This study provides the first comprehensive assessment of opioid agonist therapy (OAT) in Nepal. It was conducted by the National Centre for AIDS and STI Control (NCASC), Harm Reduction International (HRI), Recovering Nepal (the national network of people who use drugs in Nepal) and the Network of Asian People Who Use Drugs (NAPUD)- to assess the coverage, quality and cost analysis of OAT in the country.

The study used a mixed-methods research design to assess current OAT coverage and access in Nepal. It utilised qualitative approaches, such as focus group discussions and key informant interviews, alongside quantitative financial OAT costing data.

• Current OAT coverage stands at 13%, which is significantly below the Nepal government’s target of 40% coverage by 2026.
• Services are available in only 10 of the country’s 77 districts, and 40% of all OAT clients live in sites within the Kathmandu Valley, resulting in inequitable access. Several key cities with high concentrations of people who inject drugs have no OAT sites.
• The coverage gap is not driven by a lack of demand but by political neglect, policy contradictions between punitive and public health approaches, and diminishing external funding alongside minimal domestic investment.
• Nepal’s OAT programme is guided by outdated, 12-year-old drug policies and guidelines, which fail to fully uphold OAT principles from a public health perspective. Other key drug-related policies, including the Narcotic Drugs (Control) Act 1976 and the Drug Control Policy 2006 require revisions..
• The absence of a national coordination mechanism among relevant stakeholders, along with negative perceptions of OAT among the general public and policymakers, hinders programme scale-up.
• Additional barriers to expansion include the lack of take-home doses, high-threshold service models which particularly limit access for women and young people, and hidden costs that increase out-of-pocket expenses for clients.

• The performance and quality of OAT sites are compromised by inadequate human resources, poor infrastructure, frequent drug stockouts and the reduction of social and behavioural activities due to limited funding.
• The Global Fund to Fight AIDS, Tuberculosis and Malaria is the only international funder for Nepal’s OAT programme, and its reporting indicators, particularly those related to retention, overshadow broader programmatic achievements and fail to capture the wider health and social benefits of OAT, which reinforces negative narratives about site performance.
• The Global Fund’s rate of retention indicator classifies people as having left treatment (i.e., dropped out) if they do not attend an OAT site visit for more than four consecutive days in a month. In practice, this requirement is difficult for many people to meet, particularly those who must travel long distances to access services.
• NGO-led and community-led sites generally provide more accessible and acceptable services than their government counterparts; however, funding reductions have placed significant constraints on these programmes.

The OAT programme in Nepal is inexpensive compared with those in other low- and middle-income countries.

The annual cost per person was:

• USD 284 for the NGO-run main site
• USD 284 for the NGO-run satellite site 1
• USD 258 for the NGO-run satellite site 2
• USD 312 for a government-run social support unit site.
• By comparison, a systematic review of the cost-effectiveness of harm reduction programmes found the annual unit cost of OAT was USD 368 in Vietnam, USD 405 in Indonesia and USD 543 in Kenya.
• Another systematic review reported that the global average annual unit cost of OAT in low- and middle-income countries is USD 522, which is almost double the cost in Nepal.
• In line with cost-effectiveness research worldwide, key stakeholders interviewed for this study consider OAT programmes cost-effective because they prevent HIV infection and have broader benefits in relation to health, education, employment and reduced incarceration.
• Unit costs for OAT in Nepal are expected to decrease further with national-level expansion and scale-up of services. However, the OAT programme remains heavily dependent on Global Fund financing and has minimal domestic funding, undermining its financial sustainability.
• In the context of shifting global health financing and reduced funding under the Global Fund’s eighth replenishment, the long-term sustainability of OAT in Nepal will largely depend on increased domestic commitment and investment.
• The country’s HIV treatment programme proves what is possible. Antiretroviral treatment was initially donor-funded, but the Nepal government has now taken ownership, procuring medicines through domestic resources. There is no reason this cannot happen with OAT.

• The Global Fund principal recipient, in consultation with NCASC, should assess the OAT programme’s sustainability in the context of the transition from Global Fund funding.
• Informed by the proposed OAT sustainability assessment, the Ministry of Health should formulate a multi-year action plan to guide the country’s transition from the Global Fund, which includes a clear commitment to, and co-financing for, the OAT programme from the Nepal government.
• The Global Fund should allocate funding for budget advocacy to ensure community and civil society representatives are equipped to advocate for government investment and social contracting for harm reduction.