The two-hour map

Nepal’s “two-hour map” is a planning model for emergency obstetric and newborn care. It asks which facilities should be made fully capable so people can reach emergency care within two hours. The goal is reliable access, not merely a large number of designated sites.

Analysts used AccessMod, a geographic modelling tool, to estimate journeys across Nepal’s actual roads and terrain. The model selected 267 facilities that could cover 98.8 percent of the population. This exposes a crucial difference between a facility appearing on a map and being able to provide care when needed.

The map is useful, but the floods revealed its weakness. Travel times depend on roads, bridges, and other links remaining open. Nepal must therefore test the network under disasters, not only normal conditions. A hospital may be close in the model yet unreachable after a flood or landslide.

Nepal’s plan is to concentrate investment in 267 facilities that can reliably provide emergency obstetric and newborn care. This is fewer than the 371 facilities previously designated for EmONC, but the selected sites would be expected to function properly.

The number came from a geographic analysis using AccessMod. Analysts looked for the smallest facility network that could keep nearly everyone within two hours of emergency care. Their result was 267 facilities, covering 98.8 percent of Nepal’s population. The measure therefore combines service capacity with physical access.

Implementation has begun at provincial level. Gandaki prepared a Rs374 million cost plan to close equipment and staffing gaps at priority sites. The plan was included in a provincial safe motherhood roadmap with annual government funding. The floods show that the network also needs backup routes and disaster testing.

The disaster began when a roughly 600-metre-wide section of glacier and bedrock broke away at about 5,200 metres. Nepal issued an alert 38 minutes later, but many downstream people had too little time. Roads and bridges in Rasuwa, Nuwakot, and Dhading were partly destroyed, and health facilities also fell or became inaccessible.

The affected population included an estimated 5,030 pregnant women. About 250 could require emergency obstetric and newborn care during the following three months. At one receiving hospital, nine women gave birth, while others arrived with infections or reduced fetal movement. Four women needed referral, using two army helicopters and two ambulances.

The flood did not remove pregnancy complications. It made reaching care harder and slower. Before the disaster, most referrals in the corridor already took more than two hours, and monsoon conditions lengthened travel by 39 percent. After roads failed, the next functioning facility could be much farther away.

Nepal once focused on building more facilities and bringing maternity care closer to communities. That approach helped move births from homes into clinics. But later evidence showed that designation did not guarantee readiness. In 2021, 57 percent of maternal deaths occurred inside health facilities.

Nepal had designated 371 facilities for EmONC, yet only about half of comprehensive sites were fully functional. Just 2 percent of basic sites were fully functional. The map looked well covered, but many facilities could not provide the services their labels promised on a given night.

The new strategy concentrates equipment, staff, and training in 267 priority facilities. It aims to make those sites dependable while retaining access for 98.8 percent of the population. The floods do not disprove this approach, but they show that concentrated services need backup routes and plans for sudden network failure.

Nepal reduced its maternal mortality ratio from 539 deaths per 100,000 live births in 1996 to 142 in 2023. This was a major public health success. The central change was moving births out of homes and into health facilities, where complications could be recognised and treated.

Ministries and donors supported the expansion, while tens of thousands of female community health volunteers helped connect women with clinics. The approach was straightforward: build more facilities and bring care closer to communities. For much of three decades, that strategy improved access and outcomes.

The progress also revealed a new problem. More women reached facilities, but some facilities could not save them. The 2021 study found that 57 percent of maternal deaths occurred inside health facilities. Nepal is now trying to preserve the gains by making fewer facilities fully capable rather than relying on many weak designations.

A priority hospital cannot be treated as the only possible answer when its road or bridge may fail. Planners can examine how access changes if a facility, bridge, or road is closed. This turns disaster resilience into part of the network design rather than an afterthought.

The article identifies GIS modelling as the practical tool. AccessMod already estimates travel times over real terrain. The same system can model failure by closing a bridge or flooding a route. Planners could then locate alternative facilities, compare travel times, and identify where transport or additional capacity is most needed.

This matters because a consolidated system creates dependence on key links. One closed road can leave many women far from the next capable hospital. The article’s unfinished proposal points toward testing the 267-facility network under disaster conditions. Specific backup measures are not detailed in the supplied text.

A pregnancy complication can become fatal when treatment is delayed. The article calls time the decisive variable in obstetric emergencies and notes that about one pregnancy in seven develops a complication. A disaster can therefore turn a treatable emergency into a life-threatening one by blocking the journey to care.

Emergency obstetric and newborn care is needed for serious complications, including haemorrhage and eclampsia. In practical terms, this means a capable facility must have trained staff, equipment, medicines, and the ability to provide urgent treatment or surgery. Those requirements explain why a designation alone is not enough.

Nepal’s data show the issue clearly. In 2021, 57 percent of maternal deaths occurred inside facilities, while only about half of comprehensive EmONC sites were fully functional. The priority network aims to make selected hospitals dependable. It must also preserve rapid access when roads, bridges, or facilities fail.