<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e29c7e80680e0c031ejpeg.jpg" alt="" width="1086" height="724"/><figcaption>Charikot Hospital. Photo: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s medical industrial complex has modernised healthcare in the country, but it has also pushed treatment out of reach of most citizens.Collusion between politicians and medical magnates has made it so expensive to become a doctor that it has set off a chain reaction to make hospital treatment unaffordable.Meanwhile, government hospitals are <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/">under-funded, under-staffed and under-motivated</a>. Most medical personnel in district hospitals and health posts moonlight in private clinics, and patient treatment is substandard.Desperate families have to sell property, jewelry and other assets <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">to afford private treatment</a>, pushing even some middle-class families below the poverty line.Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, Nepali TimesBut there are notable examples of government hospitals that are running well because of various models of partnership with non-profits, foundations and charities. They prove that affordable high quality healthcare is possible, and those hospitals need not be so expensive to run.There is <a href="https://archive.nepalitimes.com/news.php?id=18362#.YrQjS-xByrc">Dhulikhel Hospital</a> which has a tiny registration fee, treatment is low cost, an insurance scheme pays for most treatment, and patients are charged according to their capacity to pay. Despite being a government hospital, Dhulikhel has upheld a consistently high standard of care and treatment.United Mission to Nepal has run a hospital in Tansen for over 60 years, a community hospital in Okhaldhunga, and was till recently managing Patan Hospital, providing high quality care at low cost to patients.Other public-private partnership institutions that could be models to be replicated across Nepal include:<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e59c7e80680e0c031fjpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><h3>Bayalpata Hospital</h3>After <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Bayalpata Hospital</a> was established in Achham 20 years ago, for many years it did not have a single doctor. Treatment was so poor that even emergency cases had to be taken on a grueling 12 hour drive down to Dhangadi.In those days HIV tagged along with the migrant workers returning from India, and there was a full-blown AIDS and TB epidemic in Achham and other district in Far Western Nepal. The mortality rate, already very high among women and children, soared.In 2009, Nepali and American medical students inspired by the community health model of <a href="https://www.nepalitimes.com/latest/paul-farmer-on-my-mind/">Paul Farmer</a> set up Nyaya Health Nepal (formerly Possible) taking over  Bayalpata under a public-private partnership with the government.Since then, Bayalpata Hospital has upgraded its facilities (left) and <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">treated nearly 1.5 million patients for free</a>, some of them for complicated caesarian and orthopedic surgeries.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeUp to 100,000 patients from Achham and surrounding districts come to Bayalpata because they get free treatment there, and many families have saved themselves from sinking into poverty.Bayalpata also runs a network of community health centres with an Electronic Health Record (EHR) system that digitally keeps track of all patients in the catchment area. The presence of just this one hospital has improved the health parameters of surrounding districts, bringing down the maternal and child mortality rates. Achham once had the highest maternal mortality rate in Nepal, today institutional deliveries make up 90% of total deliveries, and very few women die at childbirth.“We have a simple objective: to show that providing free and high quality treatment to the most underserved area of the country is possible at a very low cost,” explains Srijana Devkota of Nyaya Health Nepal.Once <a href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">fully funded by international foundations</a> to run hospitals in Bayalpata and Charikot, NHN now provides free medical treatment in Achham for just Rs200 million a year, of which half now comes from the Sudurpaschim Province and local municipality.+977 - 4100517<a href="https://www.nyayahealthnepal.org/">https://www.nyayahealthnepal.org/</a><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e89c7e80680e0c0320jpeg.jpg" alt="" width="750" height="401"><figcaption> </figcaption></figure><h3>Spinal Injury Rehabilitation Centre</h3>The <a href="https://www.facebook.com/SpinalNepal/">Spinal Injury Rehabilitation Centre</a> (SIRC) in Banepa is a public-private partnership  providing treatment and rehabilitation to people with spinal injuries. It was started by journalist and civil rights activist Kanak Mani Dixit after his miraculous survival and recovery in a trekking accident in 2000 along the Annapurna Circuit that damaged his spinal cord.SIRC now <a href="https://www.nepalitimes.com/here-now/injured-use-internet-to-reach-physiotherapists/">helps rehabilitate up to 100 spinally injured patients</a> a year, and the numbers are going up every year due to injuries sustained in highway accidents and falls from trees and cliffs. The facility was located in Banepa because of its proximity to highways and nearby trauma centres. The hospital has also been providing community treatment and tele-rehabilitation services for follow-ups.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">POOR HEALTH MAKES NEPALIS POORER</a>, EditorialThe hospital has medical officers, urologists, physiotherapists, occupational therapists, nursing care, prosthetics, orthotics, psychologists and consultants. Those who cannot afford to pay are still treated for free, others are charged the same rate as Bir Hospital.“Because patients often have to stay for more than five months, it may be difficult for them to afford the cost, so we charge them according to their capacity to pay,” says SIRC’s Raju Dhakal.SIRC’s annual running cost is Rs50 million, of which most comes from grants by non-profits and other fund-raising activities. The government also chips in with a budget for the physical construction and equipment as well as occasional allocations to cover budget shortfalls.infosirc@wlink.com.np, spinalnepal@gmail.com<a href="https://www.sirc.org.np/">https://www.sirc.org.np/</a><h3>Charikot Primary Health Centre</h3>The 2015 earthquake damaged <a href="https://www.nepalitimes.com/latest/unique-hospital-handover-in-dolakha/">Charikot Primary Health Centre</a> along with 98% of the medical facilities in Dolakha district. But the disaster was a blessing in disguise for the Charikot centre. It was rebuilt and upgraded to a full-scale 50-bed hospital and managed first by Médecins Sans Frontières and then by the non-profit Nyaya Health Nepal (NHN). Residents of Dolakha did not have to make expensive journeys to Kathmandu because medical treatment was available for free at Charikot.Read also: <a href="https://www.nepalitimes.com/opinion/dangers-of-privatising-health-insurance-in-nepal/">Dangers of privatising health insurance in Nepal</a>, Gaj B Gurung and Sushil KoiralaIn 2020, NHN handed over management of the hospital to Bagmati Province and Bhimeshwor Municipality which now run the facility with low cost treatment for up to 300 patients a day. The Charikot experiment has been hailed as a model for successful transfer by a private non-profit to the local government, and it has been running well despite the presence of two private hospitals in Charikot.“It has been a seamless handover from Nyaya Health to the government, and the level of care and treatment is the same,” says chief physician Binod Dangal. “We perform caesarean sections, orthopedics, telemedicine, free check-ups for the elderly, children and pregnant women, mental health counselling, and chronic illness monitoring.”+977 49 421125<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ea9c7e80680e0c0321jpeg.jpg" alt="" width="1080" height="608"><figcaption> </figcaption></figure><h3>Sagarmatha Chaudhary Eye Hospital</h3>For the past 30 years, the <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">Sagarmatha Chaudhary Eye Hospital</a> in Lahan of Siraha district has been providing the cheapest cataract surgery in the world for just Rs1,200 per operation.Thirty years ago when the hospital started, it had only 12 beds. It now treats 470,000 people every year with patients coming in from as far away as southern India and Bangladesh, and they pay the same amount as Nepalis. Just in the last three years, the eye hospital has treated 321,000 foreign nationals.“It is possible to provide the services at an affordable cost because we are a non-profit, and have an economy of scale,” explains Abhishek Roshan of Sagarmatha Chaudhary Eye Hospital.Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe hospital has <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">also set up 15 eye care centres throughout the district, and takes treatment directly to the people</a> so they do not have to make the journey to Lahan. It has a separate department for paediatric services, care for newborn babies with vision problems. In 2021 alone, it performed 1,170 eye surgeries on children.Apart from providing treatment of retina, cornea, glaucoma, oculoplasty, the hospital also serves as an international research centre, collaborating with institutions like The London School of Hygiene and Tropical Medicine.The hospital subsidises its eye treatment for patients with revenue from its agribusiness ventures. A part of the hospital’s land is dedicated to fish farming, and an orchard for litchi and mangoes, as well as a bamboo grove.“Income from those ventures help us keep the cost of treatment down,” says Roshan. The hospital is also supported by Christian Blind Mission (CBM), the European Commission and Arvis.+977-33- 560080https://www.erec-p.org/sagarmathaRead more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

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Taking wealth out of health

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219c9c7e80680e0c02c6jpeg.jpg" alt="" width="1000" height="662"/>This year’s health budget kept the contribution to health insurance of the previous year's allocation of Rs7.5 billion. However, the plan to hand over the institutional management of health insurance programs to the private sector through the Ministry of Finance defeats the fundamental goal of the health security.This is not entirely surprising, of course, because the Health Ministry had passed a <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">narrow and poorly thought model of health security</a> for Nepal, and there were already concerns that it would eventually be handed over to the private sector and traded as a commodity.A private company can contribute to a health insurance program. But can they really contribute to national public health security, understand equity, expand <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">access to the poorest and the most marginalised</a> population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">National health insurance not as easy</a>, Sonia AwaleThe private sector has a role in contributing to achieving Universal Health Coverage by mainly serving the affluent. The poor neither can afford private health insurance nor access expensive private hospitals. Even if they are admitted to hospitals, they have to bear <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">catastrophic expenses</a> pushing them into the vicious cycle of poverty.The private insurance companies only pool the resource, they do not share the risk for those who cannot afford to pay the premium. It will be naïve to assume that such companies could be easily maneuvered to deliver services as a fair-price approach. There are around 20 registered private health insurance companies and 366 private hospitals in Nepal, and some are <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling health insurance at exorbitant premiums</a> many times higher than the current premium cap.There are six national health security indexes: prevent, detect, response, health, norms, and risk. During the pandemic, insurance companies got richer by <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling fake insurance schemes</a> while the hospital profits bulged through expensive Covid treatment. Very few hospitals treated Covid patients with a humanitarian approach. None of their technical advancements helped effectively prevent, detect, and respond to the pandemic.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219f9c7e80680e0c02c7jpeg.jpg" alt="" width="1641" height="1000"><figcaption> </figcaption></figure>The current health insurance program has identified the elderly, completely disabled, leprosy, Multi-Drug Resistant TB patients, people living with HIV, and ultra-poor as target populations to waive their premium. Though not adequate, this is an equity approach.But none of these target populations are <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">eligible for private health insurance</a>, or they will have to pay a much higher premium. It will be unwise to assume that these companies will change overnight and be equitable. They are powerful enough to influence government policy and have the power to bend them to suit their commercial interests.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, EditorialInstead, the government should <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">strengthen the Health Insurance Board</a> and explore ways to integrate health security with the broader social security scheme. In the short term, there are urgent but straightforward reforms like recruiting adequate and skilled human resources, strengthening the organisational systems, revising the design of service purchase strategy and equity, and gradually, having effective providers/purchasers split for better implementation.Ultimately, the program will benefit by forming a broader and more robust social security structure, co-incidentally introduced at the same time by the government. It would be able to absorb costs by pooling tax-based health care contributions and merging subsidies given to the treatment of cancer, renal failure, and other chorionic diseases under one integrated umbrella.But the current government does not appear serious about <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">reforming health insurance</a>, and simply does not understand the fundamental principles of health security. Health insurance is not just limited to providing health care, but is a part of broader health security.Read also:  <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe idea that health security can be strengthened by passing the buck to the private sector amounts to abandoning the constitutional commitment to provide health care, not as a service but as a citizen's fundamental right. The Nepal government is a signatory to achieving the health targets of the Sustainable Development Goals.As argued by Nepali Congress leader Gagan Thapa, who is one of the pioneers who <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">pushed health insurance</a> in Nepal, they contribute to strengthening the health system, strive for healthy populations, cushion the poor and provide them access to health services. It is a vehicle for mobilising adequate health resources, enhancing health security, and ultimately achieving Universal Health Coverage.These goals cannot be met by trading the people's health as mere commodities.Gaj Gurung has a PhD in public health from Chulalongkorn University and Sushil Koirala is a public health expert. Both are based in Bangkok.Read more: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee

Dangers of privatising health insurance in Nepal

In 2013, while writing <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Flu,294">a weekly health column</a> in this paper, I explored the potential for <a href="https://www.cdc.gov/coronavirus/mers/index.html" target="_blank" rel="noopener">MERS </a>(Middle Eastern Respiratory Syndrome) to spread among Nepalis working with camels in the Gulf states. Despite all the dire predictions of how that coronavirus could be brought back to Nepal and spread in the population, it is still a mystery why there was no MERS outbreak here. Viruses do have their own predilections.This time, although <a href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/" target="_blank" rel="noopener">Nepal officially has had only one person diagnosed</a> with the novel coronavirus (COVID-19) who later recovered, it is utterly foolhardy to think that we may escape this pandemic. In Italy, there were only four cases in 20 February, but three days later it soared to 400 cases. That virulence is what is new about this novel coronavirus.Even if Nepal does not have a surge of cases now, there is every likelihood that we will have to deal with an outbreak next winter. In addition how COVID-19 will interact with a summer dengue outbreak like last year in Kathmandu is anyone’s guess. It is important to be prepared with preventive aspects.Read also: <a href="https://www.nepalitimes.com/editorial/this-is-a-test/" target="_blank" rel="noopener">This is a test</a>, Editorial<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101152/636b79239c7e80680e0646e5jpeg.jpg" alt="" width="960" height="640"/><figcaption>An Army personnel demonstrates how to wear protective gear while treating possible COVID-19 patients in Nepal. All Photos: BIKRAM RAI</figcaption></figure>Masks for the general public are more for self-assurance than anything else. People who are coughing and have symptoms should wear masks. But widespread use of masks for the general public may only deplete the limited supply of masks where they are actually needed in hospitals. The most important prevention is <a href="https://www.nepalitimes.com/banner/covid-19-revives-nepals-wash-drive/" target="_blank" rel="noopener">washing hands </a>properly with soap and water 5 to 6 times per day and avoid touching the face. Keeping a reasonable distance from one another is also important. The elderly need to be especially careful.One of the most crucially helpful decisions that the Chinese government took in December 2019 after the novel coronavirus struck Wuhan was to rapidly share the molecular structure of the virus (its genomic sequence) with the world. This made it possible for drug manufacturing companies like <a href="https://www.modernatx.com/" target="_blank" rel="noopener">Moderna</a>, a biotechnology company based in the US, to start working on a vaccine.Read also: <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener">A shot in the arm for vaccines in Nepal</a>, Sonia AwaleThe first human trial against COVID-19 will start later on this month. This is incredibly fast because in earlier times, it would take at least six years before a vaccine was developed. Although an effective vaccine is the best defence against COVID-19, what can be done for prevention in Nepal here and now is more important.First, the good news. It is now well known that about 80% of COVID-19 victims will have mild symptoms not requiring hospital admission. Of the rest, 15% will be severe and 5% may be critical, possibly requiring ventilators in an intensive care unit. Even if only 0.5% of patients from South Asia’s population of 1.8 billion require ventilators, it is easy to imagine the tragic scale of this potential  emergency.The Wuhan data from Chinese doctors also revealed that it was the elderly (mostly male) that took the brunt of the disease and that children were not symptomatic, even though they may be infected by the virus. The findings also showed that about 1% of the patients who suffer from  COVID-19 die.This is the stark difference between COVID-19 and other causes of influenza where the death rate is only 0.1%. That is, COVID-19 kills ten times more people, and they are mostly above 60 years old. Although 1% may sound small, actual numbers will be numbing when large populations are infected.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101152/636b79249c7e80680e0646e6jpeg.jpg" alt="" width="3600" height="2400"><figcaption> </figcaption></figure>Besides vaccines, there are also drug studies going on to fight COVID-19. One such medicine is called <a href="https://www.kaletra.com/" target="_blank" rel="noopener">Kaletra</a>, commonly used for HIV patients. Many other drug trials (including the antimalarial drug cholroquin) are going on.The incubation period (the time from infection to symptoms) was also studied in Wuhan and forms the basis of the quarantine period of 14 days. The average incubation period is five days but may be up to 12 days. To be on the safe side a two-week quarantine is recommended, after which it is unlikely that the symptoms will manifest.Unlike some western countries, China, Singapore, Taiwan, and South Korea practiced widespread contact tracing to control the disease. If someone was diagnosed with COVID-19, the health professionals took a detailed history of  who their contacts (including family and friends) were, and followed up to see if they developed symptoms. Contact tracing helped stem the spread of the disease in these countries.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNE0aoyspsOeHIBjtexE2rB8xE3KOw">frequent health columnist</a> for Nepali Times.

Buddha Basnyat

What is novel about the novel coronavirus?

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101152/636b79289c7e80680e0646e7jpeg.jpg" alt="" width="960" height="640"/><figcaption>A quarantine zone at Nepal Army's headquarters in Tundikhel. Photo: BIKRAM RAI</figcaption></figure>By now the novel coronavirus pandemic has affected every corner of the globe. If it has not brought disease, it has at least brought the <a style="background-color: #ffffff; font-size: 16px; letter-spacing: 0.15px;" href="https://www.nepalitimes.com/editorial/fear-goes-viral/" target="_blank" rel="noopener">fear of infection</a>. Cities, and indeed entire countries, are in lockdown. Fortress Europe has raised its walls higher. Airlines are grounded. Nepal has banned trunk international routes from Friday night. Even countries with excellent public health facilities and emergency preparedness plans are overwhelmed.Nepal is now <a href="https://www.nepalitimes.com/opinion/global-thinking-and-local-action-on-coronavirus/" target="_blank" rel="noopener">so closely intertwined with globalisation</a> through migration, tourism and trade that its <a href="https://www.nepalitimes.com/here-now/nepals-economy-already-weak-takes-direct-hit/" target="_blank" rel="noopener">already-fragile economy has been badly hit</a> even before a full-blown health emergency hits. Ironically, less-developed countries seem to have a built-in resilience that comes from being crisis-prone -- since they are lower down in the economic ladder, they have a shorter distance to fall.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/" target="_blank" rel="noopener">Poor health makes Nepalis poorer</a>, EditorialDespite Nepal’s surprisingly <a href="https://www.nepalitimes.com/banner/born-in-nepal/" target="_blank" rel="noopener">dramatic improvements in mother-child survival </a>over the past two decades, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">the public health system here is in crisis</a>. State-of-the-art modern hospitals in the city, while reducing the need for Nepalis to go abroad for treatment, are out of reach of a majority of the population. Government health facilities are more affordable, but for the most part medical care there is not up to mark.Nepalis are still afflicted by easily preventable water-borne diseases like <a href="https://archive.nepalitimes.com/news.php?id=16988#.XnMUhagzbSF" target="_blank" rel="noopener">typhoid and diarrhoea</a>, vector-borne infections like malaria, encephalitis or dengue, and illnesses like <a href="https://www.nepalitimes.com/banner/nepal-tb-cases-grossly-underestimated/" target="_blank" rel="noopener">tuberculosis </a>and acute respiratory infections that spread through breathing. Great inroads have been made in reducing the impact of communicable diseases in the past decades through awareness programs, vaccinations and safer drinking water, but children in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">remoter parts of Nepal</a> are still dying of simple infections.Read also: <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener">A shot in the arm for vaccines in Nepal</a>, Sonia AwaleOn top of this, urbanising Nepal now also has the added burden of <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">non-communicable afflictions</a> like diabetes, cardio-vascular ailments and renal disease. As families move from the districts to the cities, changes in diet and more sedentary habits have given rise to an epidemic of lifestyle-related diseases. This is compounded by genetic susceptibility among South Asians for diabetes and heart disease.For example, a study by the BPKIHS in Dharan showed that while the national average for <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener">Type 2 diabetes </a>prevalence is 8.1% of the population, the incidence in Dharan was 14%, while it was only 1% in Taplejung. The prime minister’s own second kidney transplant this month showed that <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032" target="_blank" rel="noopener">ignoring risk factors and not diagnosing non-communicable diseases</a> can lead to a huge health burden for families and the state. A small percentage of Nepalis have health insurance, so many middle income families fall below the poverty line due to medical expenses. Many Nepali migrant workers have been forced to seek jobs abroad to pay back debts incurred during hospitalisation of family members.Last summer’s explosion of dengue in Kathmandu Valley was <a href="https://www.nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms/" target="_blank" rel="noopener">blamed on climate change</a>. But it was actually a perfect storm of crowded and squalid living conditions, poor drainage, greater mobility of people, and a particularly wet monsoon. None of these factors have been addressed, so we are staring at a recurrence of dengue this year even while we cope with <a href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/" target="_blank" rel="noopener">a possible COVID-19 outbreak</a>.Public health has not been a national priority for successive governments in Nepal. Even if it has, it is only in paper and has not really been translated into <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">accessible and affordable healthcare</a> for the general public. Governance failure has contributed to this state of affairs, but there is also the virus of corruption that has afflicted the entire government healthcare system. A politico-business nexus has also infected <a href="http://archive.nepalitimes.com/news.php?id=19560" target="_blank" rel="noopener">medical education</a>, putting it out of reach of deserving poorer students.Read also: <a href="https://www.nepalitimes.com/editorial/when-panic-goes-viral/" target="_blank" rel="noopener">When panic goes viral</a>, EditorialInto this mix, we now have the coronavirus scare. Officially, Nepal has just one case in which the patient recovered and has been discharged. The government has tested about 500 people, and all have been negative. Experts have confirmed that the tests are credible, and proper protocols are in place. But not enough tests have been done to determine if there are more people out there with the virus.At $75 per test, the kits are expensive. This is where international help would be needed, and if the case rate rises the country will also need help with containment and mitigation. Nepal has been lucky so far that there is no indication of community transmission yet. But our luck could turn any day.

This is a test

<a href="https://nepalitimes.com/here-now/waiting-for-bipin-joshi" target="_blank">Nepali student Bipin Joshi</a>, who was taken captive by Hamas on 7 October 2023, was not on the list of those freed following the end of the bombardment and fighting in Gaza.&nbsp; On Monday morning, the Israeli military notified Bipin's family and Nepal’s ambassador to Israel Dhan Prasad Pandit, that there is no evidence of him still being alive. However, Nepal's Foreign Ministry is yet to be notified by Israel's government of Bipin's status. The news came three days after a US-brokered ceasefire between Israel and Hamas came into effect, and hostage and prisoner exchanges by the two sides started Monday morning.&nbsp; Almost 2,000 Palestinians held in Israeli prisions are expected to be released by Israel in exchange for the hostages during the next phase of the peace deal between the two parties, and the bodies of deceased hostages remaining in Gaza are also expected to be returned.&nbsp; Bipin Joshi was among a group of Nepalis who had arrived in Israel in 2023 just weeks before 7 October 2023 as part of a ‘learn and earn’ program to work and earn in kibbutz farms there.&nbsp; Along with other students Joshi had been working on a farm in Kibbutz Alumim in southern Israel near Gaza. <a href="https://nepalitimes.com/here-now/war-in-israel-earthquake-and-grief-in-nepal">Ten Nepali students were killed </a>while taking cover in shelters near their farms in two separate attacks by Hamas fighters.&nbsp; Joshi’s colleagues, fellow Nepalis who survived the attack, recall gunmen lobbing two grenades into the bunker that they had taken cover in. Bipin hurled one of the grenades out, they say, but the other one exploded, killing and injuring Nepalis inside. &nbsp;&nbsp;&nbsp;&nbsp; Shortly after, Bipin was captured by Hamas along with a Thai national and led away into Gaza. CCTV footage showed Bipin alive and at a hospital in Gaza on the day of the attack itself after he was taken hostage.&nbsp; Thirty-one Thai citizens, who like Nepalis worked in farms in Israel, were taken hostage during the Hamas attack, the highest number of foreign captives in October 2023.&nbsp; <a href="https://nepalitimes.com/news/deft-diplomacy-freed-thai-hostages">Deft Thai diplomatic engagement</a> with officials from Iran, Egypt, and Qatar brought about the release of 23 of its nationals in 2023. Five more Thai nationals were released earlier this year.&nbsp; In August, Joshi’s family visited Israel at the invitation of the government and urged the international community to push for his return. Bipin’s mother Padma and sister Pushpa have been at the United Nations to lobby for his release.&nbsp; His family last week also released a video clip of Bipin briefly speaking on camera, reportedly obtained by Israel and said to be filmed in November 2023, around a month after he was taken captive. Joshi looks healthy in that video.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251013091028_d551c7f88204c52217152fb5db655bb5a5f8bf2cff1e6a055326ebf64453ff9f.png" data-media-id="editor_3" data-image-id="20251013091028_d551c7f88204c52217152fb5db655bb5a5f8bf2cff1e6a055326ebf64453ff9f" data-rendition-name="original" width="2848" height="1528" loading="lazy" alt="Bipin Joshi NT"> </figure>  More than 67,000 Palestinians have been killed during the last two years of the genocide in Gaza. About 1,200 people were killed during the Hamas attack on 7 October 2023, while more than 251, including Bipin Joshi, were taken as captives.&nbsp; This is the third ceasefire implemented in Gaza since 7 October 2023 after previous ones in November 2023 and January 2025. This 20-point deal facilitated by intermediaries US, Qatar, Turkey, and Egypt included terms for Hamas to give up its arms, and for a devastated Gaza to be governed by a Palestinian body of independent technocrats, while Israeli troops will withdraw in stages from Gaza.&nbsp; Hamas has agreed to relinquish control of Gaza, but has rejected the demand for disarmament, saying the group will demobilise but is prepared to resume fighting if Israel breaches the ceasefire.&nbsp; Following the ceasefire, Palestinians in Gaza have begun long journeys back to homes reduced to rubble by Israel’s two-year assault on the strip. The flow of humanitarian aid in the city has also increased following the peace deal.&nbsp; Israel's closure of humanitarian corridors in the past months had blocked the entry of food and medicine into Gaza, causing widespread famine. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has said that the restriction of aid into the beseiged city has left as many as <a href="https://www.unrwa.org/newsroom/news-releases/gaza-unrwa%E2%80%99s-lancet-study-reveals-alarming-surge-child-malnutrition">54,600 children acutely malnourished</a>.&nbsp; Meanwhile, US president Donald Trump landed in Israel on Monday as hostages were being released, and world leaders are expected to head to Egypt for an international summit to discuss the next steps in Gaza, Israel, and West Asia.&nbsp;

Nepali hostage in Gaza not alive: Israel

Jazz as healing music

Already trying to balance youth demands with legal provisions in the Constitution, Prime Minister Sushila Karki’s interim government faced yet another challenge over Dasain: a receding monsoon dumped unseasonal rain unleashing floods and landslides that killed at least 60, mostly in eastern Nepal.&nbsp; The government was rated positively for its early warning and the ‘visibility’ of its disaster response, with many comparing it to the inaction of the NC-UML coalition during last year’s floods.&nbsp; Government agencies and police proactively closed off hazardous sections of highways as Kathmandu was marooned from the rest of the country in the peak holiday season. Stranded passengers were taken care of, with police, army and local governments in Ilam coordinating rescue and relief efforts. Many of the problems were structural and inherited from decades of neglect and corruption in highway contracts. Shoddy bridges and encroachment of settlements along river banks have increased risk from more frequent extreme weather caused by climate breakdown. With Dasain over Tihar around the corner and the worst of the disaster behind, the Karki administration is trying to balance the separate demands of GenZ movers and shakers who installed her in office with constitutional provisions. It has not helped that the badly-mauled political parties are spoiling for a fight, and the three top leaders show little signs of stepping down. “Nepal’s movement did not happen in a democratic vacuum, so this government walks a very fine line in political legitimacy," says Bidushi Dhungel of the National Democratic Institute in Nepal. "In this fragile space, whatever the work done — or not done— by the interim government within its limited mandate, it may open up avenues for further dissent from old and new actors. They are &nbsp;caught between a rock and a hard place.” Civil society activists issued a statement on Wednesday calling on the main political parties to heed the writing on the wall and reform themselves. Signed by professor Krishna Khanal and former ambassador Keshab Mathema, the statement said: 'The main leaders of the main parties should say sorry, and voluntarily resign ... they must respect public sentiments and work to reform and transform their parties to be more accountable to the public, or risk being irrelevant.'&nbsp; Complicating matters further are the sometimes contradictory demands of various GenZ factions on punishing those responsible for the carnage and rampage of 8-9 September, Constitution and elections. Karki faces calls to immediately detain former PM KP Oli and Home Minister Ramesh Lekhak for their involvement in the massacre outside Parliament. Under pressure from GenZ delegates, Home Minister Om Aryal fired off a letter to the police to arrest Oli and Lekhak. But later at a confrontational midnight meeting at the prime minister’s residence in Baluwatar, all four security chiefs advised Karki that arresting the UML and NC ex-ministers could unleash violent confrontation on the streets. The interim government is in a bind. It has formed a committee headed by Gauri Bahadur Karki to investigate the killings last month as well as the arson and vandalism that followed. The question is: should it wait for the committee to submit its report before punishing perpetrators, or let police arrest those who can easily be identified in social media posts setting fire to Singha Darbar, the Supreme Court and other sites.&nbsp; GenZ’s Sudan Gurung faction has gone beyond its original demand to submit an 8-point ultimatum that includes the sacking of the Chief Justice and officials of the anti-corruption bureau.&nbsp; The Prime Minister is caught in the crossfire between managing the expectations of a movement that appointed her, and working within the framework of her interim government’s mandate and Constitution. But it is not just the government that faces challenges. The lack of clear consensus among youth factions and their outspoken collectives is surfacing.&nbsp; &nbsp;“This has been a leaderless and decentralised movement, and the traditional variables typically seen in a political revolt seem missing here," notes political scientist Sucheta Pyakuryal. “There is no organised structure, nor any ideological pull factor, therefore a big question is how much bargaining power does a movement like this have, and how sustainable will it be.” GenZ leaders seem to be in two main camps. Demands like the one for a directly elected prime minister, and the constitutional processes that can make for such an outcome, have emerged as a major point dividing the movement.&nbsp; Nepalis both within and outside the youth movement are watching Hami Nepal’s Sudan Gurung closely — especially after his recent interview with Al-Jazeera during which he expressed his interest to run for Prime Minister and seemed to not accept a win by political parties in the March elections.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251009201044_fcba7e92bb9a8812fd0ad4e9770d6f4d4189972de5229f91e9a832a26e388901.jpg" data-media-id="editor_0" data-image-id="20251009201044_fcba7e92bb9a8812fd0ad4e9770d6f4d4189972de5229f91e9a832a26e388901" data-rendition-name="original" width="2916" height="1000" loading="lazy" alt="One month on NT"> <figcaption>GROUND ZERO: The destroyed centre of Nepal's government with Singha Darbar (in green scaffolding), the Attorney General's Office, Supreme Court, and in the distance, Parliament building. Also seen are the nearly finished new Parliament Complex and the new Supreme Court buildings. Drone shot taken on Thursday morning. Photo: SUMAN NEPALI</figcaption> </figure>  Gurung’s participation in the NDRRMA’s disaster management meeting and manner of his interaction with officials at the event was met with both bouquets and brickbats. Interestingly, some of the criticism was youth activists themselves. &nbsp;“There's a lot of self-involvement and self-importance that seems to be guiding a fragmented young leadership, as opposed to constructively engaging in how to concretise reforms,” says Dhungel. “There seems to be very little stocktaking of what's happened in the past, and what's happened in other countries to try identify where lapses could be before they occur."&nbsp; In the absence of unified positions and level-headed leadership, the youth who spearheaded post-protest negotiations, as well as the GenZ movement in general, risk losing public goodwill already dented by the destruction of state property on 9 September. This also leaves an opening for political parties which are on the defensive and licking their wounds to capitalise on youth discord.&nbsp; Says Pyakuryal: “Post revolution, the political landscape becomes extremely unpredictable and therefore there is a risk of co-optation from several Machiavellian political actors including political parties, monarchists, as well as other forces, and that is concerning.” The immediate and visible transformation that Nepal’s youth expect will not manifest right away, and while there is a need for long-term political planning, the caretaker government must also undertake measures that have a palpable impact on the daily life of citizens. &nbsp;&nbsp; “While youth frustrations must be addressed urgently, statecraft isn’t just about fulfilling short-term goals,”says Pyakuryal. &nbsp; Many, including the youth themselves, now see the need for GenZ to have a more united stance and to move beyond making demands that the interim government cannot fulfil and start mobilising for elections — even by forming its own party.&nbsp; A strong showing in elections can enable them to enact the changes they want to strengthen Nepal’s democracy, and make future governments more accountable.&nbsp; This week, the Election Commission announced 16 November as the deadline to register new parties for the 5 March polls.&nbsp; Youth representatives have said that they want to be active participants in the political process, particularly in national-level politics. The Constitution defines ‘youth’ as being between the ages of 16-40. In the 2022 elections, the Election Commission stated that over 41% of locally-elected representatives were from ages 21-40 years.&nbsp; If young Nepalis are to contest the election outside the banner of mainstream parties, this leaves electoral aspirants little more than a month to decide whether to form a loose coalition with existing parties, a separate political party, or to contest elections independently. “This is first of a kind movement, where political language is digital, not ideological, where organising is done through online platforms and where there is no one leader spearheading the movement,”says Pyakuryal. “I don’t know if ‘anti-corruption’ or ‘political reform’ have a strong enough ideological pull to band people together in the long run.” Indeed, the RSP was formed only four months before the 2022 elections and cashed in on anti-incumbent and anti-corruption sentiments of voters — mainly driven by social media. But controversy and strife within their party means it has largely lost its public trust.&nbsp; Nepal’s September Uprising and its aftermath have shown that a majority of young people are entirely disillusioned with establishment parties and politicians, even using ‘ex-political parties’ as a phrase of reference. Any new young political figures that emerge from this movement and this election will have to work with mainstream parties in a multiparty democracy.&nbsp; &nbsp;“The reality of politics is that change is not possible without engaging with existing political institutions and actors,” says Dhungel. “To say that they do not want to engage, negotiate, or identify allies or proactively seek out input from at least the reform-minded individuals within each of those outfits is political naivety, and may lead to a lack of institutionalised reform.” However, Dhungel notes that the youth leadership would have more agency if they are clear not just on what they want to change, but about whether they are interested in active politics or civic engagement. “The window of opportunity that is fast closing is to really negotiate hard and push for internal reforms within political parties and across the electoral system,” she adds. Pyakurel also adds: “GenZ are smart and politically mature, I hope they see these loopholes. I am optimistic about the direction they take.”

One month on

7:30pm Tuesday, 9 September.&nbsp; I was driving my daughter back from a relative’s house in Baneswar where she had taken refuge after a curfew was declared the previous day while she was in school. She was riding pillion on the back of my moped. We drove past Parliament <a href="https://nepalitimes.com/news/nepal-s-8-september-massacre">where 19 people had been killed by police </a>the previous day. We passed Thapathali, where the Kantipur highrise was on fire. The sky had gone dark, and the stinging smoke made it hard to breathe. A gas cylinder exploded, and the crowd dispersed briefly. The blast provided a moment to escape the raging mob. By myself I may not have been so scared, but my daughter’s safety made me more afraid. I had never been this frightened in my journalism career, even while covering the Maoist insurgency 20 years ago. At the Tripureswor intersection there were more angry crowds. The further we got from the epicentre of the GenZ demonstration, the more elderly the protesters looked. Many were muscular gentlemen with tattooed arms. Prime Minister K P Oli had just <a href="https://nepalitimes.com/news/kathmandu-burns-despite-pm-resignation">resigned</a>, but the crowd was still chanting “के पी चोर, देश छोड”. Soon, we were surrounded by an enraged mob. &nbsp;My survival instinct took over, and I started shouting “के पी चोर” and my plucky daughter screamed from behind “देश छोड”. Father and daughter waved at the &nbsp;protesters, and gave them a thumbs up. &nbsp;We finally got home, scared and smelling of burning rubber and smoke.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251007031028_c5c04095cdb6f0b24cdc2cc60bf627f49c15e0cf9b509ad149df35a2e73e1d3f.jpg" data-media-id="editor_2" data-image-id="20251007031028_c5c04095cdb6f0b24cdc2cc60bf627f49c15e0cf9b509ad149df35a2e73e1d3f" data-rendition-name="original" width="1200" height="1600" loading="lazy" alt="Reporter's diary of 8-9 September"> <figcaption>A building in Baneswar was damaged by protesters. </figcaption> </figure>  ARSON AND LOOTING I was born in the remote mountains of western Nepal in Rukum, the district that was the stronghold of the Maoist guerrillas after they launched an armed struggle in 1996. I moved to Kathmandu for higher studies, and as a student witnessed the popular uprising of 2006 against Gyanendra’s absolute monarchy. I have covered violence and chaos. I have been caught in the crossfire between the rebels and state security. I covered the violent <a href="https://nepalitimes.com/here-now/nepal-s-historic-youth-dissensus">street protests</a> of the 2006 People’s Movement that ended the war, the Madhes movement and the Indian blockade of 2015.&nbsp; But never was I more scared than during the 30-minute drive home through the city with my daughter at the back of my moped.&nbsp; Last month’s protests were initially led by youth groups which had loosely banded together as GenZ to protest corruption and impunity. On 8 September, I drove to the Mandala in my trusty moped to cover the rally, some protesters were in school uniform. There was singing and chanting. Just before noon, a slightly older group of protesters peeled off from the sit-in in front of Everest Hotel, broke through the half-hearted police cordon and moved towards the intersection outside Parliament. Most of the original young demonstrators remained at the sit-in, while the grownup protesters who were clearly not a part of the GenZ, started to break the perimeter wall of the Parliament complex. The young protesters looked a bit confused about what to do next as they also neared the Parliament gates. Violence was not a part of their plan, and the infiltration had begun in earnest. A group of organised older rioters broke through the western wall, even as police were concentrated along the main south gate. These agitators seemed focused on a single mission: to burn down the Parliament building, and they went about it purposefully.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251007031032_1fcd474774c8e110e833485cf54a7e63e8c8388ec78c2b4d3ae6e830c203c183.jpg" data-media-id="editor_4" data-image-id="20251007031032_1fcd474774c8e110e833485cf54a7e63e8c8388ec78c2b4d3ae6e830c203c183" data-rendition-name="original" width="1280" height="960" loading="lazy" alt="Reporter's diary of 8-9 September NT"> <figcaption>Blood seen in Baneswar.</figcaption> </figure>  Too late, the police used water cannons to disperse those by the south gate. I went closer, my press card dangling from my neck. A tear gas canister whizzed past my head. I was not able to see clearly, and backed away to safety. The police opened fire at point blank range, killing 19 protesters. Hundreds of injured were carried to the nearby Civil Hospital. There are many video clips on social media of task force police kneeling, taking aim with SLR rifles and shooting, they show protesters being hit and falling. The riot police fled, and the Armed Police Force and Nepal Army soldiers came out, but remained close to the trucks that had transported them to the intersection. Seeing that the security forces were not stopping them, the crowd then went on an arson rampage — it became a free-for-all as government buildings were set on fire one after another. Most of the arsonists were not GenZ, they were in the mid-30s, and I heard many shouting slogans for the<a href="https://nepalitimes.com/opinion/why-the-monarchy-still-sways-nepal-s-republic"> restoration of the monarchy</a>. Others were there simply to vandalise and loot. After having chased the police away from the Parliament building, they posted pictures and videos, having the run of the premises, instigating new arrivals to continue with the arson, and also brandishing looted automatic weapons. A curfew was declared, but this did not stop the rampage throughout that evening and into the night. Unable to return home, I spent the night in a friend’s office, and returned to the Parliament area the next morning. The black asphalt was dyed red with blood. Shoes, slippers and pieces of clothing littered the street. The next day, 9 September the much-feared and expected revenge attacks ignited. There was hope that the Army would be able to protect government buildings and provide public security, but the arson, vandalism and looting went unchecked — even when the seats of government were set on fire. The military did make an appearance, but only after 10pm to enforce the curfew, but by then the mob had already gone home.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251007031032_578cfa7c9e56f6ffcf1ca9b148e114a87b5332268cf97720584b70906823c074.jpg" data-media-id="editor_6" data-image-id="20251007031032_578cfa7c9e56f6ffcf1ca9b148e114a87b5332268cf97720584b70906823c074" data-rendition-name="original" width="1200" height="1600" loading="lazy" alt="Reporter's diary of 8-9 September NT"> <figcaption>A protester receiving treatment at Civil Hospital.</figcaption> </figure>  That was the moment I asked myself: Where have the students gone? Has the GenZ movement been hijacked? I could not see any of the GenZ-ers anywhere on 9 September. It was around midday of 9 September that millennials, including from groups like Hami Nepal came forward to the media, claiming to speak for the GenZ. They claimed to have led the protests. Others claiming to be GenZ said they were for the restoration of the monarchy, but they did not look the age.&nbsp; Mobs were out of control, burning down the prime minister’s office, the Supreme Court, the CIAA and the official and private residences of ministers. Within 27 hours Nepal became a country without a government, and leaders without homes. Important official documents went up in flames with the buildings that housed them. PM Oli resigned, too late to save the day. The Army occupied itself airlifting ministers from their official residences. Former prime minister Sher Bahadur Deuba and his wife foreign minister Arzu Rana Deuba were dragged out, beaten up and their home set on fire. They were rescued and taken to an army base. It became hard to tell over the next few days if the Army was providing them security, or keeping them incommunicado in detention. The Army was negotiating with GenZ as well as pro-monarchists at its headquarters, but moved the talks to President Ram Chandra Paudel’s office on 11 September.&nbsp; Former chief justice Sushila Karki was nominated interim head of government by GenZ delegates voting on Discord, and <a href="https://nepalitimes.com/news/march-to-5-march">mandated to hold elections</a> on 5 March.&nbsp; Will that happen? Things are too fluid at the moment. And my mind is still reeling from the fear and panic of that moped ride with my daughter through rampaging mobs. Did all that really happen in front of my eyes, or was it just a nightmare?&nbsp; Bhadra Sharma is a reporter for The New York Times based in Kathmandu.

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