Even though Nepal’s government health services have improved since the end of the Maoist insurgency in 2006, a number of pressing challenges remain. These include physical access to healthcare, limited health post opening times and poor medical supplies, and ineffective state monitoring. In the circumstances, healthcare users have to make trade-offs between costs and quality. In this paper the authors call for a flexible needs-based approach to health services and improved central evaluation and monitoring. To that end, four recommendations are proposed. In the wake of the recent devastating earthquake, these issues are even more critical. This paper is the second in a series on basic services in Nepal.