The Asia and the Pacific SDG Progress Report 2024 published by the UN’s Economic and Social Commission for Asia and the Pacific (ESCAP) earlier this month shockingly revealed that the region will achieve all 17 Sustainable Development Goals (SDG) only by 2062, and not by the target year of 2030. &nbsp;
While the region has taken positive steps towards eliminating poverty, and bolstering sustainable industry, innovation and infrastructure; progress in other goals related to hunger, health, clean water and sanitation, affordable and clean energy and sustainable cities and communities have been less noteworthy. These require much more political will.&nbsp;
The UN adds in a supplemental note that while the country has shown progress to meet most targets in gender, inclusion and maternal-child health, Nepal is lagging behind in SDGs #2 and #10: achieving food security and combating undernourishment, as well as in reducing inequalities within and among countries.
Translated from UN-ese, this means: many Nepalis (especially children) still go to bed hungry every night, and some Nepalis are more equal than others. &nbsp;
Chronic hunger is measured by wasting and stunting in children. One of the targets under the SDG’s second goal is to eliminate stunting and wasting in children under five. The 2023 Joint Child Malnutrition Estimates by UNICEF, WHO and the World Bank Group stated that in 2022, stunting affected 26.7% of children under five in Nepal. The Demographic Health Survey in 2022 put stunting slightly lower at 24.8% of children under five.&nbsp;
To be sure, Nepal has reduced stunting significantly from 67% in 1995, when it was one of the highest in the world, to where it is now. But that is a nationwide figure, and there are parts of Nepal that are still far behind.
In Karnali Province 36% of children under five years of age are stunted. It is 29% in Madhes Province. Despite a reduction in Nepal’s poverty rate and improvements in the national nutrition levels, hunger still persists in these areas.
Food insecurity and undernourishment do not exist in a vacuum, they are also symptoms of societal inequities. Stunting is nearly three times as high among Nepali children from the lowest wealth group than among children of richer families. &nbsp;Undernourishment is directly affected by a mother’s education level.
Inequality is widening across the world. Oxfam International’s report Inequality Inc in January stated that while the richest five men in the world have doubled their fortunes since 2020, almost five billion people globally have become poorer during the same timeframe.
But not all the news is bleak. The school meals program managed by the World Food Programme (WFP) has been crucial in providing nutritious meals to children for more than four decades. In 2022, the program directly provided school meals to more than 250,000 children in nearly 2,500 schools across the country. The Nepal government has been gradually taking over the program, and stepping up funding while making the program cash-based, allocating around 6% of the national education budget for school lunches this fiscal year.&nbsp;
The fourth Nepal Living Standards Survey was published last month and showed that the proportion of Nepalis living below the poverty line had dropped from 25.16% in 2011 to 20.27% in 2023. The Gini index for Nepal in 2023 stands at 0.30, and the survey indicates that there are larger inequalities in per capita consumption spending in urban areas.&nbsp;
The most recent study on inequality in Nepal by Oxfam and the non-profit HAMI was in 2019, which found income and wealth gap to be wide, and widening. The Nepal Living Standards Survey and it showed that the proportion of Nepalis living below the poverty line had dropped from 25.16% in 2011 to 20.27% in 2023. But the income of the richest 10% of Nepalis is more than three times that of the poorest 40%. In 2022, Nepal ranked 112 in Oxfam and Development Finance International’s Commitment to Reducing Inequality (CRI) Index, which ranks countries on their policies to tackle inequity.&nbsp;
Landlessness, corruption, and lack of access to quality public services are some of the key contributing factors to inequality in Nepal. But again, these inequalities do not exist independently of one another. Gender inequality contributes to land and economic disparity, to education and resources. One inequality compounds another.&nbsp;
The moral of the story is that hunger, inequality, exclusion, landlessness, accountability and governance are all connected. As they say in development parlance: inequality is intersectional.
Shristi Karki

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More equal than others

Nepal’s major hospitals are not prepared for emergency response and care in an event of another earthquake or pandemic, according to a recent new study published in the International Journal of Emergency Medicine. The paper lists a serious lack of preparedness at emergency units of hospitals, and compares the capacity of private, government, and teaching hospitals in Kathmandu.
The study was the first of its kind conducted in Nepal and its investigators aimed to build on the Emergency Care Systems Assessment (ECSA) conducted by Nepal’s Health ministry the WHO in 2019. The ECSA report had identified 39 key items to improve emergency care in the country. <a href="http://archive.nepalitimes.com/news.php?id=17851#.ZA7O-3ZBy3A" target="_blank">Another survey in 2011</a> had shown that only two of the hospitals in Kathmandu Valley at the time had earthquake resistant buildings.
&nbsp;The cross-sectional pilot study looked into seven tertiary hospitals in the Valley out of which three are academic, two are governmental, and two are private institutions. Included in the study are TU Teaching Hospital, Patan Hospital, Dhulikhel Hospital, Bir Hospital, the National Trauma Centre, Grande Hospital and HAMS Hospital.&nbsp;
Researchers used a cross-sectional mixed-method study to gather data on facility characteristics, human resources, clinical services, and signal functions of seven major tertiary-level health facilities in the Kathmandu Valley.&nbsp;
Read also:&nbsp;
<a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health">Taking wealth out of health</a>
<a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>
Investigators identified three respondents from each of the seven institutions who are directly involved with the emergency department in a clinical care or administrative leadership role. Respondents included physicians, nurses, hospital administrators, and general hospital staff.
Emergency response—which is at the forefront of natural disasters and pandemics—during two major disaster events in the country, the 2015 Gorkha earthquake and the Covid19 Delta wave in 2021, showed that Nepal’s emergency response and care was subpar, write the authors.
“This study was designed and conducted so that we recognise our weaknesses, and start slowly improving them,” said Olita Shilpakar, an emergency physician at TUTH, and one of the authors.
The study concluded that while all the facilities surveyed had general availability of round-the-clock emergency services, there were significant gaps as well as differences in infrastructure, diagnostic, consultant, and human resource availability.
“The WHO estimates nearly 40% of lives can be saved with appropriate emergency care,” said Ramu Kharel, an assistant professor of emergency medicine at Brown University in the USA who led the study. “Improving emergency care is one of the most efficient public health interventions. Our study identified many opportunities for us to improve emergency care at hospital levels.”
Government hospitals were characterised by a lack of a designated triage area, as well as the unavailability of Obstetrics/Gynecology (Ob-Gyn), orthopaedics, paediatrics, or psychiatry consulting services.
Academic hospitals had limited isolation rooms or infectious diseases and were found to not have adequate access to toilet facilities. There was limited availability of social work services and security personnel.&nbsp;
In private hospitals, protocols for time targets in triage, triage for children below five years of age, trauma care, and burn care among other services were found to be missing. Safety protocols for managing hazardous exposures were not there, and there was a lack of protection for staff and patients from violence.&nbsp;
While government hospitals that typically care for low-income populations reported better availability of ancillary services and social care services, private hospitals not supririsngly scored the highest in access to and availability of health infrastructure.
Meanwhile, academic facilities were found to have more written protocols given their increased likelihood for research and teaching compared to governmental and private facilities. However, academic institutions were found to have the highest rating with greater availability of consulting services.
Common barriers across all institutions included a lack of training in key emergency procedures, written protocols, point-of-care testing, and ancillary patient services.&nbsp;
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 Kalaunee
Researchers have recommendations regarding the triage system and time metrics, training and education, written protocols for emergency care, and health infrastructure in order for the health facilities included in the study to improve emergency care. Investigators also highlighted a need for specific training, and cross-collaboration between the institutions to strengthen Nepal’s emergency services.
“The findings of this study will allow us to find areas of collaboration between institutions as well. For example, some hospitals have better protocols, others have better triage systems,” said Kamal Thapa, one of the study investigators and an emergency consultant at Grande Hospital. “We need to work together to improve emergency care. Ultimately, our concern is <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer">good patient care.</a>”
Emergency medicine is a new field globally, and especially so for Nepal but evidence from other countries has shown that even simple interventions— like having a good triage system in hospitals— have a significant impact in saving lives.
Said Kharel: “The next step for these hospitals is to use the findings as a guide to take steps towards addressing gaps identified in this report. Furthermore, we need to conduct larger research around the country to look at gaps in emergency care in rural area facilities.”
Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial

Emergencies in Nepal's Emergency Rooms

<figure><img width="1618" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131156/63723b939c7e80680e0c95cfjpeg.jpg" alt=""/><figcaption></figcaption></figure>This is the 16th instalment of Diaspora Diaries, a regular series in Nepali Times with stories of Nepalis living and working abroad.  I grew up in Dang, where they used to call me an awara as I was not doing anything productive. No one wanted to invest in my future. But one day my aunt offered to help me secure loans so I could <a href="https://www.nepalitimes.com/here-now/diaspora-diaries-2/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/diaspora-diaries-2/&amp;source=gmail&amp;ust=1665030592020000&amp;usg=AOvVaw1skz1K2PgE7zbhkrpS9BMB">migrate overseas</a> for work. Even getting a passport felt like such a hassle back then, as I had to come to Kathmandu.  Within three months of applying through an agent in 2009, I got my visa for Saudi Arabia to work as a drive<a href="https://www.nepalitimes.com/here-now/diaspora-diaries-3/" target="_blank" rel="noopener noreferrer">r</a>. After paying Rs90,000 borrowed at 36% interest, this village awara finally got on a plane to Saudi Arabia.  My salary was supposed to be 1,500 riyal ($400) as per the contract, but I was paid only 1,300. I was supposed to work as a driver,  but they sometimes made me wash dishes, sweep the floor or do other odd jobs. One year just passed like that. When things did not improve for the better, me and five other Nepalis who were also promised better paying driving jobs decided to speak up for our rights. But the mid-level staff would not listen to us. It was not about washing dishes or mopping floors being less dignified than driving, this was simply not what we had signed up for. I wrote letters to the owner of the company with just two requests: to let me work as a driver, or send me home.  <img width="640" height="666" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131156/63723b969c7e80680e0c95d0jpeg.jpg" alt="">But the mid-level staff made sure that the letters did not reach the owner of the company. It was a futile exercise. As time passed, I learnt more about the owner. One day I saw him in his car and ran towards it to express my grievances. I knew the owner had a soft spot for Nepalis, and he listened to me intently. By this time, I had already learnt Arabic so was able to communicate well. The five other Nepalis with me also spoke up. He was kind and assured us that our concerns would be addressed once he was back from his work trip to America.  Our mid-level supervisors did not take it well that we had bypassed them, and gone directly to the boss. They started torturing us mentally, and stopped paying even the salary that was lower than the contracted amount. They were rude to us, and made us miserable. But as I said, I am the type that will fight for my rights. There was no other way to stop the mistreatment, so one morning at 4AM, the five other Nepalis and I locked all the gates of our company, trapping workers inside. The supervisors called the police, and we were detained. It was only after a few weeks that the owner came, and set us free. He listened to our concerns, and fired the supervisors. It turns out they were ripping him off, and also cheating us by taking a cut from our salaries. The supervisors were also expats, some with families in Saudi Arabia. Their visas were canceled, and they were sent home. The owner was on our side, and the reason he had a soft corner for Nepalis was that previous workers from Nepal had helped his company’s business take off and expand internationally. We finally felt listened to. Our salaries were restored to the contracted amount, and we finally got our driving licenses. As a full time heavy truck driver, I felt happy. Things are going to be better now. For the next few years, I worked hard at the company, driving my food truck regularly <a href="https://www.nepalitimes.com/here-now/diaspora-diaries-3/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/diaspora-diaries-3/&amp;source=gmail&amp;ust=1665030592020000&amp;usg=AOvVaw0lyngXt9uvrL4sshpLm5_X">to Qatar and UAE</a>. We got an extra bonus of 300 riyal after each trip. My truck had a small rest room with a small kitchen. These were long drives, up to 4,000km roundtrip and could take days. It would get boring on the long highway, and we Nepali drivers would talk to each other on group calls. It was a way to pass the time, and also keep ourselves awake. When not chatting with other Nepali drivers, I would have the music on.There were other allowances for heavy truck drivers, my monthly salary was raised, and my savings were adding up. My dream of buying land and building a house in Nepal was getting closer with every kilometre I drove. For a simple man like me, it was all I could ever ask for. I worked everyday, saved every penny. <figure><img width="960" height="730" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131156/63723b999c7e80680e0c95d1jpeg.jpg" alt=""><figcaption>This is me in Saudi Arabia. (Face blurred at request of author.) </figcaption></figure>Life was good. Until everything changed.My sister in Nepal, whom I had been taking care of, gave birth to a daughter. There was a complication, and the baby had to be put into intensive care soon after. I took care of their medical bills, but while the baby recovered, my sister’s health deteriorated. She was only skin and bones and could not even hold the baby. The doctors in Nepal couldn’t figure out what was wrong.I stuck around in Saudi Arabia for another year, and kept sending money to pay for my sister’s medical bills. During the long drives, I used to talk to my family about her health and could not hold back my tears. After a year, in 2018 I could not bear it any longer and returned to Nepal even though my company asked me to stay on. I took my sister from Teaching Hospital to Bir Hospital to hospitals in India for treatment. She was hospitalised for over a year and the medical bills kept adding up — one expensive test after another. All my savings from years of work in Saudi Arabia were used up.Her husband, a teacher at a school with a modest salary, could not afford her medical bills. He is a doting husband, and was distraught by her condition. I had to step in to help, there was no one else.This disproportionate responsibility of paying for my sister did not weigh on me that much. I had always looked after my little sister ever since we were children. My brother-in-law was also doing as much as he could.Eventually, my sister recovered, and although she is in much better health now she does have occasional relapses. She is still fragile. But most importantly, she is alive. She is with us. I am sure we would have lost her, had I not been in Saudi Arabia, earning so I could pay for her medical treatment. What more could a brother ask for? She tells me I saved her life. It is true.I am now a driver in a car rental company in Nepal, and earn just about enough to survive. I am still poor, and do not have any property in my name. The other five drivers with whom I was in Saudi Arabia are also all back in Nepal, and have invested their savings in transport and agriculture businesses. All my savings were gone, but I have no regrets. There is no remorse, because what could be more precious than my sister's life? I am now trying to <a href="https://www.nepalitimes.com/banner/migration-not-a-wish-but-necessity-for-nepalis/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/migration-not-a-wish-but-necessity-for-nepalis/&amp;source=gmail&amp;ust=1665030592020000&amp;usg=AOvVaw3rEOFtKsFJRrShc6QmTvh1">go overseas again</a> to recoup my savings. I am still relatively young, and have another few years in me to work hard once more in the desert heat. It is the only way to  break out of the poverty that has trapped me. Translated from a conversation with the author, who requested anonymity. <a href="https://www.nepalitimes.com/here-now/diaspora-diaries-3/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/diaspora-diaries-3/&amp;source=gmail&amp;ust=1665030592020000&amp;usg=AOvVaw0lyngXt9uvrL4sshpLm5_X">Diaspora Diaries</a> is a regular column in Nepali Times providing a platform for Nepalis to share their experiences of living, working, studying abroad. Authentic and original entries can be sent to <a href="mailto:editors@nepalitimes.com" target="_blank" rel="noopener noreferrer">editors@nepalitimes.com</a> with Diaspora Diaries in the subject line.

Saving to save my sister

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131124/637233e59c7e80680e0c4905jpeg.jpg" alt="" width="760" height="443"/>Monkeypox cases are increasing worldwide and now with India seeing more infections, public health experts have warned that Nepal needs to be vigilant.While the disease does not pose the same degree of threat as Covid-19, officials say it is better to remain cautious. The World Health Organization (WHO) has already declared a health emergency.“Monkeypox symptoms take time to show. If the infection spreads in Nepal, it could be too late by the time it gets identified,” warns Sher Bahadur Pun, infectious disease specialist at Kathmandu’s Teku hospital. Infected people may be reluctant to be tested.Meanwhile, officials say they have already started preparations against monkeypox with increased surveillance at the Nepal-India border area and health workers on high alert.“We have instructed border personnel to check people with visible rashes and send them to dermatologists,” says Sameer Adhikari of the Health Ministry. “Lab personnel have been alerted and health workers have been provided with guidelines.”Monkeypox is not a new disease but is a rare zoonotic infection caused by a virus similar to smallpox but not as severe. The virus was first discovered in monkeys in 1958 and the first human case was identified in 1970. The disease was previously confined to central and West Africa.Monkeypox is primarily transmitted from rats and monkeys, and from one person to another by coming in contact with an infected person’s lesion, by touching a contaminated object or from respiratory droplets. It can also be spread by kissing, hugging, touching, or sex.A person taking care of an infected individual, children, infants, pregnant women and immune-compromised individuals are especially at a high risk of contracting monkeypox.Monkeypox does not yet have a vaccine but some smallpox jabs can prevent the infection, including the ACAM2000 and Jynneos shots. Because smallpox and monkeypox are caused by related viruses, smallpox inoculation is effective for both.Monkeypox is usually a mild condition and symptoms appear within 6 to 13 days and resolve within 3 weeks. Common symptoms include fever, headache, back and muscle ache and swollen lymph nodes and exhaustion. People quickly develop rashes that are contagious till they dry up and burst.Monkeypox is rarely fatal, however, it can be dangerous and cause pneumonia, and skin and eye conditions in some individuals. Previously up to 10% of infected individuals died due to the infection.At least 75 countries have reported monkeypox cases so far with Spain registering the highest at 3,125 followed by the US at 2,316, the UK 2,137, Germany 2,268, France 1,453, Canada 615, the Netherlands 712, Brazil 592 and Portugal 588.Most monkeypox cases do not need medical attention but if fever is too high, certain medicines can be taken. Individuals need to hydrate themselves, have a healthy diet and get good sleep. Scabs should not be scratched, hands should be kept clean and the skin dry.The good news is that many of the safety measures to prevent Covid-19 from transmitting such as masking up, avoiding crowded spaces and sanitising can also keep monkeypox at bay.Translated by Aria Parasai from the <a href="https://www.himalkhabar.com/news/131330?fbclid=IwAR2jdwW01dFzVzjh_nHfRSr2d5sGoj_KyHtVrwAjM8jGJsKWuL4evSLZXco">Nepali original</a> at Himalkhabar.comRead more: <a href="https://www.nepalitimes.com/banner/1-mask-up-2-avoid-crowds-3-get-boosters/">1. Mask Up. 2. Avoid Crowds. 3. Get Boosters</a>, Sonia Awale

Preparing to prepare for monkeypox

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722eef9c7e80680e0c24ebjpeg.jpg" alt="" width="768" height="1024"/><figcaption>Bhavana with her young son. Photo: RITA ALE MAGAR</figcaption></figure>It was a night that Rita Ale Magar says she will never forget. Bhavana, 17, from remote Dumre Dara village walked 2.5 hours to reach a birthing centre of Udaypur.The underage mother was already 16 days overdue, her blood pressure was alarmingly high and she was going through prolonged labour. She was having difficulty pushing out the baby and was in severe pain.This was the most complicated case the centre had received, and the nurses were understandably nervous. But Nurse Rita had to lead the team and take the decision to try to save both the mother and her baby who were at high risk.“This was the moment when I had to use all the knowledge that I was taught by my mentors,” recalls Rita, who is a beneficiary of the Simulation-Based Mentorship Program (SBMP) of the group, One Heart Worldwide.After nearly two hours, the baby was born but that was only the beginning of the ordeal. The baby was not breathing and had no heart rate or muscle tone.“All of us thought the baby was dead, but we had to try our hardest to save him. I had less than a minute to give my best,” adds Rita, still shaken as she narrates her experience.It was at that point she remembered the ‘Golden Minute’ session she had learned about at the mentorship program -- the time needed for newborn resuscitation of babies born with asphyxia and deprived of oxygen.Nurse Rita quickly cut off the umbilical cord, put the baby on the resuscitation table and gave him electric suction which allowed it to start breathing. But the baby still looked pale, and was having difficulty crying.At the same time, the mother’s condition was worsening, she was bleeding profusely. The nurse sought help from a paramedic team to ventilate the baby with an Ambu bag while she tended to the mother.The baby's condition started to improve, but since there was no neonatal intensive care unit at the birthing centre, Rita referred the baby to a hospital in Biratnagar. The baby boy has since recovered and is now healthy.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722ef19c7e80680e0c24ecjpeg.jpg" alt="" width="389" height="515"><figcaption>Nurse Rita Ale Magar used the ‘Golden Minute’ to save a newborn who was suffering from severe complications. Photo: ONE HEART WORLDWIDE</figcaption></figure>“I was panicking but I benefited from my mentorship, and I will always be grateful to the clinical team from One Heart Worldwide who had trained me,” she adds.One would think that health professionals would not want to work in villages with minimal resources, but the opposite is true for Rita for whom being stationed in the far-off government birthing centre has been a challenge, but fulfilling when she can save lives like this recent case.Nurse Rita has delivered over 200 babies in the last three years. The birthing centre was initially under-equipped and she was the only Skilled Birth Attendants. This is where the One Heart came in to provide hands-on simulation exercises to nurses to get them ready for real-life birthing complications.Two nurses who received that simulated training were instrumental in saving the underage mother and her baby. They also counseled family members.Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">Who will save Nepal’s poor new mothers?</a> Rojita AdhikariThe patient, Bhavana did not know about the risks associated with pregnancies and was adamant about giving birth at home because she herself was born at home. Additionally, she had not seen anyone going to the birthing centre for delivery.Even after she was long past her due date Baavana was still not convinced about institutional delivery. It was only when she realised she was putting herself and her baby at risk did she relent.“Ultimately, she made the right decision but it was almost too late. Luckily, she survived. Saving her was so rewarding also because this could set an example to other villagers,” adds the nurse.But it is not easy for the villagers to get to the birthing centre due to the rugged terrain which further discourages them from accessing institutional delivery. There is no proper transport or ambulance service either. Most people have to walk over four hours to get to the centre which is especially inconvenient for pregnant women and girls.Says Rita Ale Magar: “But no matter how hard the journey, it is worth the effort because us nurses are here at the birthing centre to help mothers like Bhavana and their newborns.”Read more: <a href="https://www.nepalitimes.com/banner/no-conceivable-reason-for-unwanted-pregnancies/">No conceivable reason for unwanted pregnancies</a>, Rojita Adhikari

Balancing life and death in Nepal

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ec9c7e80680e0c0322jpeg.jpg" alt="" width="269" height="642"/><ul><li style="font-weight: 400;" aria-level="1">Belamati Nepali of West Rukum was diagnosed with intestinal cancer and underwent surgery in Lalitpur. Her husband Khadke sold the family livestock to pay for his wife’s chemotherapy. He mortgaged his house to a local lender for Rs500,000, which he will lose if he doesn’t pay it back by October. But the money has run out. He says, "I am worried about losing my home, but I am now even more afraid of losing my wife.”</li> <li style="font-weight: 400;" aria-level="1">Aman Dhamala’s 23-year-old son was seriously injured in a landslide last year in Kalikot. A local hospital could not treat him, and he borrowed Rs250,000 to hire a helicopter which came seven hours later. His son died in the helicopter before reaching Kathmandu. "If we had a better equipped hospital in Kalikot, my son would be alive today. Now I am left with nothing but a huge debt.”</li> <li style="font-weight: 400;" aria-level="1">Suman Lamichhane broke his right leg in a fall 12 years ago in Gorkha, but because of improper treatment there, the National Trauma Centre in Kathmandu had to amputate it. Suman does not have a family. He had to sell everything he owned for treatment, but could not save his leg.</li> <li style="font-weight: 400;" aria-level="1">Punsiram Tharu’s son was diagnosed with retinoblastoma at Kanti Children’s Hospital this month. Treatment would have cost Rs300,000, and there was a 95% chance of recovery. But the Rs100,000 the government provides for cancer treatment was not enough, Punisram does not own any property, and no one back home will lend him money. The daily wage earner cannot afford his son’s treatment.</li></ul><ul><li>Six-year-old Roshan Tamang was taken home to Kavre by his parents midway through his cancer treatment in February because they could no longer afford his treatment. “I had to sell all my property for my son’s chemotherapy, but we were not sure he would get better, and we ran out of money. It broke my heart to take him back home,” Roshan’s father said. Roshan died at home three months ago.</li></ul>Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, EditorialNepalis are losing their lives and homes paying for expensive medical care. Others are living with life-long disabilities because they cannot afford treatment.Every year, the WHO estimates that 500,000 people across the country are pushed below the poverty line, and another three million face financial burden because of expensive medical care, and lack of insurance. That is over 10% of Nepal’s entire population.The cities have modern private hospitals which have made it possible for many Nepalis not to have to go abroad anymore for treatment. But these hospitals are out of reach of most Nepalis. The WHO recommends more than 10% of a nation’s total budget to be invested in health. This year’s budget allocates only 6.87%, which is even lower than other developing nations.Most of that money is allocated for construction and unnecessary equipment, there is not enough to train new doctors and nurses or retain them in rural hospitals.There was some hope with the introduction of the national health insurance policy, but the benefit amount of Rs100,000 per household is not enough for critical care.Instead of streamlining a national insurance scheme so healthcare is more equitable, the finance minister announced plans in his budget speech last month to privatise it.Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health/">Taking wealth out of health</a>, Anita Bhetwal<h2>Fix what is broken in Nepal's health system</h2><h2>Decentralised healthcare and a national insurance program can achieve equitable medical treatment for all Nepalis</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ee9c7e80680e0c0323jpeg.jpg" alt="" width="1024" height="683"><figcaption> </figcaption></figure>Ujjwal Thapa, the founding chair of Bibeksheel Sajha Party, died on 1 June last year due to complications from Covid-19.Thapa’s treatment, which cost Rs2.5 million, was crowdsourced after he was unable to put together enough money to pay mounting hospital bills. His family raised Rs6.8 million for the treatment of a young politician known for his integrity and vision for the country.Thapa needed financial support despite belonging to an upper middle class family with a house and business in Kathmandu.Covid-19 exposed the pre-existing failure of Nepal’s public health system and high cost of treatment at private facilities have forced many families into a vicious cycle of poverty, as well as countless preventable and premature deaths.Nepal’s healthcare mechanism is at odds with the constitutionally guaranteed fundamental rights of Nepalis, and needs a complete overhaul. Government hospitals cost less, but treatment is sub-standard and private care is too expensive.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 KoiralaNepalis have had to sell property and livestock to pay hospital bills, and fall prey to loan sharks. Others have had to abandon treatment midway or entirely knowing that doing so would mean certain death.The government subsidises treatment for diseases including cancer, Alzheimer's and kidney failure, as well as for families of those who were killed or injured during the conflict. However, the amount does not even cover transportation for treatment in most cases. Bureaucratic red tape means not all patients receive the benefits.Arun Shahi, an oncologist at Patan Hospital says that cancer treatments might take up to five years, and cost as much as Rs20 million: “How much is the Rs100,000 government subsidy going to cover?”Particularly tragic are the stories of children whose parents have had to discontinue treatment for lack of money. Doctors at Kanti Children’s Hospital say they have seen at least five such cases from Achham, Sindhuli and Sarlahi districts in the last six months.“It is heart-breaking to be forced to send young children home, and we are very much aware that the lack of treatment will mean they will not live,” says Bishnurath Giri, a paediatric oncologist at Kanti.Read more: <a style="font-weight: 600;" href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudhathokiIn Nepal, medicine for chronic diseases like diabetes and high blood pressure cost about Rs1,000 per month. Kidney dialysis, required to be done thrice weekly, costs Rs2,500 per session. Cancer treatment cost a minimum of Rs300,000, while bone marrow transplants at private facilities cost up to Rs3 million. A brain surgery, which is not available at government hospitals, costs around Rs2 million at the Neuro Hospital in Bansbari.Meanwhile, the overall costs of a liver transplant could be as high as Rs3 million. Sagar Poudel, who sees up to 30 patients with liver disease at the Chitwan Medical College every day, says that at least five of those patients require liver transplants, but cannot afford it.For families in remote areas, even a fall from a tree or injury in a highway accident can sink them deeper into poverty. Many of Nepal’s migrant workers admit they seek overseas employment to pay debts incurred for medical treatment of family members.The average cost of treatment for an accident and surgery in private hospitals is Rs200,000. Just an ICU bed in a private institution in Kathmandu costs Rs20,000 per day, while the daily cost for patients needing ventilators is Rs100,000. Critical care at government hospitals is only about Rs15,000 cheaper.Additionally, the absence of a medical audit for treatment in Nepal, unlike in foreign countries, has led Nepali service providers to charge money arbitrarily by directing patients into unnecessary tests and treatments.Read also: <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">Health insurance must be an election agenda</a>, Gaj B GurungAnd since patients do not have technical knowledge of medical treatment, it is difficult for them to decide on the choice of service. "It is up to the patient to decide, but healthcare providers have taken the decision out of their hands," says Poudel, the liver transplant surgeon.And when families cannot afford treatment fees, hospitals are known to hold new mothers and babies, mentally ill patients, as well as bodies of deceased family members hostage.The over-saturation of private health institutions in Kathmandu has also led to unhealthy competition between private hospitals which have been known to pay ambulance drivers commissions for bringing patients to them. Tests performed in one hospital are not recognised by another, and a patient needs to take them all over again.Patients were already bearing the brunt of expensive medicines and over-prescription of unnecessary medications. Big pharma pays commissions to hospitals and doctors for prescribing drugs. Indeed, up to 75% of the total expenditure or medical treatment is spent on pharmaceuticals."While there is a big managerial weakness in the government health institutions, the private sector is engaged in unethical profiteering, and ordinary Nepalis are squeezed between those two problems,” explains physician Kiran Raj Pandey, author of Up is the Curve: A Genealogy of Healthcare in the Developing World.Read more: <a style="font-weight: 600; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeAccording to the National Health Accounts Report 2018, Nepalis spend 80% of their out-of-pocket expenses on private medical treatment. Nepal’s healthcare mechanism is not only causing people to spend a significant portion of their income on treatment, but also increasing indebtedness.Experts have time and again called for the elimination of out-of-pocket healthcare payments due to continued investment into an unregulated private medical sector.“The state has let hospitals and clinics charging arbitrary fees off the hook, this needs urgent fixing,” says public health expert Kedar Baral.The answer is a citizen-centric national health insurance program to reduce the burden of medical costs. Public health expert Sharad Onta says: “Healthcare cannot be a commodity, and patients are not customers."Meanwhile, Baburam Marasini, former director at the Epidemiology and Disease Control Division says that the treatment cost of 90% of patients will be reduced if health services are decentralised to primary health centres as well as local and provincial hospitals.Introducing a national health insurance scheme would then also mean sustainability for district hospitals and local primary health care centres.Read more: <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">This is how to upgrade Nepal’s rural health</a>, Sewa Bhattarai

Sick of it

<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

Taking wealth out of health

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111124/6372175d9c7e80680e0ba9e2jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: BIKRAM RAI/NEPALI TIMES ARCHIVE</figcaption></figure>If Nepalis are to vote on issues rather than personalities in this year’s elections, they should pay attention to the manifesto of the Nepali Congress (NC) which has put an emphasis on the 2017 National Health Insurance Act.It was the NC’s firebrand leader <a href="http://archive.nepalitimes.com/article/from-nepali-press/Reviving,3589" target="_blank" rel="noopener noreferrer">Gagan Thapa</a> who pushed that legislation when he served as Health Minister. He is now the party’s general secretary, and sees <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener noreferrer">health insurance</a> as a way to improve the access and affordability of quality health care in Nepal.Even for a country like Nepal, universal health coverage is not a distant dream if there is the necessary political will. The Covid-19 pandemic has already made it evident that investing in health care and prevention is central to the well-being of the society with added economic benefits.Many countries in the region have health insurance for their citizens. An example is <a href="https://www.social-protection.org/gimi/gess/RessourcePDF.action?ressource.ressourceId=54059" target="_blank" rel="noopener noreferrer">Thailand's Universal Health Coverage Scheme</a>, lauded as the best model for a developing country.The Nepal Health Insurance program was initiated to achieve universal health coverage and was one of the key agendas in the 2015 election with widespread political support. The program actually started in 2016 and the Health Insurance Act was enacted in 2017.With Ministry of Finance (MoF) funding, it offers monetary protection to people by paying directly to the service providers’ on-behalf of insured members.In a few years, Nepal’s health insurance program has had a scalable impact. Our 2020 study in the Kaski district showed that in patient expenses of insured families was less than that of non-insured ones, and were also better protected against catastrophic expenses than the non-insured.Broadly, the program aimed to improve the health quality through provider and purchaser split, and by employing a strategic purchasing approach. For instance, in Thailand, the National Health Security Office purchases services for 43 million people independently which has played a large role in improving health care services.Health insurance generates an additional health budget, as it is a pooling mechanism. The MoF has allocated the insurance budget without curtailing the current national health budget.Unfortunately, the insurance scheme design and implementation have been drowned out by political rhetoric resulting in operational ambiguity and erratic implementation. Without a serious political will to strengthen the program, it is likely to come to grief before long.Insured people are dissatisfied with service providers for their historically low-quality services. In fact, the quality of care has worsened in places after the insurance scheme was introduced, resulting in a high drop-out rate.In turn, service providers are frustrated over the Health Insurance Board (HIB)’s sluggish reimbursement process and some have even stopped their facilities. The HIB does not have adequate skilled human resources to speed up the reimbursement, nor has it formulated an efficient service purchase mechanism.The Board has not been able to function as a prudent insurance manager because of the lack of basic organisational policies on human resources, finance, monitoring and evaluation, communication etc. There are also crucial design errors in the insurance program, such as reimbursement strategy, un-equitable premiums, and provider/purchaser split, to name a few.The current program primarily employs fee-for-service (FES) which is a traditional, retrospective and input-based approach with a cumbersome process to review, validation of cost, and payment. The FES was selected despite other programs including <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener noreferrer">free health service</a> and safer motherhood implementing relatively efficient, output-based and prospective approaches such as capitation.There are also traditional and cultural problems within the MoH, and HIB as a semi-autonomous body does not have the influence or muscle to monitor and negotiate with service providersThe premium amount and benefit package was fixed through very limited study which was a modest Rs2,500 and Rs 50,000 respectively in the beginning, later increased to Rs 3,500 and Rs100,000 but with no scientific basis.This benefit package is quite small for a family of five. The amount gets smaller with increased cost for the high prevalence of non-communicable and chronic diseases in the general population.Apart from the targeted groups (with premium subsidy), the flat premium amount of Rs3,500 for the rest is largely unbalanced. The richest 10% of Nepal's population has more than 26 times the wealth of the poorest 40%. What this means is that while Rs3,500 is peanuts for some households, it could be a monthly household food expense for others.Despite this, the HIB claims that there is no clear provider and purchaser split between MoH and HIB, the former has a high influence on the latter’s organisational structure, as such, many staffing decisions are still pending the ministry’s approval years later.The majority of the HIB staff are seconded from the Ministry of Health,  none of them are health economists or have financial background. Learning by doing is a costly, ineffective and inefficient approach for a high-priority national program.Similarly, the Health Insurance Board is incapable of coordinating with line ministries for the program's effective implementation. For example, the Act has delegated the NIB’s members to standardise service providers' quality control. However, its board is dominated by MoH members.This results in poor service quality, leading to dissatisfaction amongst insured populations and in the high dropout rate and under-utilisation of the services.Nepal’s health insurance program must undergo a serious and urgent reform to prevent it from becoming obsolete:Short to medium term recommendations:<ol><li>HIB needs to develop organisational guidelines to streamline reimbursement. The focus must be on demand generation to enrol rich, healthy and poorest groups equitably.</li> 	<li>The health service purchasing strategy must be reviewed, and this should also guide the structure and human resources needed.</li> 	<li>Private health service providers will inevitably be integrated into the program given the access gaps created by the limited number of public providers. But private providers are often more politically placed and vested interest can put HIB in a weaker negotiating position.</li> 	<li>HIB should develop standards for hospital/PHCC preparedness, provide additional training and incentives for the health workers and develop monitoring tools.</li> 	<li>Integration with other social security funds and health programs will improve efficiency and reduce duplication and wastage. Coordination with these funds will help access data on informal, and formal sector populations and cross-share promising practices particularly on investment.</li> 	<li>HIB should partner with existing research agencies and health economists to conduct studies and use ground-up feedback to reform.</li></ol>Long term recommendations:<ol><li>Premium-based pricing won't be fair or sustainable because of poverty and amidst high informal sector employees. So HIB should look into the possibility of fully tax-funded schemes for the informal sector populations.</li> 	<li>Provider and purchaser split: The provider and purchase split might go through lengthy technical and political discussion after HIB fulfils the majority of short and medium plans eventually. It requires having clear roles and responsibilities between MoH and HIB, understanding of the scope of work and mutual trust.</li></ol>Gaj Gurung is a public health practitioner currently based in Bangkok, Thailand. He has PhD in public health from College of Public Health and Sciences, Chulalongkorn University. His PhD evaluated the Nepal Health Insurance Program implementation fidelity and its effectiveness in reducing the out-of-pocket health expenses amongst insured populations.

Health insurance must be an election agenda

<figure><img width="640" height="422" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111120/637216cb9c7e80680e0ba9b2jpeg.jpg" alt="a group of people waiting in a hospital room"/><figcaption>PHOTO: SONIA AWALE</figcaption></figure>It had been three months into Sonam’s marriage that a slight trembling in her hand started. At first, she blamed it on the cold and weakness. But it was followed by a full seizure. And another seizure.
When her in-laws found out, they thought she had been possessed by an evil spirit. They were quick to shun her, and take her to a <a href="https://archive.nepalitimes.com/news.php?id=18953#.Ym_BxtNBzAM">dhami shaman</a> to exorcise her. Weeks passed and Sonam seemed to have recovered till she had another seizure. Her condition quickly deteriorated and she was taken to a hospital in Kathmandu where she was diagnosed with epilepsy. 
“People in Nepal commonly misunderstand epilepsy as a sign of being possessed, or having <a href="https://www.nepalitimes.com/latest/the-other-pandemic-mental-health/">mental health issues</a>,” explains Ishan Adhikari, a clinical neurologist and neurophysiologist at the Medharma CliniX in Kathmandu. “The patients are stigmatised and most cannot get access to medicine and proper care, especially in rural areas.”
Better diagnostic tools and treatment of epilepsy has helped patients, but epilepsy is still largely misunderstood, owing to the <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">lack of proper health monitoring</a> and public awareness.
An estimated <a href="https://www.who.int/news-room/fact-sheets/detail/epilepsy">50 million people have epilepsy worldwide</a> and more than 5 million are diagnosed every year, 80% of them in lower middle income countries. In Nepal, the estimate is that more than 1% of the total population suffers from the condition. 
Epilepsy is one of the oldest ailments in human history, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051941/">dating back to 4000 BCE</a> in Mesopotamia. Writings on an ancient Assyrian tablet suggest that being possessed by the demon was responsible for convulsions and other involuntary movements now understood as epilepsy. 
Read also: <a href="http://archive.nepalitimes.com/article/nation/dementia-brings-new-problem-that-families-have-little%20knowledge-of,2151">Remembering Dementia</a>, Kenji Kwok
Epilepsy is a chronic non-communicable neurological condition characterised by recurrent seizures that involve a part or the entire body. About 10% of people have at least one seizure in their lifetime, but not all are categorised as epilepsy. 
“I have come across young children, diagnosed with epilepsy, who displayed signs of headache and light convulsions and had a deteriorating academic performance,” says Adhikari.
Abhinav was 12 when he started having headaches and light tingling in his hands, making it hard for the young student to concentrate at school or home. He stayed alone and isolated from friends and family. 
Abhinav's once good academic performance slowly deteriorated. Worried, his parents took him for a checkup where he was diagnosed with epilepsy even if he had no signs of brain injury or family history of seizures. 
“There is no specific cause of epilepsy, but its highest risk factors are severe brain injury, stroke, brain infection or brain tumour,” says Adhikari. “Family history of epilepsy plays a small role as only 10% of cases are <a href="https://archive.nepalitimes.com/article/nation/Life-%20with-sickle-cell,1460" target="_blank" rel="noopener noreferrer">inherited</a>.”
Read also: <a href="https://archive.nepalitimes.com/news.php?id=12757#.Ym_D_tNBzAM" target="_blank" rel="noopener noreferrer">Misdiagnosed and ill-treated</a>, Sophia Tamot
However, unlike other neurological diseases, epilepsy is treatable. Of those diagnosed, 70% can be fully treated for seizures, while the rest can be medicated for a seizure-free life. Other treatments include vagal nerve stimulators, a ketogenic diet and brain surgery.
But if undetected on time or uncontrolled despite medication, it can lead to a fatal condition called Sudden Unexpected Death in Epilepsy (SUDEP). This has been seen in people who ignore their condition despite being diagnosed due to the fear of being stigmatised. 
Indeed, people with epilepsy experience <a href="http://archive.nepalitimes.com/news.php?id=6640#.Ym_CldNBzAM" target="_blank" rel="noopener noreferrer">reduced access</a> to educational and employment opportunities. One young Nepali patient who used to work at a bank was forced to quit after she had a seizure at work, she was accused of disturbing the workplace.  
Because of its <a href="https://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener noreferrer">association with mental illness</a>, families in Nepal often take patients to <a href="https://archive.nepalitimes.com/news.php?id=18953#.Ym_BxtNBzAM" target="_blank" rel="noopener noreferrer">faith healers</a> or even force-feed urine to patients. Fearful of ostracisation, families tend to keep them hidden at home, sometimes locked up.
Epilepsy seizures disrupt electrical activities of the brain distorting neurochemicals. Due to imbalance in the brain’s homeostasis, patients can have learning difficulties, anxiety or <a href="https://www.nepalitimes.com/latest/tackling-nepals-mental-health-pandemic/" target="_blank" rel="noopener noreferrer">depression</a> which is misinterpreted as <a href="https://www.nepalitimes.com/latest/tackling-nepals-mental-health-pandemic/" target="_blank" rel="noopener noreferrer">mental illness</a> or being possessed instead of being treated for what they are, a neurologically induced condition. 
Read also: <a href="http://archive.nepalitimes.com/article/nation/impact-of-lead-on-intellectual-development%20,3820">Taking the lead on lead</a>, Sonia Awale
Epilepsy accounts for more than 0.5% of the global burden of disease and has <a href="https://www.nepalitimes.com/here-now/nepals-economy-already-weak-takes-direct-hit/" target="_blank" rel="noopener noreferrer">economic implications</a> such as lost work productivity. Moreover, families have to pay expensive hospital and medication fees. The patient might also need a designated caretaker which adds to slashed family income.  
“Public financing for medical costs can alleviate the financial burden from epilepsy, the state must recognise it as a burden to the country’s economy,” says Adhikari.
Nepal also <a href="http://archive.nepalitimes.com/news.php?id=6640#.Ym_CldNBzAM" target="_blank" rel="noopener noreferrer">lacks equipment and anti-seizure medication</a> to properly treat epilepsy patients, particularly in rural areas. A recent survey by Nepal League against Epilepsy showed that 70% of hospitals did not have diagnostic tools like ECG, CT scan and MRI machines. 
On the other hand, there are insufficient number of neurologists who can diagnose the disease across the country, and most are based in Kathmandu. Alternatively, there have also been cases of misdiagnosis and overdosing on medication aggravating the condition of the patient. 
Another survey on Epilepsy by Krishna Rajbhandari showed that anti-convulsants were prescribed based on geographical locations and their availability, instead of what was necessary.
A <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener noreferrer">state-sponsored</a> awareness campaign to focus on equitable diagnosis, treatment and a strong healthcare system with necessary equipment and medications is a must.
Says Adhikari: “We need many more trained doctors in epilepsy for better diagnosis and treatment, as well as medication assistance programs that deliver anticonvulsants and other medicines at a lowered rate or for free to rural areas.”
Some names have been changed.
Read more: <a href="https://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486">Stigma and Silence</a>, Ketan Dulal

Treating an epidemic of epilepsy in Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e899c7e80680e0b7923jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: ANTONIO BELTRÁN RODRÍGUEZ</figcaption></figure>Daily wage labourers Dharma and Gita lost their jobs during the pandemic. The young couple exhausted their meagre savings in less than a month, after which they started to buy food on credit. Still unable to repay loans, they limited their diet to one small meal a day.Soon, Gita started feeling weak. She often had a fever and cough. As the lockdown extended, her health deteriorated and the medicines were of little help. The couple even took a PCR test which came out negative. They visited five different health centers and bought bags full of medicines. The treatment was so expensive they had to sell their two cows. A month later, and heavily in debt, she was diagnosed with tuberculosis.Tuberculosis mainly afflicts the poorest. The numbers are staggering: one in every three people globally is infected by Mycobacterium tuberculosis, and even if they carry the bacteria most people do not get sick unless their immune system is weakened due to disease or malnutrition.And yet, this easily preventable and curable biblical disease thrives in Nepal and the Subcontinent due to inadequate measures taken to prevent, diagnose and treat the infection.A 2020 National TB Program report revealed that over 100,000 people are living with tuberculosis in Nepal. This figure is much higher than previously estimated but has most likely increased since as many patients have been unable to access treatment during the pandemic.Of these cases, 40,000 patients were not diagnosed or treated at government centres, which means nearly one in every two people were not diagnosed. Oftentimes, people reach standard TB treatment and care after months or even years. Their pathway to cure is complex, long and include misdiagnosis leading to unnecessary prescriptions. This in turn could lead to unnecessary death and suffering. Patients are also ostracised by friends and families, resulting in self-isolation from communities.These challenges are exacerbated by Nepal’s limited health infrastructure. Health care centres are understaffed and poorly managed, maintenance of laboratory equipment, as well as supply of quality chemicals for tests, are erratic.Across Nepal’s Tarai, settlements are overcrowded, people live in extreme poverty, hygiene and sanitation are at a bare minimum. In the hills and the mountains, difficult geographical terrain and poor road networks pose obstacles for people seeking health care.These deeply-rooted structural inequities collectively resulted in magnified impact on TB service delivery during the pandemic. As a result, we observed increased deaths from the disease.In 2018, global leaders committed to reducing TB by 2022. To meet this goal, we need comprehensive intervention programs with sufficient investment for prevention, early diagnosis and treatment. There are four key areas that require increased funding to decrease TB fatalities:1 PreventionWe saw how the world community got together to rapidly develop vaccines for Covid-19 with unprecedented funding and resources. TB on the other hand has only one vaccine and a very weak one at that. Developed over a century ago, BCG does not prevent adults from developing TB disease.UnderNepal's national TB program, young children living with adults who have TB are provided medicines to kill any TB bacteria they have inhaled and prevent the development of the disease. The Birat Nepal Medical Trust for the first time in Nepal is providing a shorter 12-dose course of TB preventative medicine to adults infected with the bacteria to stop them from getting sick and spreading the disease.In 2020, only $684 million of the estimated $2.16 billion needed globally for TB research and development was available from donors. Covid-19 on the other hand received over $100 billion in just two years to develop vaccines. The pandemic exposed this global inequity, and is proof of what sufficient funding and political commitment can achieve.If funding for the global TB prevention program is increased by 3-4 fold, we could design better community-based services, develop a more effective vaccine and promote shorter treatment regimens, all of which will achieve a TB-free Nepal sooner.TB awareness and health promotion messages also do not get as much coverage in the media as they used to. World TB Day, observed every year on 24 March, should serve as a reminder that TB is an epidemic and needs accelerated efforts for elimination.2 Diagnosis and InnovationGovernment health centres provide TB diagnosis and treatment free of cost. Yet, people spend a lot of money and time before they are correctly diagnosed and enrolled in treatment. This is because symptoms of the disease are common to many infections. People develop cough and fever and immediately resort to taking paracetamol and general antibiotics before realising that they have TB.Moreover, Nepal needs to quickly adopt GeneXpert machines which use PCR testing, and chest X-ray that diagnoses early-stage TB effectively and efficiently. Investment should be concentrated to expand, strengthen and maintain these diagnostic tools at health centers all over the country. Health care providers should be similarly trained to operate these machines.GeneXpert technology should be deployed with active case finding where community health workers make home visits to screen and identify TB patients. This method also commonly known as contact tracing was applied in containing the spread of the Covid-19 virus, and has been used in TB programs for decades.Although proven to be effective, new diagnostic technologies are expensive and active case-finding strategies require large and sustained financial commitments. One might question if a country like Nepal can afford such investments. But the question we should be asking is, can we afford not to?The costs of the continued TB epidemic are far greater than the investments required to reduce it. Investing in better  tools including tax waivers on the import of TB diagnostic machines and test kits, and increased global funding for implementation of active case finding strategies for low and middle-income countries like Nepal are urgently needed.3 Community-based Treatment and Care Incomplete or delayed treatment can cause drug resistant TB and even death. Therefore, the treatment of tuberculosis should be patient-centred.TB programs have been implemented in Nepal for over half a century, we now have plenty of experience to employ the best strategies and  to eliminate the scourge.One of the challenges to eradicating TB is the long duration of treatment. Under the DOTS program, tuberculosis patients have to visit health centres daily for medication to be taken in the presence of care providers. But this could expose them to other TB patients, and resulting stigma. It is also time-consuming and comes with additional transport expenses.Investment in research and development of shorter course treatment regimens, and scaling up telemedicine is a priority area.4 Social Protection TB and poverty form a vicious cycle, each fuelling the other. It is mainly the neediest in society who are most affected. Having TB increases financial strain in their families with far-reaching socio-economic consequences. Children may have to forgo education and seek employment to compensate for the loss of income in families with an infected adult. Providing cash to families after the diagnosis will alleviate the financial burden.TB also causes malnutrition making people more vulnerable. Providing diversified food packages with appropriate nutritional value will be a big support, it will also help reduce the mental stress of fulfilling family needs.But these are just a few recommendations, a study to identify feasible and acceptable support for people with TB will enable us to design an improved tuberculosis support program. These should incorporate health education to people with TB and their families to better understand the disease, cope with its treatment and overcome stigma.Ultimately, it is the government’s responsibility to protect the lives of its people. Therefore, investing in and incorporating locally appropriate social protection schemes within the TB program should be the key agenda and priority of policymakers.The slogan this World TB Day today on 24 March is ‘Invest to End TB. Save Lives’, which reiterates the need to increase funding to prevent, diagnose and treat TB. Without substantial investments that will accelerate collective efforts of the community, country and the world, it is unlikely we will win the fight against TB, reverse the huge setback caused by the pandemic or save lives.Kritika Dixit is the Research Manager at Birat Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. Rajan Paudel is the Research Associate at BNMT.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8c9c7e80680e0b7924jpeg.jpg" alt="" width="80" height="109"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8d9c7e80680e0b7925jpeg.jpg" alt="" width="82" height="109">Read also: <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/">For Nepal, a game-changer in TB control</a>, Buddha Basnyat and Maxine Caws

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