Rheumatic heart disease (RHD) is a major public health problem in Nepal that affects young children and adolescents. Historically, many young people suffered severe valvular disease and died awaiting heart valve replacement. For some years, the Nepal Heart Foundation (NHF) advocated for a more comprehensive program to reduce the burden of RHD. In 2007, the government of Nepal announced funding for an RHD control program to be implemented by the NHF. The core focus of the program was to deliver antibiotics for the secondary prophylaxis of RHD. The NHF has developed a program of community awareness, free medication, RHD register development, health worker training, guideline development, and clinical audit. These services are being implemented with expanding geographic scope. This paper provides a narrative overview of the Nepalese experience designing, implementing, and beginning to evaluate this program. Challenges and successes relevant to register-based programs are highlighted.