Because of the large uncertainty intervals around health gain for DOT strategies, it remains inconclusive whether DOT strategies are more cost-effective than SAT. It is evident, however, that family-member DOT is a cost-saving intervention.

Purpose The under-5 mortality rate in Nepal remains high in comparison to neighboring countries and developed nations. The result of this problem on Nepal’s social, economic, political and cultural development makes it an urgent priority requiring the Nepalese Government to address this issue. The purpose of this paper is to find out if Nepal’s high female labor force participation (FLFP), the caste system and no paid maternity leave are contributing factors to under-5 deaths in Nepal. Design/methodology/approach Data for this study were taken from Nepal’s cross-sectional demographic health survey 2016–2017. The study sample included 5,060 children born to 3,074 mothers in the five years preceding the survey. Data were collected by interviewing respondents via a structured questionnaire selected through stratified random sampling methods. Findings The study found that the hazard ratio for FLFP, the caste of the mother and paid maternity were 1.145, 1.485 and 0.556, respectively, with a p-value <0.001. Therefore, the risk of death in children under-5 years for a working mother, a Terai caste mother and a mother who did not get paid maternity was 14, 45 and 48 percent, respectively, higher than for non-working mothers, mothers from other castes and mothers who got paid maternity. Originality/value This research demonstrated that FLFP, the caste of the mother and paid maternity leave are important factors for determining the risk of death in children under the age of 5.

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