 Nepal was embroiled in a bloody civil war from 1996 until 2006.  Surprisingly, however, they are still on track to meet 16 of the 19 Millennium Development Goals by 2015.  While they are unlikely to meet the reproductive health targets, some of the goals Nepal is on track to meet include under-five and maternal mortality targets and disease-specific goals (halting the spread of HIV and malaria).  The question is, how was Nepal able to meet these targets even when dealing with civil conflict and internally displaced people?
	Devotka and van Teijlingen identify multiple reasons why Nepal was successful even during such trying times.  Some of the relevant items with regard to maintaining and strengthening health systems include:

Neither side purposely disrupted health systems during the conflict.  Though the conflict led to a decrease in service utilization, due to access problems, the rebels overall looked favorably on health services and made no efforts to deny access to citizens during the fighting. 
The rebels made an effort to ensure health clinics in their area were still sufficiently staffed and supplied.  Most clinics in rebel-held areas were sufficiently staffed and had supplies.  While many of the clinics were operated without trained health professionals, they still received regular training and supplies. 
Key actors increased coordination in response to the conflict, while maintaining a low profile.  Regular meetings continued between the Ministry of Health (MOH) and community officials.  In addition, the international organizations that responded by providing services kept a low profile.  The one issue identified here, however, is the lack of clarity coming from the country level to all actors.  While provisions were made for free care to poor citizens, criteria as to who qualified was not laid out to clinics.  Similarly, communication between the MOH and international organizations was not identified as a strength of the program.
Public health and more traditional service providers also increased their efforts during the conflict.  In addition, community clinics were handed over to the communities to manage, as the federal government did not have adequate resources to manage them during the conflict.  Programming for the elderly and indigent was increased, and many traditional female “attendants” saw their role increased.
GDP in the country continued to rise during the extended conflict, and infrastructure improvements likely also contributed.  These factors likely helped the country stay on track for the MDGs.  The infrastructure improvements (roads and electricity) likely improved access for many citizens.

	There are clear lessons for developing a health systems strengthening approach in other conflict situations here.  Namely, commitment from both sides of the conflict to not disrupting the health provision infrastructure in the country is key.  Ensuring clinics still run and funds are in place can help to minimize the effects of access and migration.  In addition, the government must be able to hand off some of the management to provincial or community levels, especially in rebel-held zones where they have limited access.


	So what are the takeaways from the Nepal case study? 