, Science and Technology (MOEST) is significantly minimized. This model has proven scalable and sustainable for national implementation programs in comparable LMICs, such as the Pakistan Life Savers Programme (PLSP), which achieved sustainability by adding training into a single national school curriculum.17

IV.2. Pedagogical and Logistical Strategy for School Rollout

The logistical challenge of training millions of students requires a novel, high-efficiency approach. The NHTC must establish a “Master Trainer” program focused on rapidly training existing secondary school science or HPE teachers. These certified teachers will then deliver standardized BLS training across their districts, leveraging NHTC’s existing provincial health training center network.6

Due to budgetary and resource constraints inherent to LMICs 18, the MOEST, in collaboration with NHTC, must adopt a scalable training model: Video Self-Instruction (VSI) using low-fidelity, durable, feedback-enabled manikins. This approach is recognized globally for its effectiveness in conveying the core lifesaving skills—compression rate and depth—even without high-cost, high-fidelity equipment or constant instructor presence.19 The video training must be standardized and developed in Nepali language, drawing on precedents established for adapting guidelines for healthcare personnel.21

A centrally funded procurement strategy is necessary to supply schools with robust, low-cost training equipment. Local availability confirms manikins, including miniature or half-body models, are available in Nepal at prices ranging from Rs. 9,300 to Rs. 22,222 per unit.22 While initial capital investment is required, it is justified by the subsequent low recurrent cost of instruction time. The National Examinations Board (NEB) must formalize a practical competency checklist for BLS (Hands-Only CPR) to be administered by certified school trainers, ensuring standardization before final secondary examination.

1. Pillar II: Universalization via Licensing Mandates

V.1. Driving License Requirements (Department of Transport Management)

The mandate must extend beyond the youth trained in schools to capture the currently active adult population. Linking BLS certification to universal licensing requirements provides the most efficient mechanism for this saturation.

Current Regulatory Status: The Department of Transport Management (DoTM) currently includes knowledge of “First aid and emergency procedures” in the theoretical written examination for a general driving license.24 However, this requirement assesses theoretical knowledge only; the DoTM does not mandate a dedicated, accredited practical certification course for general license applicants.24

Policy Mandate: The DoTM must immediately integrate mandatory, NHTC-accredited BLS certification as a prerequisite for both initial license applications and the final practical driving test.25 This policy is not unprecedented: the Ministry of Health and Population already enforces a clear regulatory precedent by requiring mandatory, NHTC-certified training for specialized vehicle operators, such as ambulance drivers, as per the National Ambulance Directives, 2021.7 This confirms the government’s institutional acceptance of linking specific medical competency training to transport licensing.

The implementation shifts the requirement from simply testing theoretical knowledge 24 to requiring validated certification (proof of practical skill). NHTC will be responsible for accrediting designated training centers (which may include professional driving schools or vocational centers) to deliver the standardized, short-duration BLS course. This approach targets the population segment most likely to witness road traffic accidents 2 and ensures quality control consistent with national health standards through NHTC accreditation.6

V.2. Mandating BLS for Government Service and Public Sector Employment

To further embed life-saving skills within the public response infrastructure, BLS certification should become a mandatory requirement for hiring and promotion across all civil services, especially those whose roles involve direct public interaction or first response capacity (e.g., Nepal Police, Traffic Control, Civil Administration).

Current requirements for services such as the Nepal Police focus on physical and moral standards 26 and specialized training in areas like security and crowd control.27 However, immediate life-saving skills are essential for police personnel often first on the scene of emergencies. NHTC must collaborate with the Nepal Police Academy (NPA) to integrate mandatory BLS certification into the foundation training programs offered at centers like the Koshi PPTC.27

V.3. Recertification and Quality Assurance

To ensure competency retention, mandatory recertification for BLS must be enforced every two years. This recertification should be tied directly to the renewal of the driving license or government employment/professional licensure. The VSI/low-cost model discussed in Section VI can be leveraged for rapid, standardized recertification tests available at NHTC-accredited centers across all provinces, ensuring continuous maintenance of the skill base.

1. Implementation Strategy: Scaling Training in Resource-Limited Settings

VI.1. Adopting High-Volume, Low-Cost Models (VSI and Self-Directed Learning)

The primary logistical challenge in realizing universal BLS competency in Nepal is cost and accessibility. Traditional, instructor-intensive training models are prohibitively expensive and logistically impractical to scale across remote and rural areas.18

Video Self-Instruction (VSI) and Hands-Only CPR: The policy must endorse the Video Self-Instruction (VSI) model. Research confirms that laypersons exposed to ultrabrief Hands-Only CPR videos are more likely to attempt CPR and demonstrate superior skills regarding chest compression rate compared to untrained individuals.19 This focus on Hands-Only CPR maximizes effectiveness while simplifying the training module. NHTC must develop and utilize standardized VSI training in Nepali language, adapted from guidelines like those of the American Heart Association (AHA).21

Equipment Strategy: Infrastructure limitations in many LMIC settings, such as the lack of consistent power or climate control, render high-fidelity simulation devices unsuitable.18 The solution lies in the bulk acquisition of durable, low-fidelity simulation models 18, specifically feedback-enabled manikins. These manikins—such as those utilizing light feedback systems or smart technologies 29—provide immediate, objective feedback on compression depth and rate, ensuring quality skill acquisition without constant instructor oversight. While initial manikin costs can range up to Rs. 58,000 for professional kits 23, the high capital expenditure is justified by the subsequent low recurrent cost of instructor time, enabling the program to meet the massive volume demands of both the school and licensing mandates simultaneously. BLS training, utilizing these self-directed tools, offers a proven high-impact, low-cost solution compared to perpetually building and staffing advanced medical clinics in remote locations.28

VI.2. Provincial Rollout and Capacity Building

To achieve geographical equity, the implementation strategy must be thoroughly decentralized. The seven Provincial Health Training Centers (PHTCs), already coordinated by NHTC 6, must be immediately empowered and funded to act as central hubs for Master Trainer development, curriculum dissemination, and quality control at the provincial level.

Initial funding and resource capacity must be augmented by strategic partnerships. NHTC should leverage collaboration with Non-Governmental Organizations (NGOs), civil societies, and international partners, which already have a presence in capacity building in Nepal (e.g., WHO 1, CECAB 31, Disque Foundation 32). These partnerships can provide initial funding, share logistical expertise, and assist in community-level delivery, particularly where formal government infrastructure is nascent.

VII. Economic Analysis and Sustainability

VII.1. Cost-Benefit Justification for Universal BLS Training

The economic argument for mandatory BLS training is compelling. While comprehensive cost data for out-of-hospital cardiac arrest (OHCA) in Nepal is limited, regional studies highlight the substantial economic burden posed by cardiovascular disease and related acute events. Heart failure treatment, for instance, results in significant health expenditures, reaching up to $4,513 annually per patient in regional Asian countries, with hospitalization costs often exceeding $10,000 per case.33

Prompt bystander intervention through effective BLS can prevent death and reduce long-term disability, translating directly into avoided hospitalization costs, decreased reliance on complex post-resuscitation care, and reduced loss of productivity.34 Studies affirm the financial utility and cost-effectiveness of bystander CPR training.35 Furthermore, the intervention offers intangible benefits: when communities are empowered to respond to emergencies, they tend to adopt a more proactive and preventive health mindset in general.28 This shift toward proactive health behaviors benefits the community in the long run by potentially reducing the incidence of chronic diseases that lead to cardiac events.

VII.2. Estimated Budgetary Requirements and Funding Model

The initial budgetary requirement centers on non-recurrent capital expenditure, specifically the bulk procurement of VSI manikins (estimated need for one manikin per 50 students in schools, plus supply to licensing and government training centers), the development of culturally adapted Nepali VSI content 21, and the initial certification of the Master Trainer cadre (NHTC, MOEST, DoTM personnel).

To ensure sustainability and long-term viability, a diversified funding strategy is essential:

1. Public-Private Partnership (PPP) and CSR: Initial capital investment should be secured through targeted funding from international development partners (e.g., WHO, World Bank) and mandated Corporate Social Responsibility (CSR) contributions from private sector entities in Nepal, especially the insurance and transport industries, which benefit directly from reduced accident mortality and liability.
2. Fee-Based Licensing: A modest, regulated fee should be incorporated into the mandatory BLS certification course linked to the driving license application process. This structured fee ensures the long-term sustainability of the training centers, covering costs for manikin maintenance, material updates, and administrative overhead. This model shifts the cost burden away from general taxation while ensuring mandatory coverage.

VIII. Conclusion and Policy Action Roadmap

The current policy landscape in Nepal, while striving to professionalize pre-hospital care, remains incomplete without a coordinated mandate for universal bystander competence. The Tri-Pillar Mandate—Education, Licensing, and Legal Reform—provides a cohesive, scalable, and institutionally aligned strategy to drastically reduce preventable mortality during the critical pre-hospital period. Legal protection must be secured immediately to underpin the entire public investment in training.

Table 1: Policy Gaps and Proposed Regulatory Solutions

Policy Area Current Status in Nepal Associated Policy Gap/Risk Proposed Regulatory Action Relevant Policy Precedent

Legal Immunity Absence of a defined Good Samaritan Law. High risk of bystander hesitation and potential legal liability.[2, 10] Enact comprehensive Good Samaritan protection (MOLJPA). Global/Regional Best Practice.2

Skill Standardization BLS knowledge is low, even among HAs; reliance on non-standard training.[4, 5] Ineffective intervention due to poor technique (rate/depth). Mandate NHTC accreditation for all BLS certification centers, enforcing VSI/Feedback Manikin standard.[6, 21] NHTC’s accreditation mandate.6

Adult Coverage Driving License requires knowledge of First Aid.24 Practical skill not verified; only theoretical literacy is tested. Shift DoTM requirement to mandatory NHTC-certified practical BLS training/certification.7 Mandatory NHTC training for ambulance drivers.7

Youth Coverage First Aid theory and activity suggestion in Grade 10 HPE.14 Inconsistent, unassessed delivery; no guaranteed skill acquisition. Mandatory practical BLS assessment for secondary school completion (NEB/MOEST). Successful curriculum integration in LMIC (e.g., PLSP).17

The successful deployment of this mandate hinges on the adoption of high-volume, low-cost pedagogical techniques, specifically utilizing Video Self-Instruction (VSI) and feedback-enabled manikins, which are scalable and cost-effective in resource-limited environments.28

Table 2: Logistical Strategy for Scalable Training

Component Constraint in LMIC (Nepal) Recommended Scalable Solution Justification/Benefit

Instructor Availability Limited supply of certified, expert instructors.5 Video Self-Instruction (VSI) and self-directed learning.28 Reduces recurrent staffing costs and bypasses remote access difficulties.[19]

Equipment Cost/Durability High cost of professional manikins; infrastructure limits.[18, 23] Bulk procurement of low-fidelity, durable feedback manikins.28 Ensures quality feedback (rate/depth) while controlling initial capital expenditure.[20, 29]

Quality Control Variability in skills retention and training standards.3 NHTC-led M&E, standardized VSI content, and mandatory recertification every 2 years. Guarantees consistency in skill transfer using scientifically proven methods.[30]

Cultural Barriers Gender disparities in public BCPR attempts.11 Explicit advocacy and training focused on Hands-Only CPR; culturally sensitive training videos. Addresses social reluctance regarding physical contact in public, promoting equitable intervention rates.

Policy Action Roadmap Timeline (Suggested)

Phase Timeline Primary Responsible Agencies Key Actions

I: Foundation & Legal Reform 0-12 Months MOLJPA, MOHP, NHTC Enact Good Samaritan Law. Secure Cabinet approval for BLS Mandate Policy. Fund NHTC scale-up.

II: Pilot & Curriculum Development 12-24 Months NHTC, MOEST, DoTM Pilot BLS integration in 10% of schools and 3 DoTM offices. Develop and certify Master Trainer cadre. Finalize VSI curriculum in Nepali.21

III: National Rollout & Enforcement 24-60 Months NHTC, MOEST, DoTM, PHTCs Mandatory BLS Certification for all Grade 10 students and new driving license applicants. Establish provincial quality assurance (QA) centers.

The Government of Nepal must move decisively to implement the Tri-Pillar Mandate, transforming its citizenry from passive bystanders into an empowered network of life savers, thereby significantly bolstering national resilience against sudden medical emergencies and fulfilling the constitutional guarantee of the right to emergency health services.

यस विषयबारे विस्तृतमा सुन्नुहोस् : नेपाली भाषामा