<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

https://www.youtube.com/watch?v=Czp7hVr4LTkHenry Marsh is a pioneering English neurosurgeon and the author of two widely acclaimed memoirs, Do No Harm: Stories of Life, Death and Brain Surgery and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/book-review-Admissions-Henry-Marsh-Neurosurgeon,4055" target="_blank" rel="noopener">Admissions: A life in brain surgery</a>. He was a colleague and friend of the <a href="https://www.nepalitimes.com/here-now/upendra-devkotas-lives/" target="_blank" rel="noopener">late Upendra Devkota</a>. Nepali Times caught up with Marsh at the <a href="http://www.neuro.org.np/" target="_blank" rel="noopener">Upendra Devkota Memorial National Institute Of Neurological And Allied Sciences</a> in Kathmandu, where he teaches post-retirement.Excerpts:Nepali Times: How did your involvement in Nepal start?Henry Marsh: Professor Devkota and I were neurosurgical trainees together in London more than 35 years ago. We became quite good friends then, and when I retired from working fulltime for the <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nhs.uk/" target="_blank" rel="noopener">National Health Service in Britain </a>four year ago, I really wasn’t ready to stop working. I wrote to the professor, who’s known to all his English friends as Dev, and I said, “Would you like me to come out to Kathmandu and help train some of your team?” and he said,“Please come”. This is now my fifth visit over the last four years. <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/from-the-nepali-press/i-want-to-live-my-last-among-friends/" target="_blank" rel="noopener">Tragically he died last year</a>, and everything therefore changed profoundly.Why were you drawn to Nepal?I was drawn because I like seeing the world. A lot of the potential privileges you have as a doctor is that you have a specialised set of skills which transfer over the world and English is really the international language of medicine.The great privilege of working in a cooperative professional way is that you get a much better insight into the country than if you are merely a tourist. For me, it is true travel but it is work – it is not easy always, and if you come to a country like Nepal to help your colleagues, you have to come again. You can’t just sort of dive in and then dive out again. It calls for a fairly major commitment, both in terms of time and financially and sort of emotionally as well.What do you remember most about Dr Upendra Devkota?The man was just this little ball of fire – he was extraordinarily energetic. There was never a dull moment with him. He was an extraordinarily dynamic person and to create an entire specialist neurosurgical hospital more or less from scratch was a quite extraordinary achievement.The problem with great dynamic individuals is the succession problem and of course none of us expected him to die at the relatively young age he did and really quite suddenly. I remember before his illness, sitting down with him in his beautiful garden and saying “What happens if you drop dead tomorrow? What will happen to the hospital?” Fortunately, he had some very good trainees and in recent years he had been giving them more and more, not exactly independence, but they were doing more and more of the work so they were fortunately able to take over the workload when he fell ill and they’ve coped remarkably well.I was involved a bit in helping them get better and training them. I take some personal pride in that as well. I was watching one of the senior ones here doing a very difficult operation a few days ago and it really was a joy to watch. He was using a microscope and he was doing a very difficult case – I was watching on a computer monitor and he really did it very beautifully. As a trainer, any senior doctors will tell you in a funny sort of way you get more pleasure from all the people you’ve trained and seeing their success rather than all the, in my case tens and thousands, patients I’ve treated over the years of my career. <figure><img width="2622" height="1612" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664a9c7e80680e059972jpeg.jpg" alt=""/><figcaption>Henry Marsh. Photo: SAKINA ABIDI</figcaption></figure>What are the challenges of specialisation in Nepal?It’s not unique to Nepal by any way, but the problem is this: if you have a relatively impoverished government and if people are reluctant to pay taxes, it’s very hard for the government to be able to afford good quality healthcare.Therefore, doctors working in expensive specialist areas like neurosurgery end up setting up their own private hospitals. This has happened in India, in Sudan which I know well, it’s happening in Ukraine and it’s happening here. You then end up with all these separate private hospitals which are basically locked in economic competition against each other. They all profess to be all working happily together for the greater good but it’s very difficult – they have to make a profit to survive and this sets doctors against each other.Now all surgeons, we all know that the more we do of a particular sort of surgery the better we get. If that workload is divided up and split between many different departments and different surgeons, no one person is really going to become very good at dealing with it.If you look at what’s happening in Europe and America, super specialisation is the game. I trained along with Professor Devkota in what’s called general neurosurgeon – I could do everything. But in recent years, we all stopped doing that, we became more and more specialised. I ended up specialising mainly in brain tumour surgery and even then, in particular sorts of brain tumours, which means I became very, very expert in that particular sort of case. That is not happening in Nepal.Do you have any solutions?I’m not here to tell people what to do because I don’t know. What I do know is that all healthcare systems reflect the underlying culture of the country. If there is a solution – it has to come from the people living in that country.Could you touch on the over-commercialisation of healthcare in Nepal?With all medicine, there’s a problem – is medicine a vocation or is it a business?Our judgement is easily distorted, unconsciously, and if you know you’re going to make a lot of money by treating the patient, or if you know your hospital needs to make money to survive, that’s probably on an unconscious level going to distort your judgement of whether to operate or not. Ultimately, with commercial healthcare, the patient becomes the means to the end of making money. With the other extreme, if doctors are only paid fixed salaries in a state system, in theory at least, the end of everything you’re doing is for the wellbeing of the patients and making money is not relevant.Read Also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor Health,</a> Editorial <figure><img width="500" height="574" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664d9c7e80680e059973jpeg.jpg" alt=""><figcaption>Henry Marsh training Nepali surgeons at the Neuro Hospital in Bansbari, Kathmandu in 2017. Photo: ESCAPMEDIA</figcaption></figure>What has your experience been like working with the hospital here?I think it’s a wonderful hospital. I love coming here. It’s not always easy for me, for various reasons, but I have absolutely no hesitation in wanting to help as much as I can. Clearly the transitional period following Professor Devkota’s death was very difficult. He was very famous, and it was like a magnetic attraction: patients came from all over Nepal to see him, often without neurosurgical problems. Inevitably now, with the change of staff, it’s been a difficult transitional period. What strikes me is the way the hospital’s survived. One might have thought it would completely collapse once he had gone but that’s not the case at all. How do we implement affordable and accessible healthcare in rural areas in Nepal?I’m not a public health expert. A major problem in Nepal, apart from the poverty, is poor infrastructure. In Europe, you can get patients fairly quickly from rural areas to central hospitals. That is often impossible in Nepal. You have to compromise, and you have to have more peripheral small hospitals out in the rural communities than you would in wealthier countries with more favourable terrain.Nepal has many problems. If you wanted to design a country to have difficult problems, Nepal is that. We all know being landlocked is a major problem for economic development. Having all these mountains and <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener">adverse geographical features makes life difficult </a>as well.Read Also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Policies-for-the-people,3640" target="_blank" rel="noopener">Policies for the people</a>, Marty Logan<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?,</a> S P KalauneeWhat are some of the values you want to pass on to the younger generation of surgeons?Firstly, to ask for help and not try to think you know everything because we don’t know everything. As young doctors, we’re often very anxious and frightened and we have to pretend to patients that we’re better than we are. We often end up pretending to ourselves as a way of boosting our self-confidence. It can be easier. I speak from personal experience; I can think of many patients who came to harm because I made this mistake. I didn’t ask for help from someone more experienced than myself.My message to young doctors is it is OK to feel frightened. That’s the nature of the work. You can’t be a good doctor, particularly when you’re young and fairly inexperienced, without being anxious and frightened. Don’t feel ashamed to say "I don’t know", not to the poor old patient, but don’t feel ashamed to say to a senior colleague “I need your help”.The other advice I give to young doctors, apart from ask for help, is listen to patients. So many doctors, including myself when I was younger, just sort of talk at patients rather than talk with them. Purely in terms of making a diagnosis and making the right decisions, listening to the patient’s story is very important. I’ve worked all over the world and medical systems vary all over the world. Doctors vary all over the world. As far as I can tell though, we’re all the same as patients: we’re frightened, we’re anxious, we want to be treated with respect. We want to be treated with respect and doctors are often bad at doing that – particularly in rather hierarchal societies like Nepal.

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Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota

For many decades it was an accepted truth that Nepal’s main public health threat was from infectious diseases, and the most cost-effective way to address that was through prevention. In other words, the first line of defence against communicable diseases was communication.Whether it was gastric infections caused by contaminated water, respiratory ailments due to cold and pollution, or diseases spread by insect vectors like malaria – the goal was to spread public awareness about prevention. Radio jingles about oral rehydration salts or acute respiratory infections in children indirectly helped save millions of lives over the years.Many of these challenges remain. Despite dramatic progress, many Nepalis still lack safe drinking water – not just in the roadless hinterland but right here in the heart of the capital. There are frequent <a href="http://archive.nepalitimes.com/article/nation/%20jajarkot-open-defecation-free,2023">cholera</a> epidemics. Children’s lungs are still affected by indoor smoke from wood fires. Malaria is on the comeback due to resistance and there is an annual epidemic of dengue and encephalitis.Yet, compounding these endemic infections, there is now an <a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">increasing burden of non-communicable diseases and injuries</a> (NCDI). New lifestyle-related cardio-vascular afflictions, chronic obstructive pulmonary disease (COPD) caused by <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/every-breath-we-take-air%20pollution,3536">pollution</a>, or <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486">mental health disorders</a> have added to the burden of disease and disability. <a href="http://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">South Asians are already genetically susceptible to diabetes</a>, and now there are new risk factors due to migration to urban centres. While the world average for prevalence of both types of diabetes is 8%, more than 14% of people in urban centres like Dharan have diabetes – even though the prevalence for rural Taplejung, for instance, is only 1%.A study by The Nepal NCDI Poverty Commission released this week shows that the burden of NCDIs has doubled in the last 25 years. More than half of all death and disability today are caused by NCDIs, with nearly 15% caused by injuries in conflict, natural disasters or highway accidents. <img width="900" height="802" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517699c7e80680e02c275jpeg.jpg" alt=""/>Being afflicted with an NCDI (or chronic disease) is more fatal in Nepal than in developed countries because of affordability and restricted accessibility to adequate medical treatment. The poor are disproportionately vulnerable. The NCDI burden in Nepal is also different than in other parts of the world – there is a higher incidence of ischemic cardiac conditions, asthma, neurological disorders, cancers caused by untreated infections and injuries, for instance.For us, the report’s main finding, and most damning inference, is about how <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">treatment of NCDIs is driving Nepalis into indebetedness and penury</a>. The survey shows that half of all medical expenditure of families is out-of-pocket, and 60% of that is for treatment of NCDIs. This is because the government spends only 11% of its budget on health care, and only 6.4% of that is for treatment of non-communicable diseases.Despite the proven link between chronic ailments and poverty, donors still allocate only 1% of their development assistance for NCDIs.Treatment of injuries, gastro-intestinal infections, heart diseases, cancers, kidney and liver diseases are the most impoverishing NCDs for households. The report’s main conclusions are corroborated by our <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">field report</a> from Achham and Kavre this week  about how the lack of even basic surgical facilities in district hospitals and health posts is forcing Nepalis to undertake expensive and extended trips to private hospitals in the cities.Another recent study of 39 government hospitals commissioned by the Nick Simons Institute (NSI) showed a huge unmet need in remote areas for basic surgery like caesarians, orthopaedics, and abdominal operations. Nepal’s surgery rate is well below the Lancet Commission’s target of 5,000 operations per 100,000 population. Only one-third of patients currently can reach an orthopedic surgeon within two hours of travel. <img width="640" height="456" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365176b9c7e80680e02c276jpeg.jpg" alt="">The public-private partnership models that NSI and Possible are carrying out in remote government hospitals are ways to plug this gap: ensuring minimum staffing of a MDGP physician, anaesthesia assistant, staff nurse and biomedical technician in each hospital can offer basic treatment and surgery in remote areas, reduce the need for referrals, and save household income. At present Nepal’s density of hospitals with such staffing and equipment is at 0.4 per 100,000 population, as against the Lancet Commission’s recommendation of 20/100,000.The Nepal NCDI Poverty Commission report suggests additional measures: national health care delivery should respond to the increasing burden of NCDIs by decentralising.Impoverishment of households due to the high cost of treatment should be addressed through disease-specific policies for high-cost conditions and expansion of insurance coverage.It is often said that health is wealth, but in Nepal wealth is health. That can only be changed by making treatment of chronic conditions and injuries accessible, affordable, inclusive and equitable.Read also:<a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">State of the art rural hospital</a>, Marty logan <a href="http://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<a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">Communicating about non-communicable diseases</a>,  Elina Pradhan and Bigyan R Bista

Poor  health

India and Pakistan are twins separated at birth. Tensions between them have been at a hair trigger ever since independence and has erupted into full scale conflict at least four times in the past 80 years.
The 22 April terrorist attack in Kashmir that killed 25 Indian tourists and a Nepali citizen, threatens to escalate tension between the two nuclear-armed nations. India has squarely blamed Pakistan for the attacks, and Prime Minister Narendra Modi has given his military “operational freedom” to respond. Pakistan has said it has credible intelligence of an Indian military strike and its officials have promised a “full spectrum” response — a code for a <a href="https://nepalitimes.com/editorial/thinking-the-thinkable">nuclear retaliation</a>.
For Nepal, the killing of its national in the Pahalgam attack comes as another stark reminder that in conflicts from Afghanistan to Iraq, from <a href="https://nepalitimes.com/opinion/how-to-agree-an-armistice-in-ukraine">Ukraine</a> to Israel, <a href="https://nepalitimes.com/news/10-nepalis-from-one-town-fighting-in-ukraine">Nepalis are getting caught in the crossfire</a>. The last time full-scale fighting broke out between <a href="https://nepalitimes.com/opinion/peacemongers-at-india-pakistan-border">India and Pakistan</a> on Kargil in 1999, at least 22<a href="https://nepalitimes.com/here-now/india-s-trial-by-fire-for-soldiers-from-nepal?%27%5C%22="> Nepalis fighting for the Indian Army</a> were killed in action.
Three of Nepal’s immediate neighbours (China, India, Pakistan) have nuclear weapons, and they do not have good relations. With China supplying weapons, <a href="https://nepalitimes.com/editorial/war-and-warming">missile technology</a> and other support to Pakistan, this triangular friction could set off a regional conflagration.&nbsp;
<a href="https://www.nature.com/articles/s43016-022-00573-0" target="_blank">Research at Rutgers University</a> has calculated that even a week-long tactical nuclear exchange between India and Pakistan would throw up so much smoke and debris into the atmosphere that it would block out the sun for years, and lead to a collapse of the <a href="https://nepalitimes.com/news/grow-nourish-sustain-together-world-food-day">global food system</a>. This does not take into account the radioactive fallout that prevailing winds would blow up to <a href="https://nepalitimes.com/here-now/lives-on-the-line-in-the-himalaya">the Himalaya</a>, contaminating glaciers that are the sources of <a href="https://nepalitimes.com/here-now/saving-what-is-left-of-himalayan-rivers">Asia’s main rivers</a>.
The impact of <a href="https://nepalitimes.com/news/climate-breakdown-linked-to-thame-flood">climate breakdown </a>on High Asia was already ringing alarm bells about its <a href="https://nepalitimes.com/news/himalayan-icecap-melting-faster-than-thought">shrinking ice cap</a> reducing the dry season flow of water downstream. Water was going to be the next strategic commodity, geopolitical experts warned, and the next wars in Asia would be over water.
That water war is already happening. India retaliated to the Kashmir attack by suspending the <a href="https://www.nytimes.com/2025/04/24/world/asia/india-pakistan-indus-waters-treaty.html" target="_blank">Indus Waters Treaty</a> of 1960 mediated by the World Bank that has withstood at least three wars between India and Pakistan. The treaty gives India control over the three eastern tributaries of the Indus (<a href="https://en.wikipedia.org/wiki/Beas_River" target="_blank">Beas</a>, <a href="https://en.wikipedia.org/wiki/Ravi_River" target="_blank">Ravi</a> and <a href="https://en.wikipedia.org/wiki/Sutlej" target="_blank">Sutlej</a>), while Pakistan got water from the Indus and two of its western tributaries (<a href="https://en.wikipedia.org/wiki/Indus_River" target="_blank">Indus</a>, <a href="https://en.wikipedia.org/wiki/Chenab_River" target="_blank">Chenab</a> and <a href="https://en.wikipedia.org/wiki/Jhelum_River" target="_blank">Jhelum</a>.
Pakistan was assured of 70% of the annual flow, and India could use a reasonable amount of water for<a href="https://archive.nepalitimes.com/news.php?id=15231"> irrigation and hydropower</a>. &nbsp;Within days of its threat, India stopped water flowing down to Pakistan from the Chenab river and is reportedly preparing to do the same on the Jhelum.
The sabre-rattling has reached a crescendo. Besides threats and counter-threats there are also symbolic drills, with the Indian Air Force practicing landing on an expressway in Uttar Pradesh by its Rafale, Su-30 and Jaguar fighter jets to demonstrate ‘operational readiness’. In response Pakistan test-fired its Abdali ballistic missile that can carry a nuclear warhead and has a range of 450km.&nbsp;
The danger is that with ultra-nationalist rhetoric and the beating the war drums by both sides, India’s government and Pakistan’s military may have to ‘do something’ to appease domestic public opinion. But any tactical strike, an artillery exchange, or territorial incursion could quickly escalate out of control.
Expecting an Indian retaliation for the Pahalgam killings, Pakistan is using<a href="https://nepalitimes.com/opinion/interfaith-collaboration-for-nuclear-disarmament"> nuclear deterrence </a>and warning of “catastrophic consequences”. The two neighbours came close to a nuclear exchange in 2019 after an attack on the Indian military in Kashmir, and prompt international intervention led by the United States cooled tensions.&nbsp;
This time, the <a href="https://nepalitimes.com/news/trump-shock-wave-hits-nepal">Trump administration</a> is too distracted and not as engaged. Pakistan has denied it was responsible for the terrorist attack and called on Washington to stop a possible Indian retaliation. India and Pakistan have stopped overflights by each other’s airlines, and some international carriers have even stopped flying over Pakistan fearing an air war.
Washington, Beijing, the UN and the EU have all urged restraint. Iran, which has good relations with both India and Pakistan has sent its foreign minister to urge both countries not to go into a tit-for-tat war. Iran has its own nuclear flashpoint to worry about with tensions in Israel, &nbsp;Yemen and Syria.
India and Pakistan both share similar problems of joblessness, <a href="https://nepalitimes.com/here-now/why-nepal-s-poverty-rate-is-stuck">poverty </a>and <a href="https://nepalitimes.com/here-now/climate-change-new-threat-to-nepal-s-rhinos">environmental threats</a>. Neither side needs the threat of a senseless war, and we in the neighbourhood do not need it either.&nbsp;
Kunda Dixit
This Editorial is brought to you by <a href="https://nepalitimes.com/" target="_blank">Nepali Times</a>, in collaboration with <a href="https://inpsjapan.com/en/" target="_blank">INPS Japan</a> and <a href="https://sgi-peace.org/" target="_blank">Soka Gakkai International</a>, in consultative status with UN ECOSOC.

Nukes in the neighbourhood

The newly-formed Himalayan Art Council is set to launch Nepal’s National Art Protection Platform that seeks to preserve <a href="https://nepalitimes.com/banner/the-history-of-heritage">Nepal’s unique cultural heritage </a>using<a href="https://nepalitimes.com/here-now/artificial-censorship"> AI-powered tools</a>. The Council seeks to safeguard <a href="https://nepalitimes.com/banner/nepali-art-going-places">Nepali art works</a> from neglect, theft and counterfeiting as well as preserve existing artwork and celebrate living masters by giving them a cultural space to continue the <a href="https://nepalitimes.com/banner/sacred-survival">sacred art traditions</a>. "We are introducing a new digital platform designed to preserve, verify and elevate <a href="https://nepalitimes.com/banner/nepals-new-generation-of-alternative-artists">Nepal’s art for generations to come,</a>” says a statement from the Council, adding that the digital platform will use AI told for authentication and blockchain to keep track of works of art. Artists can now be protected by <a href="https://nepalitimes.com/multimedia/ayo-ai?fbclid=IwAR1uwmTVq4gUB70ljfRezjzukD9ArWXPuMnUikopeQ8PoiZMjicToPSwhKE&amp;=1">AI tools</a> that detect forgeries, identify their work even when unsigned, and ensure they receive proper recognition and credit. The archives will be searchable with translated inscription and interactive guides. Says curator Meena Lama: “AI and blockchains are tools that give us the power to detect fakes and identify unsigned paintings and track every piece. With these tools we can restore trust, secure authorship and give artists the dignity they deserve.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250514170544_2ab58f6313c0458f75114a692b0016bd9efb3b59d5f8f07f0da72e1e37b82f53.jpg" data-media-id="editor_6" data-image-id="20250514170544_2ab58f6313c0458f75114a692b0016bd9efb3b59d5f8f07f0da72e1e37b82f53" data-rendition-name="original" width="1300" height="1000" loading="lazy" alt="Artwork at the Traditional Art Exhibition at Patan Museum."> <figcaption>Artwork at the Traditional Art Exhibition at Patan Museum.</figcaption> </figure>  The Council is also holding an exhibition of Nepali cultural masterpieces with 50 historical <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-the-art,671">thangka and paubha </a>by past masters and <a href="https://nepalitimes.com/review/between-the-sacred-and-everyday">contemporary works by current artists</a>. This curated collection is a living tribute to <a href="https://nepalitimes.com/here-now/when-yaks-go-so-does-culture">Himalayan culture</a> with economic depictions of deities, mandala and sacred narratives. The exhibition at <a href="https://nepalitimes.com/multimedia/a-portal-into-patan-s-past-and-present">Patan Museum</a> also provides an opportunity to meet painters and custodians of art and culture. Read also: <a href="https://nepalitimes.com/review/golden-deities">Golden deities</a>, Sewa Bhattarai ‘The exhibition is only the first step in a long journey to ensure that Nepali art is no just seen but fully understood, <a href="https://archive.nepalitimes.com/article/nation/Narratives-of-Faith-and-Memory-Remembering-the-Lost-Sculptures-of-Kathmandu-exhibition,987">protected and remembered</a>,’ the Council says. Artist Kailash K Shrestha of Artudio has spent decades promoting thankha and paubha traditions because of their beauty and devotional meaning. But he also says artists are underpaid, exploited and ignored. He adds, “AI and blockchain are not just buzzwords, they are powerful tools that can protect Nepal’s artists from fraud, verify authenticity and build a permanent record of provenance.” Traditional Art Exhibition Till 17 May Patan Museum

Digital protection for Nepal’s art

Most Nepalis thought they had seen the last of it after <a href="https://nepalitimes.com/news/11-56-25-april-2015-wkc9q2an">the 25 April 7.8 magnitude </a>earthquake ten years ago. But the Himalaya had more surprises in store. On 12 May, another 7.3 magnitude tremor that some said was an aftershock, but was strong enough to itself be a major earthquake, struck Dolakha.&nbsp; Not many people had heard of Singati till then — a cluster of houses by the Tama Kosi River along a narrow gorge that is the roadhead to Rolwaling Valley.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110520_57b6e316656851f71eca56ca6f98d9bbcc820c1a00d62af3c990725b4361244d.jpg" data-media-id="editor_1" data-image-id="20250508110520_57b6e316656851f71eca56ca6f98d9bbcc820c1a00d62af3c990725b4361244d" data-rendition-name="original" width="1000" height="1500" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110520_016534fb2b6a79957402281cda768efb83a146786377e39e11df3e251d37159e.jpg" data-media-id="editor_2" data-image-id="20250508110520_016534fb2b6a79957402281cda768efb83a146786377e39e11df3e251d37159e" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> </figure>  It was here that dozens were killed on 25 April in the first earthquake. Hundreds of <a href="https://archive.nepalitimes.com/article/nation/Singati-rising-from-rubble-rebuilding,3703">Singati survivors</a> had lined up for food and relief supplies in the morning of 12 May when the second earthquake triggered a rock slide that buried a nearby camp. At least 50 people were killed. &nbsp; Three hours later, a US Marine Corps UH-1Y Venom helicopter landed in a nearby cornfield to pick up the wounded, and flew off. The aircraft lost contact with air traffic control in Kathmandu and its wreckage was located high on Kalinchok four days later. Six American servicemen, two Nepal Army soldiers, and five wounded civilians from Singati were killed. Today, Singati bears little physical scar of the multiple tragedies that struck the town ten years ago. Most <a href="https://nepalitimes.com/multimedia/bungamati-builds-back">houses have been rebuilt</a> as urban-style concrete structures, and Singati has become an economic hub on the road leading up to several hydropower plants and a<a href="https://nepalitimes.com/banner/off-the-beaten-trek-in-nepal"> popular trekking destination</a>.&nbsp; The town looks less like a village and more like a suburb of the Dolakha district headquarter of Charikot, 47km away.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110520_196f341d1df1403ba133e5dfeb837eec20d7cbcb4c8c56b17cc5598810de5df2.jpg" data-media-id="editor_6" data-image-id="20250508110520_196f341d1df1403ba133e5dfeb837eec20d7cbcb4c8c56b17cc5598810de5df2" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110524_ae66c4a92430f67db51b5e11e017059eedfbac4cb18c8e073f2a50cca1fe904e.jpg" data-media-id="editor_7" data-image-id="20250508110524_ae66c4a92430f67db51b5e11e017059eedfbac4cb18c8e073f2a50cca1fe904e" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> </figure>  “The demand for construction material, cement, iron rods and bricks peaked after the earthquakes,” says Suresh Khadka, who owns a hardware business here and now supplies material to the 456MW Upper Tama Kosi hydropower project that is undergoing repairs after it was damaged by a landslide last year. The demand for cement boomed since most residents believe, not necessarily correctly, that <a href="https://nepalitimes.com/banner/in-a-disastrous-state">cement houses are safer</a>. Although Khadka did well selling construction material after the earthquake, he worries that most new structures do not follow seismic-resistant building codes.&nbsp; The construction boom financed by bank loans has in turn forced many from Singati to <a href="https://nepalitimes.com/banner/making-overseas-migration-better">migrate overseas for work</a> so they can service their debt.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110524_50caa4530bd5ff9120cf7ab70a62173846d337ef448ff8bac339f3faa375a9e2.jpg" data-media-id="editor_10" data-image-id="20250508110524_50caa4530bd5ff9120cf7ab70a62173846d337ef448ff8bac339f3faa375a9e2" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> <figcaption>Suresh Khadka</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110520_ef8b7d3993fc3b5df852bbf952feb3fbabc96d6883b0d5eb74ee5c60f4123b83.jpg" data-media-id="editor_11" data-image-id="20250508110520_ef8b7d3993fc3b5df852bbf952feb3fbabc96d6883b0d5eb74ee5c60f4123b83" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> <figcaption>Phu Doma Sherpa (right)</figcaption> </figure>  “My family had no choice but to borrow money to rebuild our home since the government compensation was not enough, and ten years later we are still paying off the loan,” says Phu Doma Sherpa, 60. Because of the shortage of qualified masons and proper seismic engineering, <a href="https://nepalitimes.com/here-now/structural-problems">many of the buildings are of questionable building standards </a>and the traditional architecture has been abandoned, admits Kul Bahadur Budathoki, deputy chair of the municipality. “But these buildings were more expensive than what the government grants could cover, many people here are heavily in debt and the men have <a href="https://nepalitimes.com/here-now/every-day-is-closer-to-pay-day">migrated to the Gulf to pay their loans</a>,” Budathoki says.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250508110520_32f89e97b7e757fc9286c0bbb671f48ea8d4468e9634fa646d7247c650ad8480.jpg" data-media-id="editor_14" data-image-id="20250508110520_32f89e97b7e757fc9286c0bbb671f48ea8d4468e9634fa646d7247c650ad8480" data-rendition-name="original" width="1501" height="1079" loading="lazy" alt="Climate magnifies earthquake risk in Nepal village NT"> <figcaption>Kul Bahadur Budathoki</figcaption> </figure>  Singati is in a multi-hazard zone. The <a href="https://archive.nepalitimes.com/article/nation/Singati,3091">12 May 2015 earthquake </a>could have led to the collapse of Nepal’s largest glacial lake, <a href="https://nepalitimes.com/here-now/stairway-to-heaven">Tso Rolpa</a>, upstream. Due to global warming, the glacier has turned into an expanding lake 3.5km long, and its collapse would have unleashed a catastrophic Himalayan tsunami down the Tama Kosi Valley, with Singati directly in its path. Singati has literally risen from the ashes of 2015, with its residents beginning to recover from the trauma and financial toll. But it is not out of danger as <a href="https://nepalitimes.com/news/climate-breakdown-linked-to-thame-flood">climate breakdown </a>magnifies the risk from future earthquakes.

Climate magnifies earthquake risk in Nepal village

The streets of Patan are alive this month with lavender jacaranda trees under rain-washed skies as <a href="https://nepalitimes.com/banner/the-red-god-rises-again-in-patan">the chariot of Rato Matsyendranath</a> is pulled across town. This is the festival of the rain god, and inevitably the heavens opened up and pre-monsoon showers pelted the chariot as it started being pulled in Pulchok last week. Thousands of devotees, onlookers and the chariot procession organisers thronged the streets on the first day last week. The rhythmic cymbals and drums exuded a vibrant energy as the enormous four wheels turned and the chariot lurched.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025051007050_81df97744db16f732a419dc1f1579d235ce3df37642b078f50b83bd4bd026688.jpg" data-media-id="editor_1" data-image-id="2025051007050_81df97744db16f732a419dc1f1579d235ce3df37642b078f50b83bd4bd026688" data-rendition-name="original" width="1000" height="1503" loading="lazy" alt="Divine chariot"> </figure>  The<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Red-rain-god,3141"> red rain god</a> has Hindu and Buddhist antecedents, alternatively called Bungadya and<a href="https://nepalitimes.com/here-now/kathmandu-s-gravity-defying-chariot-festival"> Karunamaya</a> — reflecting Kathmandu Valley’s syncretic mixture of the two religions.&nbsp; “Bungadya is a profoundly <a href="https://nepalitimes.com/opinion/12-full-opinion/marketing-the-intangible">intangible form of heritage</a>,” explains heritage expert Monalisa Maharjan. “It embodies traditional knowledge,<a href="https://nepalitimes.com/multimedia/reviving-nepal-s-craft"> artisanal skills passed down through generations</a>. Local communities and specific families have specified roles in being custodians of the heritage, ensuring their survival over the centuries.” There are many legends and stories about this annual tradition. Lichhavi king Narendra Dev is supposed to have brought Rato Matsyendranath from Assam to Kathmandu Valley to convince Guru Gorakhnath to lift a spell that created a two-year drought in Kathmandu.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250510050520_347a9a398f8a9abc4a7fb4e2774fde8264cccbdce8bdab23851ab3f0e73c3e8a.jpg" data-media-id="editor_6" data-image-id="20250510050520_347a9a398f8a9abc4a7fb4e2774fde8264cccbdce8bdab23851ab3f0e73c3e8a" data-rendition-name="original" width="1503" height="1000" loading="lazy" alt="Divine chariot"> </figure>  Matsyendranath was Gorakhnath’s mentor, and upon seeing him, the serpents were released, unleashing the rains. The chariot festival honours the return of this life-giving rain. The deity is seen as an icon for thriving agriculture, t<a href="https://nepalitimes.com/here-now/before-the-next-monsoon">he arrival of monsoon</a> showers, and the welfare of the community. Read also: <a href="https://nepalitimes.com/opinion/the-reign-of-the-god-of-rain">The reign of the god of rain</a>, Vidhu Prakash Kayastha Till this day, the Rato Matsyendranath festival is no ordinary celebration. Patan does not sleep for a month as the chariot is pulled through various neighbourhoods. It unfolds at a state level with the president (formerly the king) attending the climax of the Bhoto Jatra in Jawalakhel later this month.&nbsp; The intergenerational transmission of tradition is unique in the world, and the reason the festival is one of the most vibrant cultural expressions that thrives despite inroads of modernity. The other unique aspect is that it is a transnational festival, binding Patan with Guwahati in the Indian state of Assam.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025051005058_8bc685ada13045d863b28e3eed91c931da2b510714586af6fd7eb5d1e298a24a.jpg" data-media-id="editor_9" data-image-id="2025051005058_8bc685ada13045d863b28e3eed91c931da2b510714586af6fd7eb5d1e298a24a" data-rendition-name="original" width="1000" height="1503" loading="lazy" alt="Divine chariot"> </figure>  “Unlike Nepal, where the deity commands grandeur and devotion, many in Assam are unaware of Rato Matsyendranath,” says Khagen Sharma of Gauhati University, which convened <a href="https://nepalitimes.com/news/nepal-assam-connection-revived">a symposium in February in Guwahati on the rain god</a>. Attending was a delegation led by Lalitpur Mayor Chiribabu Maharjan, organisers of the festival, and builders of the chariot. After the symposium, a committee was formed to explore and revive the tradition in Assam as well. Although the team had planned to visit Nepal this month, logistical challenges delayed the trip. Still, there are plans to build a Guru Matsyendranath statue in Assam to reestablish regular worship practices in the Guwahati shrine.&nbsp; The vines used to build the chariot in Patan are sourced from the jungles of Assam. But Sharma notes that in recent years unclear regulations have blocked the official import of the vines, although they are still brought to Nepal informally. The <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/makers-of-machhindranath,2204">chariot making</a> has also had a taste of modernisation in recent times. In the past, even a single nail or piece of steel was avoided. But over time, the wooden structure, particularly the shaft between the wheels, has been replaced with bronze. When that too proved unstable, metal clamps were introduced, which have become a pragmatic compromise.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250510050524_b2a819a5791612f14c81d30fc393dbd3f99f0c64b90a9110e8b0855d944bfa93.jpg" data-media-id="editor_12" data-image-id="20250510050524_b2a819a5791612f14c81d30fc393dbd3f99f0c64b90a9110e8b0855d944bfa93" data-rendition-name="original" width="1500" height="998" loading="lazy" alt="Divine chariot"> </figure>  Another welcome change is the focus on safety. Builders climbing the chariot’s tower now wear harnesses and there are efforts in crowd control. The most visible change in recent years has been the involvement of Patan’s enthusiastic youth in the festival — the tradition is now passing to a new generation. Says Matsyendranath expert Vidhu Kayastha: “There is more energy, the young people in red t-shirts this year were very organised, these modern touches aren’t diluting our culture, they’re keeping it alive in new forms.” He adds, “We are <a href="https://nepalitimes.com/here-now/searching-for-a-homeland-away-from-home">reconnecting with our roots</a>, we have more resources, more awareness than ever before. We must not be swept away by western values that may not serve us, and in some ways, cause more harm than good. We must revive our own culture.”&nbsp;

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