Nepal’s health sector continues to suffer from an equity gap: even when families have access to medical care, it is either unaffordable or of poor quality. &nbsp;&nbsp;&nbsp; Enter: a combination of artificial intelligence and telemedicine that could allow the country to leapfrog technology and reach people so far deprived of medical treatment.&nbsp; Over a tenth of Nepalis are forced to live with disease and disability because they cannot afford medical services. In government hospitals where treatment is supposed to be free, quality of care is poor. Many lose their lives simply because they do not get the right treatment in time. “Creating and using AI models may not sound like top priority for a country where even the most basic healthcare is still inaccessible,” admits Bishesh Khanal, co-founder of the NepAl Applied Mathematics and Informatics Institute (NAAMII). “But those that can benefit from AI are precisely countries like ours.” NAAMII’s research integrates AI, computing and robotics in healthcare and agriculture. By creating computational models, &nbsp;researchers use machine learning to devise tools to address medical &nbsp;conditions. With support from IISH (Institute for Implementation of Science and Health) NAAMII is working on an AI-guided screening tool for cervical cancer, which uses smartphone-captured images of the cervix to visually inspect and detect the condition even remotely. “With visual inspection, gynecology experts can diagnose patients of cervical cancer within minutes,” Khanal explains. “The problem is that Nepal’s socioeconomic and geological conditions make it difficult for such medical expertise to get to places."&nbsp; With AI tools and telemedicine, caregivers in remote regions can &nbsp;identify disease in consultation with specialists in the city. Another project NAAMII is working on is an AI-assisted tool that allows a smartphone to act as a microscope to detect diarrhoea parasites in contaminated vegetables, stool, and water. Read also: <a href="https://www.nepalitimes.com/news/healthcare-moving-from-hospitals-to-homes">Healthcare moving from hospitals to homes</a>, Sonia Awale  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230709120748_b06b42866f77704ff6a7540df744be4c03bb6460e62960d8c28d23ce9cd1e936.jpg" data-media-id="editor_1" data-image-id="20230709120748_b06b42866f77704ff6a7540df744be4c03bb6460e62960d8c28d23ce9cd1e936" data-rendition-name="original" width="1600" height="900" loading="lazy" alt="AI healthcare NT"> <figcaption>Researchers at NAAMII discuss options for using AI for medical diagnosis. Photo: NAMMII</figcaption> </figure>  AI models that can also detect defects in the intestinal tract, and an algorithm for patients with a muscle disorder called dystonia that can classify what type of the disease a patient has, are some of the other technology NAAMII boasts. NAAMII’s work in the health sector aims to add to existing care providers so that even in remote regions, advanced medical procedures can be carried out by personnel with less expertise. AI models are also deployed at the Hospital for Children, Eye, ENT and Rehabilitation Services (CHEERS) in Bhaktapur, under the aegis of the non-governmental BP Eye Foundation. The centre developed a learning-based model integrating telemedicine with AI that allows non-skilled health workers to predict if patients have certain eye, ear, nose, and throat diseases. Two AI models to predict diabetic retinopathy and glaucoma, both of which are common causes of vision loss, were developed by feeding thousands of photographs to the AI system. These diseases are often overlooked or missed by doctors at clinics, but with both of these models diagnosis was more than 90% accurate. This disease prediction support is now provided at the Foundation’s outreach clinics across the valley, and also at the health camps organised by CHEERS. A 52-year-old patient from Lele came to a mobile clinic recently and although diabetic, was not on medication. She thought glasses would correct her vision loss. An image of her eye, analysed by the AI model at the camp, revealed that she had proliferative diabetic retinopathy. She was referred to a virtual consultation from an ophthalmologist at the CHEERS Hospital in Bhaktapur. Her eyesight was saved. &nbsp; “Telehealth and AI prediction is a model that can reach specialised diagnosis and treatment more easily to people who do not have to make an expensive trip to a hospital,” says Pranita Upadhyaya an IT professional at CHEERS. She adds: “Patients in remote villages can now receive virtual consultation with specialists. The AI models further ensure they are treated correctly for the exact condition they have.” AI also helps community health workers to build capacity and skill, as they can compare and confirm their own diagnosis with ones made by AI and at city hospitals. But there are also technological hurdles in implementation because of the scarcity of data in rural settings. Upadhyaya explains: “AI models rely on sizeable, varied datasets. These models lack the ability to contextualise like humans, and so when deployed in rural areas where medical records are sparse and datasets are biased, it affects the precision and dependability of AI forecasts.” To bridge this data gap the 2019 Digital Nepal Framework has provisions for a national digital health mobile application, a centralised telemedicine center, a comprehensive electronic health record, mobile health units, and the provision of e-maternal care. Read also: <a href="https://www.nepalitimes.com/here-now/an-eye-for-two-eyes">An eye for two eyes</a>, Yugottam Koirala  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230709120752_04df4f35b8b41ac1c45600f6d6df030c7027309c8e98231f81c334f0c9ed2802.png" data-media-id="editor_3" data-image-id="20230709120752_04df4f35b8b41ac1c45600f6d6df030c7027309c8e98231f81c334f0c9ed2802" data-rendition-name="original" width="1926" height="958" loading="lazy" alt="AI healthcare NT"> </figure>  Like with everything else in Nepal, although this blueprint looks impressive on paper, implementation is almost non-existent, even after the government allocated Rs22 billion for it over the past four years. “Ultimately, how AI enters healthcare is through individualised, specific services,” says Khanal. “There will have to be separate AI tools and products for each niche within healthcare. We will always have to rely on the private sector to keep spurring the development of new AI products. The government’s role should be in formulating and regulating.” As of now, clear regulatory frameworks governing the use of AI or automated systems in Nepal’s healthcare are practically non-existent. The National Ethical Guidelines for Health Research 2022 sets the standards for research practices in health, but omits any implications of digital technology. The National Science, Technology and Innovation Policy 2019 mentions AI only in passing. “AI in and of itself cannot be operated without concrete ethical guidelines in place,” cautions Upadhyaya. “When coupled with healthcare, especially in unique contexts like rural Nepal, a whole new array of special ethical considerations arise. Regulations should strike a balance between facilitating innovation and ensuring responsible use of AI technologies.” Thanks partly to the pandemic, Nepal’s healthcare is shifting into the digital sphere, and this will make deployment of AI in the health system easier. This shift has been accelerated by public-private partnerships such as Nyaya Health Nepal in Achham, which works with the Ministry of Health and Population to set up Electronic Health Records (EHRs) to remotely coordinate care between doctors and patients. Says Upadhyaya: “We should move forward by involving government agencies, private sector, academia, and healthcare professionals to drive AI innovation in healthcare while safeguarding patient rights and societal well-being.” &nbsp;&nbsp; Read also: <a href="https://www.nepalitimes.com/here-now/the-karnali-s-hunger-emergency">The Karnali’s hunger emergency</a>, Anita Bhetwal

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Artificially intelligent medicine

<figure><img width="640" height="427" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a5e9c7e80680e0b559bjpeg.jpg" alt=""/><figcaption>Photo: SONIA AWALE</figcaption></figure>The spread of <a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer">telemedicine</a> is one of the most remarkable spillover effects of the <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">Covid-19 pandemic</a> worldwide, and could also transform healthcare in Nepal.In the US, the Center for Disease Prevention and Control (CDC) specifically recommended that health care facilities and providers offer clinical services through virtual means as a result of which growth in telehealth usage is 38 times higher than before the pandemic.The US was amongst the first adopters of telehealth and has also been a mature user of tele-ICU services, with an estimated 11% of American ICU beds under telemonitoring. Adoption of telemedicine was <a href="http://archive.nepalitimes.com/news.php?id=14607#.YhzApy8w3u1" target="_blank" rel="noopener noreferrer">slow to catch on </a>in the developing world due to insufficient communication infrastructure and status quo biases plus regulation deficiencies. But it witnessed a breakthrough during the pandemic, thus making the virtues of telemedicine apparent. Argentina had passed legislation to validate electronic prescriptions and launched TeleCovid, a public telemedicine provider.In Australia, Singapore, Indonesia, and the Philippines, governments have been making consistent efforts to advance the use of telehealth through subsidies, funding, and loosening certain health regulations during the pandemic.In developed countries, this was enabled by three factors: increased consumer willingness to use telehealth, greater provider willingness to use telehealth, and regulatory changes enabling greater access and reimbursements.While it is evident that government intervention and public sector support have been the key to creating favourable business environments for telehealth in those regions, Nepal seems to stand out.Read also: <a href="https://www.nepalitimes.com/latest/covid-crisis-can-spur-digitisation/" target="_blank" rel="noopener noreferrer">Covid crisis can spur digitisation</a>, Ashutosh M DixitDuring the pandemic, many startups and corporates in the country launched telemedicine and digital health services to meet the growing need. But, will the surge in telemedicine services be sustainable post the pandemic or will it retreat? In Nepal, the majority of dispensaries, hospitals, and doctors are located in urban areas where only 21% of the population resides. Even then, they are concentrated in better off urban centres.Which means rural, peri-urban, and urban slums lack adequate access to quality primary healthcare. Much of the care delivered in underserved areas is through public sector primary or community health centers.Health tech startups and firms have made a successful market entry at the height of the pandemic, the result of which led to an exponential boom in online consultations via apps, medicine delivery, and even health service at the patients' door.These gains should not detract from the need to enable to specialist and super-specialist care to the untapped population of Nepal.The government's telemedicine strategy in 25 remote districts in Nepal is defunct due to financial and operational constraints. How strategic choices and the manner of those choices cascade to the bottom of pyramid markets will determine the sustainability of health tech startups.During the Covid-19 pandemic, telehealth companies recorded an average growth of 70% in basic telemedicine demand as compared to 2020. As promising as it sounds, online consultations on their own may not be enough for it to thrive post-pandemic.It has to be integrated into other services like home healthcare where the physicians go to the patients' home to provide medical services including routine checkups, administering medication and collection of medical samples for diagnostic purposes. Read also: <a href="https://www.nepalitimes.com/banner/drones-to-the-rescue/" target="_blank" rel="noopener noreferrer">Drones to the rescue</a>, Lucia de VriesFully integrated patient record allows clinicians to serve the people best, no matter whether they are present physically or remotely. Home delivery of prescribed medications adds to the safety and convenience of patients. Another emerging trend in the industry is modern healthcare subscriptions which may help expand the service offerings through the app and make services financially accessible to patients.Built on proprietary technology, telehealth apps are seen to be the core products. Through the app, patients or their dependents can avail services of online video consultations, book hospital appointments, or even order medicines online.However, acquiring and retaining customers may be challenging due to changing customer needs and preferences in the long run. It is for this reason that companies have to offer more than the basics, with better user engagement and experience.This means business analysis and planning exercises, phase-wise implementation, regular updates, and zero errors leading to faster processing of information and lower latency.Globally, telemedicine has the potential to revolutionise healthcare by bringing down provider and patient costs as well as improving the accessibility to quality medical professionals.In Nepal, telemedine should not just be an off shoot of the pandemic lockdowns but a deliberate strategy to improve the state of public health infrastructure and services with digital connectivity options.But the private sectors' efforts to bring innovation and improvements towards digitalisation in the health care ecosystem in Nepal can be a precursor for the country's healthcare transformation. Due to this the sustainability of telehealth companies must be reviewed time and time again.Read also: <a href="https://www.nepalitimes.com/here-now/digitial-path-to-social-buffers-in-nepal/">Digital path to social buffers in Nepal</a>, Ashraya DixitBishal Raj Paudyal is a Chartered Accountant and an MBA from Asian Institute of Technology in Bangkok.

Sonia Awale

Healthcare moving from hospitals to homes

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc2c9c7e80680e0a0b73jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure><ul><li>Two years ago after going through a bad relationship, a 36-year-old Kathmandu-based doctor started getting suicidal thoughts. During the long months of lockdown, he would be on the rooftop and imagine jumping off to end it all. But before long he realised that he was causing self-harm, and sought help. He was diagnosed with depression, eight months into treatment he is rid of suicidal thoughts and is back to his outgoing ways.</li> <li>The bubbly young woman used to be the life of every party, but few of her friends and relatives realised what was going on inside her mind. As the pandemic hit, she started having violent thoughts about harming others and herself. The 22-year-old tried to deal with it herself, but two months ago she sought help from a mental health doctor. She was diagnosed with Obsessive Compulsive Disorder (OCD) and started treatment. Looking back, she advises others to also seek professional help in time.</li> <li>The young woman felt worthless, lacked confidence, avoided crowds and had self-inflicted cuts on her arm. Her inability to come in terms with her sexuality aggravated her sense of insecurity. When the pandemic foiled her plans, she blamed everything on herself, she felt irritated and uncertain, stopped attending virtual classes and her eating habits changed. She finally sought help for her depression and she is now under regular psychiatric counselling and medications. Grounding exercises in particular have helped her overcome self-harm and feelings of inadequacy. “I am okay now,” she says.</li></ul>As the pandemic turns lives upside down, there has also been a global <a href="https://www.nepalitimes.com/here-now/post-pandemic-mental-health-epidemic/" target="_blank" rel="noopener noreferrer">outbreak of mental health disorders</a>, and Nepal has reported a rise in suicides. However, as these cases show, professional counselling and medication can save lives.Recoveries rarely make news, only suicides do.“Most of my patients who attempted suicide have gone on to lead normal lives after they get treatment, and oftentimes they look back to their mental health crisis as nothing more than a lapse of judgment,” says psychiatrist and researcher Rishav Koirala.There has been a sharp rise in <a href="https://www.nepalitimes.com/latest/have-suicides-increased-during-nepal-lockdown/" target="_blank" rel="noopener noreferrer">suicides in Nepal</a> since the Covid-19 pandemic in March 2020 and subsequent lockdowns. Nepal Police data shows that in the last 12 months, there have been 7,141 reported deaths due to suicides nationwide, up from 6,252 the year before.Do not shy away from seeking help. If you, or anyone you know, would like to speak to a trained mental health professional, please contact:TUTH Suicide Hotline: 9840021600Transcultural Psychosocial Organisation-Nepal Crisis Hotline: 1660 0102005Mental Health Helpline Nepal: 1660 0133666Centre for Mental Health and Counselling Nepal Toll-free: 16600185080, Hotline: 1145Koshish Toll-free helpline: 166001-22322 (Bagmati Province)Patan Hospital Helpline: 9813476123National Suicide Prevention helpline operated by Mental Hospital Lagankhel and TPO: 1166<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc2e9c7e80680e0a0b74jpeg.jpg" alt="" width="640" height="475"><figcaption> </figcaption></figure>In a survey last year, <a href="http://www.tponepal.org" target="_blank" rel="noopener noreferrer">Transcultural Psychosocial Organisation (TPO) Nepal</a> which works with mental health compared five years of suicide data for March-July to see if there was any change during the lockdowns in 2020 and 2021.The results are revealing: suicides have been increasing steadily at an average rate of 8.5% every year, but it spurted to 19.4% in the first four months of the lockdown. Researchers also conducted key informant interviews across Nepal, who reported witnessing an increase in <a href="https://www.nepalitimes.com/latest/suicide-watch/" target="_blank" rel="noopener noreferrer">suicidal behaviours</a> in the community as well as health facilities.“We now have both quantitative and qualitative evidence that mental health problems have increased following the pandemic,” says TPO Nepal’s executive director Kamal Gautam. “And given that the majority of suicides are caused by psychological problems, we can say that Covid-19 has significantly contributed to its increase.”Mental health professionals have long been warning of an epidemic of psychological disorders following the Covid-19 crisis. They have reported an increase in anxiety, depression, post-traumatic stress disorder (PTSD), hypochondria, obsessive disorders and psychotic symptoms among the general population in the last two years.Economic collapse, job loss and slashed income due to the pandemic as well as <a href="https://www.nepalitimes.com/latest/in-nepal-lockdown-a-domestic-violence-spike/" target="_blank" rel="noopener noreferrer">increased domestic and sexual violence</a> and added workload during the lockdowns have all acted as contributing factors. In addition, those afflicted do not have normal social interactions that used to be a safety valve during more normal times.Moreover, many patients on treatment and medication have relapsed due to the limited access to health services, counselling and psychotropic drugs during the pandemic, and in many cases because of Covid phobia.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc319c7e80680e0a0b75jpeg.jpg" alt="" width="1052" height="690"><figcaption> </figcaption></figure>Up to 80% of suicides have mental health disorders as an underlying cause. A significant portion of cases are also a result of impulsive behaviour.Experts agree that the official <a href="https://www.nepalitimes.com/here-now/nepals-suicide-rate-vastly-underestimated/" target="_blank" rel="noopener noreferrer">numbers on suicides are vastly underestimated</a> due to a lack of suicide registry. Official figures are based solely on police data and post-mortems, and because of stigma associated with mental health, many families also often refrain from revealing the actual cause of death.Official records also do not take into account <a href="https://www.nepalitimes.com/here-now/in-the-minds-of-nepals-migrant-workers/" target="_blank" rel="noopener noreferrer">suicides of Nepali migrant workers overseas</a>, mainly Malaysia and South Korea. Similarly, suicides among those in the LGBTIQ community who have lost their limited sources of livelihood during the pandemic have been largely neglected.“Reported cases alone are not conclusive, but given that we now have a year and a half long trend and data, we have seen a significant increase in mental health disorders, and can assume that pandemic has played a crucial part in the rise in the number of suicides,” adds Rishav Koirala.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.who.int/news-room/fact-sheets/detail/suicide" target="_blank" rel="noopener noreferrer">More than 700,000 people die by suicide</a> every year around the world, that is one in every 100 deaths -- more than HIV, malaria, breast cancer, or war and homicide. And for every suicide, there are many more who make attempts to end their lives.Nepal is among the countries with the highest suicide rates in the world and consistently ranks within the WHO’s top 10 list. The Nepal Health Research Council (NHRC)’s <a href="http://nhrc.gov.np/wp-content/uploads/2020/09/Factsheet-Adults-1.pdf" target="_blank" rel="noopener noreferrer">National Mental Health Survey</a> published earlier this year found the prevalence of suicidality (current suicidal thoughts, lifetime suicidal attempt and future likelihood of suicidal thoughts) to be high at 7.2% among Nepalis.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc339c7e80680e0a0b76jpeg.jpg" alt="" width="1464" height="752"><figcaption> </figcaption></figure>The first of its kind survey in Nepal interviewed 15,088 participants and was carried out before <a href="https://www.nepalitimes.com/opinion/coping-with-anxiety-in-new-lockdown/" target="_blank" rel="noopener noreferrer">the pandemic</a> from January 2019 to January 2020. The study revealed that 10% of Nepal’s adult population had mental health problems in their lifetime with 4.3% experiencing some disorders at present.Mood disorders and neurotic and stress-related disorders were among the most common <a href="https://www.nepalitimes.com/latest/tackling-nepals-mental-health-pandemic/" target="_blank" rel="noopener noreferrer">psychological problems among Nepalis</a>. The prevalence of lifetime disorders was found the highest in Province 1 (13.9%), in the age group 40-49 years (13.3%) and among males (12.4%). As for current disorders, Bagmati scored the highest (5.9%) as well as those in the age group 40-49 years (6.3%) and females (5.1%).These figures correlate with Nepal’s suicide data of the past five years. Despite fewer attempts, men accounted for 57% of total suicides, against 43% of women. Among minors, however, more girls died by suicide, which experts ascribe to possible victimisation and a higher prevalence of borderline personality disorder among younger females.Suicide deaths are also disproportionately distributed across Nepal with Province 1 recording 65 deaths per 100,000 populations. Lumbini and Gandaki follow closely with 58 and 52 per 100,000 respectively. Traditionally neglected by the state and economically disadvantaged Karnali, Far West and Province 2 regions have lower suicide rates.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc369c7e80680e0a0b77jpeg.jpg" alt="" width="2287" height="1816"><figcaption> </figcaption></figure>More people are dying of suicides in urban centres such as Kathmandu Valley and Ilam district, which reported 32 and 38 suicide deaths respectively per 100,000 populations last year against Rautahat’s 18 and Humla’s 6.This is in direct contrast with the global trends where 77% of suicides occur in low and middle-income countries. Unemployment and poor economic condition have long been associated with a high risk of suicides, but only up to a certain point, as proven by recent data. Japan, <a href="https://www.nepalitimes.com/here-now/dead-end-of-the-korean-dream/" target="_blank" rel="noopener noreferrer">South Korea</a> and Hungary with their higher per capita GDPs have some of the highest suicide rates in the world.“Poorer nations have weaker education and health systems, which translates into delayed or even lack of diagnosis but poverty is not a sole factor for suicides,” says Kamal Gautam. “Suicide is complex and there are multiple factors at play which means a linear approach to prevention would be incomplete, it needs an integrated approach.”Addressing underlying mental health disorders is the most effective way to prevent suicides. This means increased awareness and education about psychological disorders, which in turn can help <a href="https://www.nepalitimes.com/here-now/all-in-the-family/" target="_blank" rel="noopener noreferrer">reduce societal stigma</a>. An introduction to and discussion on mental health in the school curriculum can further sensitise the public.In addition to medication and counselling, societal structure and family dynamics is an important support system for individuals suffering from psychosis, trauma and depression. Telemedicine in particular has been essential in preventing self-harm during the pandemic-induced restrictions but mental health services need to be scaled up across the country.On the other hand, a strict regulation must be implemented on the <a href="https://www.nepalitimes.com/here-now/suicide-by-pesticide-in-nepal/" target="_blank" rel="noopener noreferrer">availability of pesticides</a>, an easy means of suicide for many. Access to alcoholic products must also be supervised with Nepalis known to self-medicate to cope with stress and trauma, in turn increasing the risk of self-harm and suicide.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141124/636cfc399c7e80680e0a0b78jpeg.jpg" alt="" width="1280" height="853"><figcaption> </figcaption></figure>But most of all, analysing suicide attempts can be a powerful tool for prevention. On average, there are six attempts behind every suicide. Up to 80% of people with suicidal ideation reveal their intention to either a family member, friends or their doctors within a month before their attempt.“We forget that even before the pandemic suicide rates were very high in Nepal and while the pandemic might have added to the problem, the figures alone don’t mean anything if we fail to also study suicide attempts to find a stronger link between the prevalence and the contributing factors,” says Rabi Shakya, psychiatrist and director of Patan Academy of Health Sciences.He adds: “Historically, there have been more suicides after than during the crisis due to the long-term socioeconomic impacts. So we must start preparing for the pandemic of mental health problems including suicides post-Covid. Our health care workers must be trained and fanned out across the country.”Nepalis are not new to mental health problems induced by a crisis. The 10-year-long Maoist insurgency killed 17,000 people but many more continue to suffer from <a href="https://www.nepalitimes.com/here-now/the-mental-scars-of-violence/" target="_blank" rel="noopener noreferrer">PTSD, depression, anxiety and distress</a>. A 2017 report published in the journal Lancet found as high as <a href="https://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener noreferrer">37.5% of the general public</a> had some form of psychological disorder.The <a href="https://www.nepalitimes.com/here-now/its-all-in-the-mind/" target="_blank" rel="noopener noreferrer">2015 earthquake</a> further added to Nepal’s epidemic of mental disorders. Survivors who had narrow escapes or lost family members reported increased panic attacks, anxiety and trauma.But <a href="https://archive.nepalitimes.com/article/editorial/the-republic-of-insomnia,3311" target="_blank" rel="noopener noreferrer">conflicts, disasters</a> and pandemics have shined a light on mental health with an increased national and foreign investment in prevention and management. With larger chunks of the population impacted, there is now more acceptance and the field is starting to get the priority it warrants.Says Rishav Koirala, WHO focal person for mental health post-2015 earthquake: “The best way to prevent suicides is to address underlying psychological disorders and crises, despite adding to the burden has helped normalise them because many more people can now relate and understand that they are treatable.”

Nepal sees spike in suicides during pandemic

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91ab9c7e80680e06f104jpeg.jpg" alt="" width="960" height="640"/><figcaption>Photo: BIKRAM RAI/NEPALI TIMES ARCHIVES</figcaption></figure>Prashuma Malla had never felt so helpless as a physician. Her patient, a man in his 40s, was suffocating, incapable of drawing in breath.But the hospital ventilators were all occupied, and the central supply of oxygen was very low. She pronated her patient while his wife sobbed near him.“With no oxygen, we can do nothing,” said the 28-year-old second year medical resident specialising in anaesthesia at Bir Hospital in Kathmandu. “It is scary. It is non-stop. I try to tell myself everything is OK. But what can we do? Eight people have already died on my watch.”Malla and her colleagues are on the <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEZnm1Wh-lIyg9tsnCRr9-mgD_R4Q">Covid frontlines in Nepal</a>. Her world is a haze of 36-hour intense, and often terrifying shifts, at Nepal’s oldest and best-known public hospital.As in many <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNELCBtyZv7D1U8LDXT-i7HJPRZbeQ">government hospitals in Nepal</a>, relatives follow patients in the wards, providing food and running to pharmacies to purchase medicine. <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGmvFGTkOC_M_eTcOYyHWYTMLFBJw">Bir Hospital is overwhelmed</a>. People are sleeping in hallways, stairways, curled up on patients’ beds, pacing from room to room.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91ad9c7e80680e06f105jpeg.jpg" alt="" width="1500" height="850"><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b09c7e80680e06f106jpeg.jpg" alt="" width="768" height="513"><figcaption>Crowded Covid ward at Teku Hospital. Photo: AMIT MACHAMASI</figcaption></figure>Doctors believe many relatives are sick as well, but the hospital does not have enough PPEs for them, and there is a serious shortage of oxygen.“We are exposed to the virus all the time,” Malla said of her shifts with the sickest of patients. “Everywhere you go is a Covid ward.”Malla and her colleagues have also become counsellors. But with every patient, her job gets harder because most are in their 30s and 40s, and increasingly some in their 20s are being brought in.In the chaos, it calms her to explain every detail to relatives. What does it mean to be intubated? Why once intubated it is hard to take patients off, and they usually die if they are taken out. No, they cannot take the body to be cremated: only police or soldiers can remove it from the hospital.“They are confused, they have never seen someone come off an intubator. I remind them: there is no guarantee,” Malla said.Every move Malla makes, every decision she takes, she reports to her superior. And every day at the shift handover, she has to be careful with the safety precautions.At the end of her shift that lasts more than 24 hours, Malla heads home on her scooter through light traffic because of the lockdown. She lives in a tiny two-room apartment with her two brothers, and is terrified of infecting them.She washes immediately, including her mask and face shield. Masks are always on, they cook together. Briefly unmasked, she eats alone on a miniature terrace. She talks on Viber with her parents in central Nepal.Every day, sometimes every hour, they remind each other to stay safe. She tries to focus on her online medical classes. She doesn’t want to fall behind. But always that nagging fear. Death is lurking. Near her. Floating and invisible.Although Nepal’s second wave appears to have peaked, and the official number of Covid-19 cases and mortality is down, there are <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGD_zw--sdgKNcbkUD2EUdjZg82Lw">doubts about how accurate the figures are</a>.The number of daily recoveries is now higher than new infections, and the official death toll is hovering around 100 every day, which is half what it was three weeks ago. The number of active cases fell below 100,000 for the first time in more than one month on Saturday. But there are still more than 1,500 <a href="https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHxZUs6NeKiFHYbFIJkkSZzx7D9vg">patients in ICUs</a> nationwide, with 450 of them needing ventilator support.More and more cases in city and <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNFpAtg51hSoSi41jBs4YjPKQ9MsVA">district hospitals</a> now are from the hinterland, and there are indications that the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGRytlb8jAYJB_hKJQNVCuwiFBmEQ">virus has spread to the remotest communities </a>in the mountains where there is no hospital care. And no <a href="https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNF2Eis06JvGsCzy_McEPymUP-h5sw">supplemental oxygen</a>.<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEsKzdZRZejQF0SGnV4lSHoAk0EHQ">In rural Nepal</a>, there is now hope from ground-breaking tele-health that is transforming medical care.Hari Neupane is fighting Covid-19 with his cell phone. He is simultaneously a doctor, nurse and mental health expert, and works with <a href="https://www.healthfoundationnepal.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.healthfoundationnepal.org&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGdGiTiG90TCoPVsSwtrWug2LqVYA">Health Foundation Nepal</a>, a Kathmandu-based volunteer-staffed telemedicine service that reaches out to patients across 35 districts in Nepal via its Kathmandu hotline.Neupane leads a team of seven doctors in Dang Valley in mid-western Nepal. Because of the large numbers of workers returning from India and its rudimentary medical facilities, Dang bore the brunt of the pandemic in both the first and second waves.As the monsoon approaches, it is soon rice planting season but a national lockdown has left fields, streets and roads empty, void of the everyday crowds and cacophony of passing trucks.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b39c7e80680e06f107jpeg.jpg" alt="" width="1500" height="1000"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b69c7e80680e06f108jpeg.jpg" alt="" width="1500" height="1000">In Dang in western Nepal, the highways are empty because of the lockdown, while farmers are busy preparing for rice-planting. Photos: HARI NEUPANE<a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGKSSvGC8yUXhCQ9FP5G-0uZmJjng">Telemedicine is new in Nepal</a>, and medical teams in the field in Nepal are supervised by Ashok Devkota, a doctor of internal medicine in Providence, Rhode Island, in the United States The organisation’s seven full-time workers and 50 part-time physicians are all volunteers.Most of Neupane’s patients across Nepal have Covid symptoms, but most have not been tested. Working closely with local health posts, Neupane’s team identifies symptoms, using cell phones – voice, photos and videos – as medical communicators.They connect patients via cell phone with pharmacies and if necessary source portable oxygen. The very sick are referred to the hospital.“We focus on people in home isolation and counsel them on the medicines they need and how to get them. We prescribe steroids and do follow-ups and notify local government officials,” Neupane explained.In Dang, cell phones have become transformative lifelines at many levels. They are a critical means of money transfers from relatives working abroad, so that families can pay school fees, medical bills and food.This year’s lockdown has made day-long walks to access medical care virtually impossible. Even if patients can get to a hospital, chances of a bed are slim. In Dang, there are only 155 intensive care beds and 15 ventilators, most of them occupied.Health Foundation Nepal advertises its telemedicine counselling through social media and newspapers. It cannot take blood tests, but with the help of local health workers can monitor oxygen saturation, blood pressure and temperature and can gauge the condition of the patients to recommend a solution.“Telemedicine existed in Nepal before but before Covid people did not accept it much, but now it is helping save lives,” said Ashok Devkota, the Nepali doctor in the US who supervises medical staff like Neupane half-way around the world Nepal. And as long as Neupane’s cell phone stays charged, he is on duty.The pandemic and political crisis in Nepal have increased the risk of Nepal becoming an imploding catastrophe. The country was just beginning to recover from the 2015 earthquake, and was struggling with pre-existing health challenges, and earlier this year was beginning to think the worst was over when the second Covid-19 wave struck.The health and economic crises <a href="https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHA2oJKTj8wDzac2WJdbkvphDJODQ">threaten the gains Nepal has made</a> in the past years in fighting malnutrition, immunisation against other infectious diseases, child labour, early marriage and women’s rights.But if Nepal is a petri dish of disasters, it is also one of innovation and individual dedication. This pandemic once again is a place where despair is often met by individual and community fortitude by medical workers like Prashuma Malla and Hari Neupane.Donatella Lorch is a former New York Times foreign correspondent who lived three years in Nepal. She blogs at: <a href="https://tangledjourneys.com/about/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://tangledjourneys.com/about/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEHm4HaaRyE_KrqKL6VlN7zbgNjlQ">tangledjourneys</a>

Nepal’s doctors are like soldiers fighting a war

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2839c7e80680e09d913jpeg.jpg" alt="" width="960" height="640"/><figcaption>Photo: BIKRAM RAI/NEPALI TIMES ARCHIVES</figcaption></figure>Prashuma Malla had never felt so helpless as a physician. Her patient, a man in his 40s, was suffocating, incapable of drawing in breath.But the hospital ventilators were all occupied, and the central supply of oxygen was very low. She pronated her patient while his wife sobbed near him.“With no oxygen, we can do nothing,” said the 28-year-old second year medical resident specialising in anaesthesia at Bir Hospital in Kathmandu. “It is scary. It is non-stop. I try to tell myself everything is OK. But what can we do? Eight people have already died on my watch.”Malla and her colleagues are on the <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEZnm1Wh-lIyg9tsnCRr9-mgD_R4Q">Covid frontlines in Nepal</a>. Her world is a haze of 36-hour intense, and often terrifying shifts, at Nepal’s oldest and best-known public hospital.As in many <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNELCBtyZv7D1U8LDXT-i7HJPRZbeQ">government hospitals in Nepal</a>, relatives follow patients in the wards, providing food and running to pharmacies to purchase medicine. <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGmvFGTkOC_M_eTcOYyHWYTMLFBJw">Bir Hospital is overwhelmed</a>. People are sleeping in hallways, stairways, curled up on patients’ beds, pacing from room to room.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2869c7e80680e09d914jpeg.jpg" alt="" width="1500" height="850"><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2899c7e80680e09d915jpeg.jpg" alt="" width="768" height="513"><figcaption> </figcaption></figure>Doctors believe many relatives are sick as well, but the hospital does not have enough PPEs for them, and there is a serious shortage of oxygen.“We are exposed to the virus all the time,” Malla said of her shifts with the sickest of patients. “Everywhere you go is a Covid ward.”Malla and her colleagues have also become counsellors. But with every patient, her job gets harder because most are in their 30s and 40s, and increasingly some in their 20s are being brought in.In the chaos, it calms her to explain every detail to relatives. What does it mean to be intubated? Why once intubated it is hard to take patients off, and they usually die if they are taken out. No, they cannot take the body to be cremated: only police or soldiers can remove it from the hospital.“They are confused, they have never seen someone come off an intubator. I remind them: there is no guarantee,” Malla said.Every move Malla makes, every decision she takes, she reports to her superior. And every day at the shift handover, she has to be careful with the safety precautions.At the end of her shift that lasts more than 24 hours, Malla heads home on her scooter through light traffic because of the lockdown. She lives in a tiny two-room apartment with her two brothers, and is terrified of infecting them.She washes immediately, including her mask and face shield. Masks are always on, they cook together. Briefly unmasked, she eats alone on a miniature terrace. She talks on Viber with her parents in central Nepal.Every day, sometimes every hour, they remind each other to stay safe. She tries to focus on her online medical classes. She doesn’t want to fall behind. But always that nagging fear. Death is lurking. Near her. Floating and invisible.Although Nepal’s second wave appears to have peaked, and the official number of Covid-19 cases and mortality is down, there are <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGD_zw--sdgKNcbkUD2EUdjZg82Lw">doubts about how accurate the figures are</a>.The number of daily recoveries is now higher than new infections, and the official death toll is hovering around 100 every day, which is half what it was three weeks ago. The number of active cases fell below 100,000 for the first time in more than one month on Saturday. But there are still more than 1,500 <a href="https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHxZUs6NeKiFHYbFIJkkSZzx7D9vg">patients in ICUs</a> nationwide, with 450 of them needing ventilator support.More and more cases in city and <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNFpAtg51hSoSi41jBs4YjPKQ9MsVA">district hospitals</a> now are from the hinterland, and there are indications that the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGRytlb8jAYJB_hKJQNVCuwiFBmEQ">virus has spread to the remotest communities </a>in the mountains where there is no hospital care. And no <a href="https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNF2Eis06JvGsCzy_McEPymUP-h5sw">supplemental oxygen</a>.<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEsKzdZRZejQF0SGnV4lSHoAk0EHQ">In rural Nepal</a>, there is now hope from ground-breaking tele-health that is transforming medical care.Hari Neupane is fighting Covid-19 with his cell phone. He is simultaneously a doctor, nurse and mental health expert, and works with <a href="https://www.healthfoundationnepal.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.healthfoundationnepal.org&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGdGiTiG90TCoPVsSwtrWug2LqVYA">Health Foundation Nepal</a>, a Kathmandu-based volunteer-staffed telemedicine service that reaches out to patients across 35 districts in Nepal via its Kathmandu hotline.Neupane leads a team of seven doctors in Dang Valley in mid-western Nepal. Because of the large numbers of workers returning from India and its rudimentary medical facilities, Dang bore the brunt of the pandemic in both the first and second waves.As the monsoon approaches, it is soon rice planting season but a national lockdown has left fields, streets and roads empty, void of the everyday crowds and cacophony of passing trucks.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf28c9c7e80680e09d916jpeg.jpg" alt="" width="1500" height="1000"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf28f9c7e80680e09d917jpeg.jpg" alt="" width="1500" height="1000">In Dang in western Nepal, the highways are empty because of the lockdown, while farmers are busy preparing for rice-planting. Photos: HARI NEUPANE<a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGKSSvGC8yUXhCQ9FP5G-0uZmJjng">Telemedicine is new in Nepal</a>, and medical teams in the field in Nepal are supervised by Ashok Devkota, a doctor of internal medicine in Providence, Rhode Island, in the United States The organisation’s seven full-time workers and 50 part-time physicians are all volunteers.Most of Neupane’s patients across Nepal have Covid symptoms, but most have not been tested. Working closely with local health posts, Neupane’s team identifies symptoms, using cell phones – voice, photos and videos – as medical communicators.They connect patients via cell phone with pharmacies and if necessary source portable oxygen. The very sick are referred to the hospital.“We focus on people in home isolation and counsel them on the medicines they need and how to get them. We prescribe steroids and do follow-ups and notify local government officials,” Neupane explained.In Dang, cell phones have become transformative lifelines at many levels. They are a critical means of money transfers from relatives working abroad, so that families can pay school fees, medical bills and food.This year’s lockdown has made day-long walks to access medical care virtually impossible. Even if patients can get to a hospital, chances of a bed are slim. In Dang, there are only 155 intensive care beds and 15 ventilators, most of them occupied.Health Foundation Nepal advertises its telemedicine counselling through social media and newspapers. It cannot take blood tests, but with the help of local health workers can monitor oxygen saturation, blood pressure and temperature and can gauge the condition of the patients to recommend a solution.“Telemedicine existed in Nepal before but before Covid people did not accept it much, but now it is helping save lives,” said Ashok Devkota, the Nepali doctor in the US who supervises medical staff like Neupane half-way around the world Nepal. And as long as Neupane’s cell phone stays charged, he is on duty.The pandemic and political crisis in Nepal have increased the risk of Nepal becoming an imploding catastrophe. The country was just beginning to recover from the 2015 earthquake, and was struggling with pre-existing health challenges, and earlier this year was beginning to think the worst was over when the second Covid-19 wave struck.The health and economic crises <a href="https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHA2oJKTj8wDzac2WJdbkvphDJODQ">threaten the gains Nepal has made</a> in the past years in fighting malnutrition, immunisation against other infectious diseases, child labour, early marriage and women’s rights.But if Nepal is a petri dish of disasters, it is also one of innovation and individual dedication. This pandemic once again is a place where despair is often met by individual and community fortitude by medical workers like Prashuma Malla and Hari Neupane.Donatella Lorch is a former New York Times foreign correspondent who lived three years in Nepal. She blogs at: <a href="https://tangledjourneys.com/about/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://tangledjourneys.com/about/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEHm4HaaRyE_KrqKL6VlN7zbgNjlQ">tangledjourneys</a>

It was 30 years ago this month that investment into ‘Baby Arun’, the 201MW first phase of the run-of-river Arun III project, was brought to a screeching halt when the World Bank officially withdrew its support. This brought about profound and fundamental changes in the way Nepal’s power sector subsequently developed. Nepalis suffered debilitating power outages between 2008-2016 due to shortages attributable to the cancellation. At the same time, the gap left by Baby Arun was filled by private sector investment in ways that were not obvious in 1995. It took 30 years, but in many ways Nepal’s power sector is more healthy today than it has ever been, and likely better than if the project was built as planned. At a projected budget of $1.08 billion, Baby Arun would have cost the equivalent of Nepal’s entire annual government expenditure in 1995. It was to be funded by concessional grants and loans from multilateral and bilateral funders, including the World Bank, Asian Development Bank (ADB), KfW, and investment by the government itself. At the time, Nepal’s total electricity generation capacity was only 230MW, and the trajectory of the power sector changed dramatically following the cancellation. In the past 30 years, $5.4 billion has been invested in the power sector led by private investors, and much of it from domestic banks and pension funds (table, right).  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829150840_c13d6f9f34d7163832b3089eabdad6f20d2d5cef3a53039e0432add2be6c32f0.jpg" data-media-id="editor_0" data-image-id="20250829150840_c13d6f9f34d7163832b3089eabdad6f20d2d5cef3a53039e0432add2be6c32f0" data-rendition-name="original" width="984" height="521" loading="lazy" alt="30 years after Baby Arun"> </figure>  Nearly 70% of the new megawatts generated were by private independent power producers (IPP) in the past 30 years, while the Nepal Electricity Authority (NEA) and its subsidiary companies added 30% of new capacity. Almost 80% of total debt financing came from domestic banks and employee retirement funds. International assistance for power generation dropped dramatically over this time, accounting for only about 15% of investment. Before 1995 new power projects used to be entirely dependent on foreign aid. Since 1995, 63% of new generation came from 171 small hydropower projects with an average capacity of 12MW, while 4% was from 21 solar photovoltaic and biomass projects developed by local IPPs.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829150844_5bc299fc78be90b95ce4727b0b3bdaa4542e17e126718cc8725d136630ffc097.jpg" data-media-id="editor_1" data-image-id="20250829150844_5bc299fc78be90b95ce4727b0b3bdaa4542e17e126718cc8725d136630ffc097" data-rendition-name="original" width="988" height="503" loading="lazy" alt="30 years after Baby Arun"> </figure>  Over three decades, investment in Nepal’s power supply came primarily from new actors that had never before been involved in this sector. The rate of electrification rose from 10% to close to 100% -- sufficient to meet domestic needs during most of the year, and in 2024 made Nepal a net exporter of power to India for the first time in its history. As practically all the new investment in this period went into run-of-river hydro and solar projects, rather than into hydropower reservoirs with seasonal storage, Nepal continues to rely on imports from India during the dry winter months. Surplus electricity generation for export during the monsoon is slated to grow rapidly as another 200 solar and hydro projects are nearing completion of construction, with over 5,000MW of power capacity. Private Power The cancellation of Baby Arun inadvertently accelerated the entry of the private sector into Nepal’s power generation. The government enacted the Electricity Act in 1992 to attract private IPPs and diversify away from total dependence from international aid, but had been struggling for several years to conclude the first agreement with the 60MW Khimti Project. There remained a large gap between the tariff that the government thought was reasonable versus what was demanded by the Norwegian investor Statkraft, and the private sector arms of the World Bank and ADB that were financing the project. The shock of World Bank withdrawal from Baby Arun put tremendous pressure on the government, then led by the UML as it is now. The Bank’s decision to terminate its involvement was ostensibly, at least partially, taken in response to a letter critiquing the project sent by the UML while it was in the opposition.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829150848_7fb3641d776fe86a09ad60a758f7e16660a409fdb15e541644f13646b0894347.jpg" data-media-id="editor_2" data-image-id="20250829150848_7fb3641d776fe86a09ad60a758f7e16660a409fdb15e541644f13646b0894347" data-rendition-name="original" width="949" height="446" loading="lazy" alt="30 years after Baby Arun"> <figcaption>BAD NEWS: Newspaper clippings from the early 90s on tender announcement ahead of loan approval (left) and secrecy surrounding environmental assessment (centre) of Arun III before its eventual cancellation in August 1995.</figcaption> </figure>  The government was forced to soften its position and agree to the investors’ terms following the cancellation of Baby Arun. It directed NEA to sign a power purchase agreement (PPA) with Khimti. It was concluded in January 1996, and this was followed by a second PPA in July 1996 with Panda Energy, the American developer of the 45MW Upper Bhotekosi project. The expensive USD-denominated agreements to buy power from two international private producers, with price escalation clauses tied to the New York Consumer Price Index, sent alarm bells ringing. There was worry that the country was heading towards unaffordable tariff rates for the consumer and potential bankruptcy for NEA as a result of inevitable future weakening of the Nepali Rupee. The government had strong-armed NEA into signing these agreements, and realised that concessionary financing terms that Nepal was used to receiving for public sector projects such as Baby Arun and Kali Gandaki A, that included below-market interest rates and 40 years repayment period with a 10 year grace period before starting repayment, were not the norm for private sector investors. Nepal’s status as a less than attractive destination for foreign investment meant that the country had few options but to accept expensive dollar PPAs from international developers with the high commercial interest rates and short repayment periods imposed by their banks because of high investment risks. In the end, the government ended up having to additionally provide a sovereign guarantee in order to close the deal at the insistence of the lenders – committing it to repayment in case NEA defaulted on paying the IPPs. It is reasonable to assume that the extraordinarily high political cost of agreeing to the PPA terms would have meant that no government would have willingly agreed to them in 1995 had it not suffered the trauma of the loss of concessionary-financed public sector projects as large as the Baby Arun. It has taken NEA 25 years to consider offering dollar-denominated PPAs again: to cover the foreign exchange portion of the investment in the 216MW Upper Trisuli-1 and 120MW Rasuwa-Bhotekosi Hydropower projects. It seemed unlikely at the time, but it turned out that the dire situation Nepal found itself in 1995 planted the seed to mobilise investment for affordable power from within the country. Double Whammy After the dual shock of first losing investment in Baby Arun and having to sign expensive power purchase agreements with international IPPs, the first proposal for an alternative strategy to mitigate the risk of foreign currency investment into hydropower projects came from a group of engineers within the Arun III team at NEA. Led by <a href="https://archive.nepalitimes.com/news.php?id=4900">Deputy Director Damber Bahadur Nepali,</a> engineers convinced the leadership that NEA needed to invest in a subsidiary company to build a series of locally-designed and domestically-financed projects that would have lower cost with rupee-denominated PPAs. They registered the Chilime Hydropower Company Limited (CHCL) in October 1995 with 51% shares from NEA, 25% from its employees, and 24% available for the general public, 10% of which was prioritised for local residents at the project site. The 22.1MW project is in Rasuwa on a tributary of the Trisuli, and mobilised debt financing from the Employee Provident Fund, which manages retirement savings for employees of the government, public enterprises, and private sector institutions. CHCL’s experience showed that NEA employees themselves believed that individual hydropower projects with operational independence from NEA could be developed profitably in Nepal by its own engineers -- and they were willing to put their own money on the line. Chilime also demonstrated that there was money in the country, particularly with retirement funds, looking for opportunities for long-term investments. Following completion of Chilime in 2003, CHCL led the formation of three other NEA subsidiary companies that completed construction in 2023 and 2024, producing 168.3MW using fully rupee-tied investment. NEA’s largest subsidiary, the Upper Tamakosi Hydropower Limited, completed construction of its 456MW plant in 2021.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829160812_ce9ab8b49c598970db3f5bf0a079061ef52f153b28d9f4ead2bb1b26bfd7c2f3.jpg" data-media-id="editor_4" data-image-id="20250829160812_ce9ab8b49c598970db3f5bf0a079061ef52f153b28d9f4ead2bb1b26bfd7c2f3" data-rendition-name="original" width="3000" height="1571" loading="lazy" alt="30 Years after Baby Arun"> <figcaption>DAMNED: The $700 million 456MW Upper Tamakosi built entirely with domestic funds before it was destroyed by the September floods last year. </figcaption> </figure>  There were some delays and cost overruns on this run-of-river project, the largest in the country with a final cost of over $700 million -- all of it sourced domestically. The five subsidiary companies launched by NEA have produced almost two times as much new power as NEA has over the past 30 years. Seven other NEA subsidiaries are currently constructing projects to add another 474MW to the national grid. But even more important than NEA subsidiaries have been local IPPs: Nepali companies which have over the past three decades enthusiastically entered the hydropower sector. From a regulatory perspective, the credit for mobilising domestic private investment to engage in power generation goes to Minister of Water Resources Shailaja Acharya, who in 1998 offered a flat feed-in-tariff of Rs4/kWh for hydropower projects under 10MW. This upfront offer removed a major barrier that early developers had faced of having to spend money to carry out a detailed feasibility study before they could even start tariff negotiations with NEA. She had laid the foundation stone of the Chilime project, and proved to be the champion of opening up the sector for domestic IPPs. The guarantee of a PPA with a fixed tariff, irrespective of project specifications, gave small power developers the confidence to apply for survey licenses and invest in feasibility studies so they could directly approach commercial banks and make a case for their project producing required revenue to repay loans. Domestic IPPs started adding power to the national grid in 2002. Their contribution was initially modest, and first projects were small and commercial lenders who took time to be confident about providing debt financing to a sector which had previously not been considered suitable for private sector investment. While the first 10 years were slow, with less than 10MW being added to the grid each year, this increased twenty fold over the following ten years, resulting in the equivalent of a Baby Arun being added by Nepali IPPs to the grid each year. A total of 84 IPPs added 232MW, 328 MW, 454MW, and 400MW of new generation to the grid in 2021-2024 (graph). There was explosive, exponential growth as domestic developers have surged ahead to account for 76% of the new megawatts added to the grid since 2020, compared to 24% by NEA and its subsidiary companies. The megawatts that IPPs are adding have followed the classic ‘hockey stick curve’ with the ‘breakout point’, signaling the rapid growth phase in 2020. Private producers are expected to accelerate new generation in the coming years with 300 solar and hydropower projects adding 11,000MW. Another 166 hydropower and 96 solar projects are currently in the survey stage, and are in line to add another 11,000MW to the construction pipeline. One major challenge is finding financing required for the projects. Domestic investment will no longer be sufficient to finance this ambitious pipeline of renewable energy projects. Project developers as well as NEA and the Electricity Regulatory Commission will have to leverage their substantial experience accumulated through the construction of over 200 projects to attract regional and international investment and hedge the risks of dollar-denominated PPAs. Following the cancellation of Baby Arun, <a href="https://nepalitimes.com/opinion/people-power/decentralising-power-in-nepal">Nepal developed a highly distributed power sector</a>. The national electricity grid is currently supplied with power from a remarkably decentralised array of hundreds of hydropower and solar photovoltaic projects spread across 43 districts and all seven provinces.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829150848_0c3aa66b34bfb08380a624f397bf3ebb4126f4d6b41a26115848b496876f501b.jpg" data-media-id="editor_6" data-image-id="20250829150848_0c3aa66b34bfb08380a624f397bf3ebb4126f4d6b41a26115848b496876f501b" data-rendition-name="original" width="1228" height="867" loading="lazy" alt="30 years after Baby Arun"> </figure>  This presents a sharp contrast to the pathway of a few large public sector hydropower projects with a sprinkling of private sector projects that was envisioned as part of NEA’s investment planning when Baby Arun was being considered the front runner for investment. The strategy then was to allow public sector investment in a few large hydropower projects with thermal plants to fill the gap. Knowing what we know now about acceleration of climate change impacts and increased extreme weather events, following this path would have made Nepal’s power sector highly vulnerable. Decentralised generation greatly improves the resilience of Nepal’s power supply as damage to power plants in one part of the country need not affect other areas that have their own generation. Following the investment plan where over two thirds of the country’s power supply would have come from power plants on the Arun River, would have greatly imperiled Nepal’s energy security. All rivers in Nepal are susceptible to flooding from cloudbursts made more frequent by climate change. The Arun River which is fed by glaciers in Tibet is also at risk to glacial lake outburst floods. Bikash Pandey is Director of Clean Energy and Circular Economy at Winrock International. People Power is his regular column in Nepali Times on global energy issues relevant to Nepal. <h2>Decentralised and Diversified</h2> In the 30 years since the cancellation of ‘Baby Arun’: Hydropower projects constructed cover capacities ranging from less than 1MW to 456MW and developed by IPPs from across the country with strong local involvement in purchasing equity shares. Renewable energy sources contributed to the generation mix through solar IPPs that further contribute to climate resilience, and cover shortfalls during low rainfall. The government is committed to solar contributing 10% of the power on the grid. Increasing solar beyond this target and providing incentives to project developers to invest in utility-scale battery storage would further improve resilience. BIG ARUN: The 900MW Arun III project under construction since 2018 at Num in Sankhuwasabha (pictured, below) is a separate initiative by a different project developer using a different financing modality. The ‘Baby Arun’ version of Arun III was cancelled in 1995.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250829150852_df534df5166eb5a9bb4cbe101627bdec7ac1df2a405a9d3988d1c86fcc8ecdeb.jpg" data-media-id="editor_7" data-image-id="20250829150852_df534df5166eb5a9bb4cbe101627bdec7ac1df2a405a9d3988d1c86fcc8ecdeb" data-rendition-name="original" width="1750" height="1312" loading="lazy" alt="30 Years after Baby Arun"> </figure>

30 years after Baby Arun

This is the 72nd episode of Diaspora Diaries, a Nepali Times series in collaboration with Migration Lab providing a platform to share experiences of living, working and studying abroad. My father ran a store and that is where I spent all my time till Grade 6. Doing my homework. Serving customers. I then moved to my maternal grandparents’ house because I used to get along with my cousin who was a year older than me. We did everything together, and were best friends. We took turns studying: I was a night owl, and he was an early riser. Before I went to bed after studying all night, I woke him up. My mother was 44 when I was born, the same year my eldest brother got married. My sister-in-law becoming a part of our family was how my mother referenced my age. I liked making money, and was always a hustler. In Grade 7, I learnt to handle a tractor and helped my brother-in-law to plough, earning Rs10 a day. As I got better, he paid me more. By Grade 9, I was already making Rs500 per day, but had to slow down to prepare for my exams. From an early age I knew I did not want a 9-5 job. There just wasn’t enough money in it. I wanted to get into business, and compared my brother who worked in the post office and what businessmen made. It did not help that my brother was honest, and never took bribes. A friend and I made money selling cheap Chinese phones at a premium to our friends. We blasted music on the phones and pretended that we were giving them a discount. After SLC, I started teaching math and other subjects. I was soon a shareholder in the same school and in the evening I was involved in our family’s floriculture business, growing amaranth and marigold for garlands.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250831020844_1b54b999d67122a50c4c7e6204cc737bcc99bf2a68db6499a4566a7f61a880b4.jpg" data-media-id="editor_0" data-image-id="20250831020844_1b54b999d67122a50c4c7e6204cc737bcc99bf2a68db6499a4566a7f61a880b4" data-rendition-name="original" width="955" height="1314" loading="lazy" alt="Diaspora Diaries 72"> </figure>  It was then that a friend suggested we learn the Korean language. We could be earning significantly higher in Korea for similar efforts. I had no plans to go abroad but he convinced me. I did not know anything about Korea, and was scolded at the language institute when I asked someone to point Korea on the map.&nbsp; It was only there that I learnt you had to pass an exam for the Korean Employment Permit System (EPS), and pay for language classes. After a week, I decided it was not for me and dropped out. But my friend convinced me to give it one more try. I did not prepare much for the exam, and it was no surprise that I failed. But it was just by one mark, and people would pity me for failing “just by one mark”. It was a brand of failure. It hurt my ego. I had to turn things around by taking the exams seriously, and locked myself up to study hard.&nbsp; Even when we had visitors, my wife told them I was not home. If I was not in my room learning Korean, I would be with a group of ten of us test-takers comparing notes and practicing late into the night. The exam was difficult, but this time I passed, the only one in my group who did.&nbsp; As someone who never liked the idea of doing a job, I still had my doubts about going to Korea. It did not help that one of my acquaintances had returned a month after he had left, and he discouraged me from migrating given that I was already making good money in Nepal.&nbsp; But my wife suggested that I give it a shot since I had worked so hard for it. And if it really turned out not to be my cup of tea, I could always return. What did I have to lose, I thought, at least I would get to visit Korea. My job there was in an electrical company that made circuit boards. I worked all day, earned good money. In the evenings, I kept myself busy with my real estate business back in Nepal. I had learnt the tricks of the trade from fellow real estate agents back home, but at the time did not have the capital to invest.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250831020848_941e961e2045058f255ad89884b51faa7d2365c68236e5cbe573d63d769ac6c5.jpg" data-media-id="editor_1" data-image-id="20250831020848_941e961e2045058f255ad89884b51faa7d2365c68236e5cbe573d63d769ac6c5" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Diaspora Diaries 72"> </figure>  In Korea, it helped that I had salary records that allowed me to get loans from financial institutions both in Korea and in Nepal. Ultimately, I started earning more from my real estate deals in Nepal than from my job in Korea. This was all thanks to my ability to take loans because of the EPS scheme. My wife has been managing the flower business while I was away. My finances grew stronger over the eight years I was in Korea. I paid off the loans that I had borrowed to buy land. But real estate did not satisfy me entirely. I wondered: what is my brand? What will I be known for? What is my contribution to society? Real estate is for wealth, but that is about it. I needed to sell one piece of land and use the revenue to start a venture. I took classes in business, and returned to Nepal six months ago and got back to my family’s ancestral roots in floriculture. In Nepal too, I am continuing the entrepreneurship training I had started in Korea with the Bridge International. Such exposure helps us reflect on our business such as our branding, vision, and proactive aspects like the importance of strong recordkeeping.&nbsp; I am now working to upgrade and expand my floriculture business. With a friend who is still in Korea I am building a cooling room to increase the shelf-life of flowers and other produce and set up a market in my village where others can sell their produce. Floriculture is our primary business, but it is seasonal and earns good money only during festivals like Tihar.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250831020848_a008ffeba13896e6918f68ff6e687c8fe11140d86a96f1ec11690547f2bcd415.jpg" data-media-id="editor_2" data-image-id="20250831020848_a008ffeba13896e6918f68ff6e687c8fe11140d86a96f1ec11690547f2bcd415" data-rendition-name="original" width="1280" height="720" loading="lazy" alt="Diaspora Diaries 72"> </figure>  So, I grow tomatoes to ensure year-round earnings. I also am engaged in other businesses like real estate and online shopping. I work round the clock in Nepal — a strong work ethic is something I picked up in Korea.&nbsp; My Korean bosses would work alongside us, that motivated us. I work just as hard in Nepal as I did in Korea. People here often ask me why I am pushing myself so hard. But making garlands comes easy to me, it is work my forebears were involved in. My childhood memories are about plucking flowers with my sister. I have a comparative advantage in this work. It comes naturally to me, it is easy and I enjoy it. And sometimes, if there are too many garlands to make, I can multitask while holding meetings. My fingers just fly. I am good at this job, but my wife is even better and faster.&nbsp; When there is too much load, we can also outsource the work. To be known as the flower guy would be great personal branding. The मखमली guy. Or the सयपत्री guy. I decided to come home for just this with a one-way ticket. “अब पासा: जाँदैन ल्हासा!” &nbsp;

The flower guy

It cannot be a coincidence that after pushing bills to constrict freedom of expression and allow greater <a href="https://nepalitimes.com/news/security-or-espionage">surveillance of citizens</a>, Nepal’s government is now tightening controls on civil society.
In a <a href="https://nepalitimes.com/opinion/guest-editorial/command-and-control">series of recent moves</a> journalists have been sued for contempt of court, imprisoned for YouTube videos, or ordered by courts to desist from investigating corrupt officials.
An amendment to the Print and Publications Act that would hand the power to shut online media to the Chief District Officer (CDO). Another draft Bill would allow a political appointee to head a new Media Council with the power to revoke a journalist’s license. The draft counter-intelligence Bill would let random officials to arbitrarily tap phones, read emails and trail citizens.
Now comes yet another draft Bill that would replace the <a href="https://archive.nepalitimes.com/news.php?id=10675">Social Welfare Council (SWC)</a> with direct government control over registration, regulation, and management of non-governmental organisations, nonprofits and charities. There are more than 54,000 NGOs, 200 international NGOs registered with the SWC.
The draft makes civil society organisations needlessly jump through hoops to carry out work that complements the government in the social sector. Critics say the Bill was drafted without any consultation with <a href="https://nepalitimes.com/opinion/comment/nepal-s-rights-groups-must-step-up-4r4z6ck4">civic groups</a>.
“This Bill’s content is questionable whether it intends to allow for civil society organisations in Nepal a free space to operate,” concludes Dr SP Kalaunee, Country Representative of BlinkNow Foundation and Chair of the Association of International NGOs in Nepal (AIN). “The draft seems oriented towards controling rather than facilitating the work of civil society organisations.”
The Bill will be open for feedback from the public, and integrates the National Directives Act (1961), Association Registration Act (1977), and the Social Welfare Act (1992) and proposes dissolving the SWC and replacing it with a new Social Welfare Department under the Ministry of Women, Children and Senior Citizens.
Non-government groups will now be required to get approval from the Registrar Office, the CDO or the provincial government depending on their area of operation. Those working across provinces will have to get permission from the federal government. &nbsp;
The government says the Bill is intended to vet organisations to see if they are engaged in espionage, violate national security, assist a foreign state, commit treason, cause strife between federal units, or incite communal violence.&nbsp;
CSOs working in Nepal have long called for legislation to better facilitate their work, minimise administrative and bureaucratic red tape which have posed operational challenges. But they are opposed to such drastic control.&nbsp;
Read also: <a href="https://nepalitimes.com/banner/the-crow-and-the-scarecrow">The crow and the scarecrow</a>, Om Astha Rai
The NGO Federation of Nepal also issued a statement this week calling the Bill ‘retrograde and cumbersome’. It added: ‘Most of its provisions are intended to further constrain and control civil society organisations rather than facilitate and strengthen them, and reduce the role of citizen participation … it is an attack on our civil liberties, inclusivity, and transparency, and curtails our <a href="https://archive.nepalitimes.com/news.php?id=5156">democratic values and constitutional rights</a>.’ &nbsp;
<a href="about:blank">Nepal’s graduation</a> from least-developed country status next year may mean less aid for Nepal, and higher interest rates on loans from multilateral creditors. The <a href="https://nepalitimes.com/news/how-usaid-cut-affects-nepal">closure of USAID </a>and reduction in bilateral grants means the work of INGOs will be even more vital – especially to meet its <a href="https://nepalitimes.com/here-now/target-2030-for-maternal-and-newborn-health">SDG targets by 2030</a>.&nbsp;
“We are competing with other countries at a time when the global aid environment is shrinking, so the support we receive is directly dependent on a conducive environment for INGOs to operate and function,” says Kalaunee. “INGOs follow regulations of the nations they operate in, they will not protest or wait around for governments to change their minds or policies.”
Social safety net
Since 1977, the work of non-governmental actors in Nepal has been regulated by the Social Service National Coordination Council (SSNCC) chaired by Queen Aishwarya.
After the <a href="https://nepalitimes.com/banner/one-moment-30-years-ago-today">1990 People’s Movement</a>, King Birendra set up the Social Welfare Council (SWC) as an autonomous body in 1992 through the Social Welfare Act. But since then the SWC has been dogged by controversy and allegations of corruption and extortion.
In 2018, the Commission for the Investigation of Abuse of Authority (CIAA) filed a Rs315 million corruption case against 14 individuals, including the Minister of Women, Children and Social Welfare and SWC chair Badri Prasad Neupane and other officials for violating public procurement laws to rent out three hectares of its property around Bhrikuti Mandap.
Civil society groups have for years called for reforms in the SWC, and a report was drawn up to restructure it before this Bill proposed its dissolution. INGOs in particular will now have to go through the Social Welfare Department and multiple ministries for permissions.
A particularly objectionable provision in the draft stipulates that NGOs must have a Board of Director made up almost entirely of secretaries of various ministries. The NGO Federation has urged the government to take a civil society-friendly approach and not tangle its work in red tape and control. It says the government has no option but to revise the bill in its current form.
“Civil society organisations need an open space to operate, and an autonomous body to oversee them,” says Kalaunee. “Non-government organisations support in the areas prioritised by the government but by definition they cannot be a part of government.”

Big, beautiful Bills

Nepal’s leaders often make grandiose promises that they will turn the country into Switzerland within a decade. We will be lucky if Nepal could even attain the per capita GDP of Swaziland.
Becoming another Switzerland or Singapore is the boastful fantasy of <a href="https://nepalitimes.com/editorial/politics-as-usual">incompetent serial politicians</a> who keep getting themselves elected again and again.&nbsp;
So, what has to change?&nbsp;
It has to be <a href="https://nepalitimes.com/here-now/looking-ahead-to-nepal-s-2027-elections">through elections</a>, but there is spreading distrust of the democratic system bordering on nihilism among Nepalis. The three main parties must have sensed by now that they are doomed if they do not get their act together and inject new untainted blood into tickets in 2027.&nbsp;
One election will not clean up the muck that has accumulated over the past 35 years, but we have to start with the next one. Politics cannot be business as usual any more, voters are fed up with what is on offer.&nbsp;
Over <a href="https://nepalitimes.com/news/push-factors-driving-nepalis-out">one-third of young Nepalis are not even in Nepal</a>, and they are not allowed to cast their ballots. But we saw in 2022 that the diaspora can have an impact on how their folks vote back home, and this trend is bound to increase in 2027. It would finally break the vote banks on which the established parties have relied on to perpetuate misrule.
Nepal needs solutions urgently to address snowballing crises on multiple fronts: social inequity, joblessness and low purchasing power, failing agriculture, breakdown of services, a pandemic of corruption feeding mal-development, low capital formation, environmental woes, and to top it all off — a runaway climate emergency.&nbsp;
Yet, there are bright spots, many of which happened despite political instability: falling poverty rate, improved health and education status, increase in forest cover, conservation successes, growth in hydropower.&nbsp;
Just imagine how much further ahead Nepal would be if it was not plagued with chronic mismanagement, <a href="https://nepalitimes.com/opinion/higher-corruption-in-high-places">corruption and conflict</a>.
It is because of these modest gains that <a href="https://nepalitimes.com/news/not-poor-but-not-rich">Nepal will graduate</a> from a ‘least-developed’ to a ‘developing country’ in November 2026, and transition to middle-income status by 2030 — even though it still has an annual per capita income below the $1,306 threshold.
The driving force for this growth comes almost entirely from remittances which make up 26% of the GDP — the third highest in the world. Inflows officially hit $12.54 billion last year, and nearly 65% of households depend on money <a href="https://nepalitimes.com/editorial/the-new-equaliser">family members send home</a>, spending most of it on basic needs.
A recent discussion at the Institute for Integrated Development Studies (IIDS) titled Diaspora Dialogue: Innovation, Identity and Global Influence looked at leveraging the 4 million Nepalis who live and work abroad to spur investment and growth.
IIDS has been involved since 1979 in policy advocacy to propose sustainable solutions to governments under at least four different political systems. The fact that we are in the state we are in now must mean that not many of the policy priorities the IIDS put forward in the past 40 years have been properly implemented.&nbsp;
For decades, we’ve heard that Nepal’s path to economic growth lies in <a href="https://nepalitimes.com/opinion/people-power/nepal-can-level-up-tourism-with-electricity">hydropower and tourism</a>, but that narrative has to change, noted IIDS Executive Director Biswash Gauchan.&nbsp;
“Forget falling water, forest and forex,” he said. “Nepal has to move to a knowledge economy, boost investment and look beyond our neighbours to the diaspora.”&nbsp;
There is an artificial bubble in real estate and banking due to remittances. Even if Nepal gets 3 million tourists a year and exports most its hydropower it will not be enough to take the annual per capita income to $6,000 by 2050.
A knowledge economy means thinking beyond enrolment rates and basic literacy to quality education relevant to the <a href="https://nepalitimes.com/opinion/investing-in-people">human resources the country needs</a>. This will ensure jobs at home in import-substitution agriculture, value-added manufacturing and export of services.
And that is where global Nepalis come in. Connectivity means the end of geography, and diaspora talent and capital can be harnessed for investment and involvement in innovation to take Nepal into a <a href="https://nepalitimes.com/here-now/smart-ageing-is-nepal-s-next-frontier">digital future</a>.&nbsp;
This needs a paradigm shift away from a rent-seeking state to a ‘whole-of-government’ strategy that can only come from a new crop of competent technocrats with integrity and vision to seize the moment. They have to see migration not as 'brain drain' but as 'brain circulation'.
Those Nepalis exist. In Nepal and all over the world. Swaziland’s anuual per capita income is $4,000 — think we can do it <a href="https://nepalitimes.com/here-now/nepal-in-2050-wk6r5r1j">by 2050</a>?

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