ABSTRACT NUMBER: ESOC2026A2464 EVALUATING A MULTI-LEVEL STROKE SYSTEMS STRENGTHENING PROGRAMME IN NEPAL: A THEORY-BASED CONTRIBUTION ANALYSIS

Abstract Background and aims The Nepal Stroke Project (NSP), implemented since 2021, is a comprehensive multi-component programme aimed to strengthening stroke care across population, hospital, health system, and policy levels. This study presents the NSP impact evaluation, assessing whether and how NSP plausibly contributed to observed improvements in stroke care and outcomes. Methods We conducted a theory-based contribution analysis guided by an Theory of Change developed iteratively with national and international stakeholders. Impacts were assessed at population, hospital, health system, and policy levels using mixed methods, including registry data, document review, surveys, focus groups, and interviews. A realist evaluation lens was applied to explore context–mechanism–outcome configurations and investigate alternative explanations. Results At the health system level, NSP achieved substantial workforce development and increased the visibility and prioritisation of stroke care. Physicians reported strengthened professional confidence, enhanced leadership engagement, and participation in international research collaborations, with external validation identified as a key enabling mechanism. However, translation of knowledge into routine clinical practice was partially constrained by structural inertia and limited regulatory support. NSP public awareness activities contributed to increased stroke knowledge in target areas, although no measurable changes in health-seeking behaviour were observed. At the policy level, NSP contributed to the development and endorsement of a national stroke protocol through sustained advocacy in collaboration with WSO and WHO. Conclusions NSP plausibly contributed to multi-level improvements in stroke care in Nepal by combining capacity building, advocacy, and international partnership. Its Theory of Change provides a blueprint for strengthening stroke systems in comparable resource-limited settings. Conflict of interest Funding: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)