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Medical experts have expressed concerns about the challenges in providing quality healthcare, citing that the budget allocated to the health sector for this fiscal year is not enough.

The government has allocated a health budget of Rs 83.99bn, which is lower than the sums allocated in the previous two fiscal years. In the fiscal year 2021-22, the Ministry of Health and Population received an allocation of Rs 122.77bn. The figure was Rs 90.69bn for the fiscal year 2020/21. 

The government has decided to make healthcare accessible and qualitative to all. It has also pledged to expand public access to specialized healthcare, and prioritized the prevention, control and treatment of Covid-19 along with other infectious diseases. Funds have also been allocated for the prevention of dengue, malaria, kala-azar, encephalitis, and other seasonal and insect-borne diseases.

As per the plan to treat and prevent infectious diseases, the government has announced plans to upgrade Sukraraj Tropical and Infectious Disease Hospital into a 300-bed facility. A Rs 460m plan has also been outlined for the construction and operation of provincial communicable disease hospitals in Pokhara, Surkhet, Doti, and Bharatpur. A budget allocation has also been announced to upgrade all provincial hospitals into teaching hospitals with super-specialty facilities. 

But health experts say the ambitious plan announced by the government to improve the country’s health sector and the budget earmarked do not complement each other. Many of the plans, they say, also seem rushed and overlook some crucial aspects such as hiring medical professionals and training them.

 “If the government wants to upgrade and operate infectious disease hospitals, then it must recruit specialized human resources and train them,” says Dr Anup Bastola, tropical and infectious disease expert. The recruitment and training parts do not figure in the budget.  

The government has also earmarked Rs 1.28bn to provide 98 types of medicines, vaccines, and basic health services free of charge from primary health service centers in 6,743 wards throughout the country. 

“Instead of purchasing medicines, the government should focus on maintaining quality healthcare,” says Dr Ajay Kumar Jha, Consultant Hematologist, Vayodha Hospital.

The government has also decided to give continuity to the provision of Rs 5,000 monthly medical allowances to individuals who have undergone kidney transplantation, are undergoing dialysis, have been diagnosed with cancer, or have spinal paralysis. The scheme was introduced in January 2018 by the government led by Sher Bahadur Deuba. It was briefly discontinued by the KP Oli led government.

Likewise, Rs 2.50bn has been allocated to continue grants for the treatment of heart disease, kidney disease, cancer, Parkinson’s disease, Alzheimer’s disease, spinal injuries, head injuries, and sickle cell anemia to poor citizens.   Some health experts and medical professionals like Dr Jha are of the view that a distributive approach to healthcare budget is no way to improve Nepal's health sector. 

“It would have been better to strengthen the services rather than distributing monthly allowance to the patients,” says Dr Jha. Arrangements will be made to provide kidney transplantation services at all provincial hospitals as per the Finance Minister Prakash Sharan Mahat. 

“If the government can provide such services in all the federal hospitals then it will help patients to seek the health care in their hometown. Additional financial burden of the patients will be lowered and crowds in hospitals in the federal capital will also be decreased,” says Dr Jha.

The government has also allocated Rs 820m to purchase health equipment for 100 hospitals that are set to be completed next year. Again, another myopic plan that could end badly, say health experts, pointing out to the fact that many expensive health equipment remain unused in hospitals and other health facilities due to a lack of proper space for their installation and untrained human resources to operate them   

There is also an allocation meant for procurement of medical equipment and and infrastructure development for BP Koirala Memorial Cancer Hospital, GP Koirala National Center for Respiratory Diseases, Sushil Koirala Prakhar Cancer Hospital, Manmohan Cardiothoracic Vascular and Transplant Center, Suresh Wagle Memorial Cancer Hospital, Ramraja Prasad Singh Academy of Health Sciences, and Bhaktapur Cancer Hospital. In addition, Rs 8bn has been announced to give continuity to the construction of 5-, 10-, and 15-bed hospitals in 322 local levels across the country. 

Dr Dipendra Pandey, consultant orthopedic surgeon, Koshi Hospital, says with an allocation going for healthcare infrastructure development, there is also a need for health professionals to run them, an issue that the government didn’t address while announcing the budget.  

“The government has talked only developing healthcare infrastructure, but has not said anything about human resources,” he adds.

The government has also announced that special programs will be conducted to save the lives of mothers and their newborn in areas with high infant and maternal mortality rates, but health experts say such programs must be run across the country.

According to Nepal Demographic Health Survey 2016, maternal deaths are a subset of all female deaths. They are defined as deaths that occur during pregnancy or childbirth, or within 42 days after the birth or termination of a pregnancy, but are not due to accidents or violence. The maternal mortality ratio for the period 2009-2016 is 239 deaths per 100,000 live births. About 12 percent of deaths of women, age 15-49, are maternal deaths, the survey reports.

“In order to prevent maternal and infant deaths, the government must come up with plans to deliver maternity services from all health institutions. It should not be limited to a few ones,” says Dr Manor Din Shaiyed.  He is of the view that the healthcare allocation should be at least 10 percent of the total budget. 

To make the geriatric wards in government hospitals more effective, the government has announced plans to set up necessary arrangements for screening and treatment of age-related diseases, including dementia, and Alzheimer's disease, in coordination with the nearest specialized hospital. Similarly, Rs 1.15bn has been set aside for the “Tuberculosis-free Nepal Campaign” to identify patients and provide free distribution of medicine.

The government has also said that Geta Medical College will be operated as the Shahid Dashrath Chand Institute of Health Sciences. A budget has been allocated for infrastructure construction, equipment purchase, and manpower management to upgrade Geta Hospital into a 100-bed facility. A budget has also been allocated for the development of infrastructure to expand the services of Rapti Academy of Health Sciences. Plans and budget have also been announced to initiate the process of establishing a 100-bed satellite hospital in Rakam, Aathbis Municipality, Dailekh under the Karnali Institute of Health Sciences.

Allocations have also been made for the capacity expansion of the National Trauma Center, and setting up primary trauma care centers in Lamki, Kailali; Saljhandi, Rupandehi; Bardaghat, Nawalparasi West; Gaindakot, Nawalpur; Bhiman, Sindhuli; and Belkhu, Dhading.

The government has also announced plans to make arrangements for specialty doctors who have completed their MD and MS under state scholarship programs to serve in government hospitals outside Kathmandu Valley. 

To improve the quality of health services, Rs 240m has been allocated for the implementation of the “one-doctor, one-hospital” program. 

Dr Pandey, from Koshi Hospital, says the government has come up with a list of plans in the name of improving the health sector and healthcare accessibility, but has not announced any program to encourage health professionals. 

“There are no proper plans to stop health professionals from migrating to foreign countries for better opportunities. Construction of hospital buildings and adding medical equipment alone is not enough.”

Sending Nepali nurses to the United Kingdom will worsen Nepali medical sector, affecting the health services, health experts have warned.  

The shortages of nurses in the country will have an adverse effect in the health sector as patients will face delays in emergency departments and in other health services. 

 Critical care will be affected and there will be scarcity of nurses to take care of patients after surgery. Also it increases the workload of the nurses and makes them fatigued.  

Nepal and the United Kingdom though have signed a bilateral agreement on health partnership opening the door for Nepali nurses to work in the UK. 

There are already international concerns over the UK’s plan to take nurses from developing countries. The International Council of Nurses (ICN), said that such wealthy nations recruiting nursing staff from some of the world’s most fragile health systems was extremely hard to justify and perhaps should be stopped entirely. 

The ratio of nurses to the British population is around 80 to 10,000 while in Nepal it is nearer 20. The government run hospitals where there are a large number of the patients are facing an acute shortage of nurses. 

Consider this case. Recently 245 nurses have been appointed in Bir Hospital and 50 nurses have been appointed to work in federal governmental hospitals. These newly appointed numbers however are still insufficient to deliver quality health care to patients.  The ICN has said seven or eight wealthy countries—notably Britain, the United States, and Canada—were driving around 80 percent of international nurse migration, to try to address their domestic shortages.

Situation of nurses in the country 

The country is already facing an acute shortage of nurses. The shortage of nurses affects health care services, posing a threat to patient’s lives. It affects patient satisfaction rate, increases medication errors and makes them fatigued. 

One nurse should serve only six patients in a general ward, four in a pediatric unit, and one in an intensive care unit with a ventilator, according to the government. It is also ideal to have at least two nurses for a single operation table and during delivery.

Nepal produces around 5,000 nurses per year and this number is insufficient to the country. The number of nurses in the health centers in the rural areas are lesser than the urban areas.  According to Nepal Nursing Council there are 1,352 specialist nurses, 73,889 nurses, 51 midwives, 37,236 auxiliary nurse midwives and 848 foreign nurses registered with the council.

The World Health Organization estimates that at least 2.5 medical staff (physicians, nurses and midwives) per 1,000 people are needed to provide adequate coverage with primary care interventions as per its World Health Report 2006.

There is a need for 70,000 nurses in the country itself. 

The country however has not been able to meet the WHO estimates. Nepal is currently on the red list of countries according to the Code of Practice. The Code of Practice for the ethical international recruitment of health and social care personnel bans active recruitment from countries with the greatest workforce shortages unless there is a government-to-government agreement in place.

“When the government is not concerned about the shortage of nurses in the country and is sending the human resources to foreign countries it’s a shameful situation,” said Sarala KC, president of Nepal Nursing Council.

She said that this decision will be counterproductive as it affects the health care system. “Its effect will be seen in the citizens as they will not be able to get healthcare. When there is a shortage of the nurses the hospitals will be closed,” KC added. 

Who is eligible? 

Though the two governments are still working to prepare an implementation protocol Nepali citizen aged between 20 and 45 and who have completed either Staff Nurse, Bachelor’s Degree in Nursing Bachelor of Science in Nursing (BSc), or Bachelor of Nursing (BN), or Master’s Degree in Nursing, holds an active professional license from the Nepal Nursing Council plus at least two years of experience in a registered hospital in Nepal is eligible for the application. The applicants can fill up an online application on the Department of Foreign Employment’s website. 

Details on the recruitment process, the initiation date for the application process, as well as other related information will be posted on the Ministry’s website. The ICN has said that international recruitment focused largely on experienced, specialized nurses, rather than the “myth” that only newly-qualified nurses were being targeted.

“That creates a serious deficit in expertise in countries that cannot afford to lose their more experienced nurses. That has really been a serious concern,” ICN president Pamela Cipriano, had said during a press conference organized by the UN correspondents association in Geneva. 

British ambassador to Nepal Nicola Pollitt after signing the agreement on 22 Aug last year had then tweeted that the deal will benefit the health sectors of both countries.  Successful Nepali nurses will not need to pay anything for the recruitment and will enjoy the same benefits as British nurses, Pollitt, she had said.

The medical experts however are of the view that sending the Nepali nurses will worsen the condition of the already ill health sector. They say that the number of nurses is already decreasing in the country as the number of nursing colleges and the number of students joining nursing education is declining. “We must increase the number of nursing students if we are to run the medical sector,” said KC. 

Over 250,000 medical resource needed 

The Medical Education Commission (MEC), a national regulatory body for medical education in Nepal estimated that more than 250,000 human resources related to the medical sector will be necessary in the country till the fiscal year 2030/31. The projection has been made on the basis of a study based on fiscal year 2020/21. 

The commission has said that a total of 358,938 human resources including female health volunteers and office assistants in both the government and private health institutions would be needed across the country. It has also said that there is a demand of 257,091 doctors and health workers in the Nepali medical sector. 

“The number of human resources are projected on the basis of the retirement and migration of the health practitioners along with the construction of health institutions in the country,” said Dr Shree Krishna Giri, vice-chair of the commission. 

Monsoon rains provide a perfect breeding ground for bacteria and viruses. Therefore, with the onset of the monsoon there is always a risk for a rise of infectious diseases. If the public is unaware, the risk for the outbreak of the infectious diseases will take a toll on the lives of people. There are chances of vector- and water-borne diseases appearing during the monsoon season, but they can be prevented through protective measures and community mobilization, health experts say. Diarrheal diseases With the rainfall water sources get polluted and as a result a large number of people could suffer from diarrheal diseases. There is a risk of diarrhea, dysentery, cholera, and salmonellosis breaking out during the rainy season. Such outbreaks are usually caused by  polluted water resources. Flooding sweeps decayed particles, dead animal carcasses, sewage and several other pollutants with them polluting clean water. “Consumption of such water and food washed and prepared using such polluted water causes diarrheal diseases,” says Dr Sher Bahadur Pun, chief of the Clinical Research Unit at Sukraraj Tropical and Infectious Disease Hospital. Last year as of 5 Sept, a total of 76 cases of cholera were reported in Kathmandu, Lalitpur, Nuwakot and Dhading districts. Case investigation revealed that the cause of the cholera outbreak was use of tap water for drinking purposes and use of commercial drinking water. Four samples of stored tap, jar and ground water from the index case household and workplace were found to be contaminated with coliform, according to the Epidemiology and Disease Control Division. Besides diarrheal diseases, health experts warn people are also likely to suffer from Hepatitis A and E during the monsoons, as the viruses can transmit to humans through contaminated water. Vector-borne diseases According to the World Health Organization, vector-borne diseases account for more than 17 percent of all infectious diseases, causing more than 700,000 deaths annually. They can be caused by either parasites, bacteria or viruses. Every year hundreds of people are infected by diseases such as malaria, dengue, chagas disease, Japanese encephalitis, the WHO says. Mosquitoes are common during summer. As stagnant water is necessary for mosquitoes to breed, monsoon creates a favorable environment for mosquitoes to breed. “Rainwater gets collected in flowerpots, pots, tires of vehicles and puddles, where mosquitoes lay their eggs. This is why there are high chances of dengue during the monsoon season,” says Dr Gokarna Dahal, chief of vector borne disease control section, EDCD. Transmitted from the Aedes Aegypti mosquito, the symptoms of dengue range from mild fever to high grade fever, headache and pain behind the eyes. It also includes muscle and joint pain, and skin rashes. In Nepal, dengue is a rapidly emerging disease. Endemic across most provinces, dengue incidence has increased in recent years, largely due to expansion of the vector Aedes aegypti and Aedes albopictus, as well as the movement of people and the introduction of imported cases, the EDCD says. The disease is quite common in Tarai region in the country. A total of 54,784 dengue cases were identified from across the country last year; 88 dengue-related deaths were reported. According to the WHO, there is no specific treatment for dengue/severe dengue, but early detection and access to proper medical care lowers fatality rates below one percent. In Nepal, monsoon season occurs during June—August. The dengue season closely follows this period with cases occurring between September and November. Given the presence of a largely susceptible human population, human movement, the presence of both Aedes vectors and all four dengue serotypes, this trend is unlikely to reverse over the coming decades. Indeed, the burden may continue to increase, likely resulting in an increasing number of severe dengue cases, particularly in and around Kathmandu, as per the EDCD. The highest numbers of cases were reported from Kathmandu (14375), Lalitpur (9614), Bhaktapur (6145), Makawanpur (5837), Chitwan (3213), Dang (2428), Dhading (1683) and Rupandehi (1215). The mosquitoes that spread dengue are active during the day. Change in the season also increases the risk of viral influenza. Health experts advise seeking medical attention in case of persistent and severe flu-like symptoms. Scrub typhus is another disease that the public need to be aware of during the monsoon season. Also known as bush typhus, Scrub typhus is an acute, febrile, infectious disease caused by Orientia tsutsugamushi. It is spread to people through bites of infected chiggers (larval mites). The most common symptoms of scrub typhus include fever, headache, body aches, and sometimes rash. Most cases of scrub typhus occur in rural areas. This is an infectious bacterial disease caused by Leptospira—bacteria found in rodents. “Whenever there is flooding, these bacteria get mixed with water and enter the human body through cuts in feet. Those working in fields are prone to the disease as they work bare feet. So, people working in fields and villages need to be aware about the disease,” says Dr Pun. Besides vector-borne diseases, snakebite cases also go up during the summer/monsoon period. In the fiscal year 2021/22, some 8,000 people came for treatment of snakebites at government health facilities around the country, according to the Ministry of Health and Population. Seven in eight of these cases involved non-venomous bites, its data showed. Only about 1,000 patients actually needed anti-venom treatment, according to the data. Of them, 100 snakebite patients lost their lives—either because they reached hospital too late or because they could not get the right treatment. To prevent snake bites

•         Never play with snakes, or irritate them. Do not provoke them
•         Use a torch light if you have to walk in the dark
•         Keep the household clean: cut grasses and bushes, fill holes, and close doors and windows properly
•         Use a stick and hit on the earth surface when walking in the dark. Snake will move away because of its vibration
•         Control rodents to prevent snake bites
•         Avoid sleeping on the floor. If it is unavoidable, use a mosquito net and tuck it well
•         Check shoes and clothes before wearing if you are in areas where snakes are abundant
•         Wear shoes

To prevent mosquito bites

•         Clothes that cover as much of your body as possible
•         Mosquito nets if sleeping during the day
•         Window screens
•         Mosquito repellents
•         Coils and vaporizers

To prevent the dengue and malaria

•         Search and destroy mosquitoes and their breeding areas
•         Keep environment clean
•         Use nets and apply mosquito repellents
•         Wear long sleeves and pants to cover arms and legs
•         Remove water from flower/plant pots and plates
•         Change water in vases/bowls
•         Remove water from tyres
•         Take medicines only on doctor’s advice

People smoking, chewing tobacco, and more recently vaping in public are some of the common scenes in Kathmandu. Although the city authority has banned the consumption of tobacco products in public places, the veto has not been effectively enforced. All forms of tobacco are harmful, and there is no safe level of exposure to tobacco. Cigarette smoking is the most common form of tobacco use worldwide, the World Health Organization (WHO) says. Other tobacco products include various smokeless tobacco products, cigars and e-cigarettes. The Kathmandu Metropolitan City reintroduced the ban on the consumption of all forms of tobacco products in public places on 17 Sept 2022, following a decision by the eleventh municipal executive meeting. “The ban on tobacco consumption in public spaces has been imposed to protect public health,” the KMC notice says. If the authorities are really concerned about public health, the ban should be properly implemented. Also, the government must raise the tax on tobacco products, experts say. Earlier too, in March 2019, the KMC had announced a ban on smoking and tobacco use during Bidya Sundar Shakya’s tenure as the mayor. Before that in 2016, the Metropolitan Police Range Kathmandu had stepped up action against smoking in public places. The KMC has even imposed a fine of Rs 100 against those violating the rule of consuming cigarettes in public spaces. Still, the ban has not worked. “The bans announced by the city and police have only been on paper,” says Dr Jaya Kumar Gurung, senior research specialist at Nepal Development Research Institute, calling for an effective implementation. Law governing tobacco control Nepal signed the WHO Framework Convention on Tobacco Control (WHO FCTC) on 3 Dec 2003. After its ratification on 7 Nov 2006, the country became a party to it on 5 Feb 2007. Based on the WHO FCTC, the government has enacted laws and procedural documents aiming at tobacco control. The Tobacco Product (Control and Regulatory) Act 2011 is the primary law governing tobacco control in Nepal under which public places where smoking has been banned are—hospitals, health institutes, public offices, public transport, court buildings, educational institutions, libraries, and auditoriums. The ban also applies to hotels, motels, resorts, restaurants, bars, dining halls, canteens, lodges, hostels, guest houses, stadiums and sports facilities. The Act also states that the sale of cigarettes and other tobacco products is illegal within a 100-meter radius of educational institutions, healthcare facilities, childcare centers, and old-age homes. But the rules on tobacco use are almost never followed. Steps survey According to the Steps Survey 2019, conducted by the Nepal Health Research Council, 3.8m people in the 15–60 years age group use tobacco in some form—smoked or smokeless. At 48.3 percent, male have over four times higher prevalence than 11.7 percent of women. The prevalence rate is increasing for smokeless tobacco. According to the survey, 17.1 percent of adults, which equates to 2.8m people, smoke tobacco products in the country. Around 3m people—18.3 percent of adults (33.3 percent of men and 4.9 percent of women)—use smokeless tobacco. Health impacts Tobacco use leads to more than 8m deaths worldwide each year, according to the WHO. More than 7m of those deaths are the result of direct tobacco use, most of them from low- and middle-income countries such as Nepal. Smoked tobacco products contain over 7,000 chemicals, including at least 250 chemicals known to be toxic or to cause cancer. Use of smokeless tobacco products can result in serious—sometimes fatal—health problems. Tobacco smoke damages the arteries of the heart, causing the build-up of plaque and development of blood clots, thereby restricting blood flow and eventually leading to heart attacks and strokes. Tobacco use (both smoked and smokeless) is responsible for a significant burden of oral disease. Both forms are known to cause mouth cancer, increase the risk of head and neck cancers, Women who smoke or are exposed to second-hand smoke during pregnancy are at an increased risk of miscarriage. The UN health body says that around 1.2m deaths result from non-smokers exposed to second-hand smoke. In Nepal, 3.7m adults (22.5 percent) are exposed to second-hand smoke at the workplace and 5.5m (33.5 percent) at home, the Steps Survey found. E-cigarettes These days, traditional cigarettes are being replaced by e-cigarettes. The use of e-cigarettes is particularly high among the young population—even schoolgoing children—because they come with various flavors like candies and do not leave behind the smell of traditional cigarettes. According to the WHO, e-cigarettes emit nicotine, the addictive component of tobacco products, which can have adverse effects on the development of the fetus during pregnancy and may contribute to cardiovascular diseases. In Nepal, e-cigarettes do not fall within the scope of existing national legislation on tobacco production, distribution, and use. Public health experts warn they pose significant health risks similar to conventional cigarettes. “The government must not ignore e-cigarettes and hookahs available in the market. They are equally harmful for public health,” warns Dr Gurung. “Laws should be enacted to regulate them.” The Tobacco Products (Control and Regulatory) Act 2011 has divided major forms of tobacco use in Nepal into two categories: smoking and smokeless tobacco products. Smoking includes cigarette smoking along with hand rolled cigarettes (Bidis). Smokeless tobacco products include Gutkha, which contains areca nut, tobacco, catechu and sweet flavor; Zarda-Paan or betel quid, rolled betel leaf with lime, betel nut and tobacco; Khaini, flavored tobacco mixed with lime; and Sokha, non-flavored raw leaf of tobacco crushed manually, mixed with lime and rolled in hands before use. Importance of tax on tobacco Experts say taxation plays a vital role in effective tobacco control measures. The current tax rates imposed on tobacco products in Nepal is considerably low. Despite increases in tobacco tax rates during the past two fiscal years 2021/2022 and 2022/2023, the percentage of tax relative to the retail price in Nepal remains at a mere 41 percent. The WHO has recommended a minimum taxation rate of 75 percent to effectively discourage tobacco consumption, but Nepal’s low tobacco tax policy has made tobacco products easily accessible to all. The government has implemented a three percent increase in the excise duty on tobacco for this fiscal year; there has been no increase in the Health Hazard Tax. “When accounting for the estimated inflation rate for the upcoming fiscal year, the overall percentage of tax will decline overall to 39 percent from the 41 percent, further hampering efforts to reach the WHO recommended 75 percent and to effectively control tobacco use,” says Anjana Lamichhane, research associate, Nepal Development Research Institute. Experts believe increased tobacco tax can drastically discourage tobacco consumption and reduce the prevalence of tobacco-related diseases, leading to sustained high morbidity and mortality rates. “If we are aware about the health of the public, the government must fix the minimum taxation rate of 65 percent to reduce its consumption,” suggests Lamichhane. “The government should increase the tax on tobacco products to raise the income of the country. If the government raises the tax on tobacco products then the income generated from there will be given to the Ministry of Health and Population. If the income of the health ministry increases it will use it in enhancing the health services in the country,” says Dr Sushil Nath Pyakurel, former acting health secretary.

Covid-19 is often measured by the number of people infected and the deaths associated with it. But the impact of the virus has extended beyond the direct effects of the coronavirus. Covid-19 is no longer a global public health emergency, but its effects still run wider and deeper. Urmila Sharma (38) of Koteshwor feels fatigued and tired. She experiences shortness of breath when walking for a little distance and also while climbing stairs. She feels that her health has not been the same after she got infected with the coronavirus a year ago. There are many people across the world who have a similar plight to that of Sharma, experiencing similar kinds of symptoms such as fatigue and tiredness. Many are suffering from heart diseases and diabetes. Such patients are visiting hospitals for a regular check-up concerning the long effects of coronavirus. Their main concern is their current health status, as they had recovered from the coronavirus infection after receiving intensive care. As per Dr Bidesh Bista, clinical pulmonologist at Civil Hospital, many of the patients who were infected from the coronavirus in the past have recovered. The lungs infected by the coronavirus have become normal, but 10-15 percent of the patients who had Covid-19 in the past still have lung fibrosis, a condition where patches are seen in the lungs. According to the Ministry of Health and Population, a total of 1,157,414 people have been infected from the virus in the country. Meanwhile 12,031 people have succumbed to the infection as of June 18. According to the World Health Organization, common symptoms of post-Covid-19 can include fatigue, shortness of breath and cognitive dysfunction. Over 200 different symptoms have been reported that can have an impact on everyday functioning. Long covid symptoms Long Covid symptoms include chest pain, fatigue or muscle weakness, palpitations, cough, diabetes, pancreas injury, abdominal pain, nausea, cognitive impairment, brain fog, disordered sleep, memory loss et cetera. In a study conducted by Jin Yin-tan Hospital in Wuhan China published in the Lancet in August 2021, in which the authors reported on one-year outcomes from the largest cohort of hospitalized adult Covid-19 survivors, it showed that fatigue or muscle weakness (63 percent, 1,038 of 1,655) and sleep difficulties (26 percent, 437 of 1,655) were the most common symptoms. Anxiety or depression was reported among 23 percent (367 of 1617) of patients. Fatigue A research conducted by Sangam Shah and others showed the post-Covid status of 300 patients admitted to the Tribhuvan University Teaching Hospital. The study revealed that most of the patients had fever (81.7), followed by fatigue (81.3) and cough (78.3). The research revealed that fatigue was the most common persistent symptom. “People have been experiencing fear, anxiety, feeling short of breath, trouble concentrating. Such complications are more in elderly people and in diabetics. These symptoms also differ how much degree of severity one had due to Covid-19,” said Dr Bista. Dr Prabhat Adhikari, internal medicine, infectious disease and critical care at Center for American Medical Specialists (CAMS), said: “Patients who were more severely ill because of the coronavirus, who were admitted in the intensive care unit have experienced comparatively higher long term effects.” To prevent the long effects of Covid-19, doctors suggest preventing oneselves from catching infection and maintaining body weight. Psychological disorders People who had Covid-19 have been experiencing psychological disorders such as anxiety, depression or other mood changes, concentration or memory problems—brain fog and sleep disturbance—as well. Though the exact causes for these symptoms are unknown, they could be because of the effects of the infection on the brain, immune system or the other organ, say doctors. They could be the result of traumatic aspects of the experience of having Covid-19. Long-term hospitalization, in intensive care units, can lead to post-intensive care syndrome, which often includes severe weakness, cognitive problems (including poor concentration), and even post-traumatic stress disorder. “If one has psychological issues one can practice yoga and meditation. Psychological consultation is necessary for depression,” said Dr Adhikari. According to a research paper published in Nature Journal, entitled Long COVID: Major findings, mechanisms and recommendations, long Covid is an often debilitating illness that occurs in at least 10 percent of severe acute respiratory syndrome coronavirus 2 infections.  More than 200 symptoms have been identified with impacts on multiple organ systems. At least 65m individuals around the world have long Covid, based on a conservative estimated incidence of 10 percent of infected people and more than 651m documented Covid-19 cases worldwide. The number is likely much higher due to many undocumented cases. The incidence is estimated at 10–30 percent of non-hospitalized cases, 50–70 percent of hospitalized cases and 10–12 percent of vaccinated cases. Long Covid is associated with all ages and acute phase disease severities, with the highest percentage of diagnoses between the ages of 36 and 50 years, and most long Covid cases are in non-hospitalized patients with a mild acute illness, the research reveals. More research necessary Though people are experiencing long Covid symptoms no proper study has been done in Nepal to conclude the long effects of the infection and its symptoms in people across the country. “The virus can trigger the immune system. No research has been done in the country regarding whether the virus in the cells have been completely damaged or not. Is the virus still overactive in the body and weak? It needs to be studied. Also there is no specific test to find out whether the above symptoms are of long Covid or not,” said Dr Anup Subedee. There have been more than 200 symptoms that actually have been reported in patients, according to the WHO. However, there are no exact number of people suffering from long Covid in the country. Protecting yourself from long Covid Some of the effects of the virus can be seen even after decades. Health practitioners recommend a number of measures to help prevent long covid. They recommend people to:

•         Take Covid -19 vaccines/boosters
•         Take vaccines against influenzas
•         Wear well-fitting masks
•         Wash hands regularly
•         Ensure well ventilation in indoor spaces
•         Prevent catching Covid
•         Increase the number of Covid tests

Seven of the 10 leading causes of deaths in Nepal are non-communicable diseases, states a 2019 report, indicating that most of the untimely deaths that occur every year can be prevented through healthier ways of living. According to Nepal Burden of Disease 2019, a study report by the Nepal Health Research Council (NHRC) and the Ministry of Health and Population, non-communicable diseases have caused most deaths in Nepal. Of the 193,331 estimated deaths in 2019, 71.1 per cent were attributed to non-communicable diseases, 21.1 percent to communicable, maternal, neonatal and nutritional diseases and the remaining 7.8 percent were due to injuries, the NHRC report has revealed. Cardiovascular diseases Cardiovascular diseases ranked on top as the cause of death of people in Nepal with a 24 percent contribution to the total number of deaths. Deaths attributable to cardiovascular diseases were 26.8 per cent in males and 20.7 percent in females. Chronic respiratory diseases Chronic respiratory diseases come second among the top causes of deaths in Nepal with 21.1 percent of total deaths attributable to them, per the NHRC report. The proportion of deaths attributable to chronic respiratory diseases was 18.9 percent in males and 23.8 percent in females. Neoplasms Neoplasm is an abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should. Neoplasms may be benign (non-cancerous) or malignant (cancerous). Deaths from neoplasms rank third among the causes of deaths in Nepal. Malignant neoplasm (cancer) was responsible for 11.2 percent of total deaths in both sexes, 10.8 per cent of total deaths in males and 11.6 of total deaths in females, per the report. Respiratory infections and TB A communicable disease caused by a type of bacteria called Mycobacterium tuberculosis, tuberculosis (TB) most commonly affects the lungs (pulmonary tuberculosis), but it can also involve any other organ in which case it is called extra-pulmonary tuberculosis. TB was responsible for 3.9 per cent of total deaths in both sexes, 4.8 per cent of total deaths in males and 2.8 percent of total deaths in females in the reporting period, goes the report. Digestive diseases Ranked fifth among the killer diseases, digestive diseases are another leading cause of deaths of Nepali people, As per the report, digestive diseases are responsible for 5.9 per cent of total deaths in both sexes. Genderwise, they account for 6.4 per cent of total deaths in males and 5.2 per cent in females. Diarrhea is one of the common digestive diseases in Nepal, the most common of illnesses among children. It continues to be a major cause of childhood morbidity and mortality in Nepal. Maternal and neonatal disorders According to Nepal Demographic Health Survey 2016, maternal deaths are a subset of all female deaths; they are defined as deaths that occur during pregnancy or childbirth, or within 42 days after the birth or termination of a pregnancy, but are not due to accidents or violence. The most common underlying causes of neonatal death are respiratory and cardiovascular disorders of the perinatal period (the timeframe from one year before to 18 to 24 months after the birth of the child) and complications of pregnancy, labor, and delivery. Maternal and neonatal diseases were responsible for 5.2 per cent of total deaths in both sexes, 4.5 per cent of total deaths in male and 6.1 per cent of total deaths in females, the NHRC report says. Diabetes and kidney diseases Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Diabetes and kidney diseases were responsible for 4.4 per cent of total deaths in both sexes, 4 percent of total deaths in males and 4.9 per cent of total deaths in females during the reporting period, the report noted. Unintentional injuries Deaths due to injuries such as falling from trees or cliffs are more common in young adults. Injuries leading to lives lost in 2019 included self-harm, falls, drowning, pedestrian road injuries and motorcyclist road injuries. Unintentional injuries were responsible for 4.2 percent of total deaths in both sexes, 4.5 per cent of the total deaths in males and 4.2 per cent of total deaths in females, the report noted. Enteric infections Enteric diseases are caused by microorganisms such as viruses, bacteria and parasites that cause intestinal illnesses. Enteric infections are a major cause of morbidity and mortality in low-income and middle-income countries, particularly among children younger than five years, the World Health Organization states. As per the report, enteric infections accounted for 3.6 per cent of total deaths in both sexes—2.5 in male and 4.9 in female.  Neurological disorders Neurological disorders range from epilepsy to Alzheimer’s disease, from stroke to headache. They also include brain injuries, neuroinfections, multiple sclerosis and Parkinson’s disease. Neurological disorders accounted for 2.3 percent of total deaths in both sexes—1.9 in male and 2.8 in female.   Proportion of deaths due to different causes Rank                        Disease                                        Both    Male    Female 1                              Cardiovascular disease               24    26.8 20.7 2                              Chronic respiratory disease           21.1 18.9 23.8 3                              Neoplasms                                   11.2 10.8 11.6 4                              Respiratory Infections and TB       8.4   8.7   8.1 5                              Digestive diseases                  5.9   6.4   5.2 6                              Maternal and neonatal disorders   5.2   4.5   6.1 7                              Diabetes and kidney diseases       4.4   4      4.9 8                              Unintentional injuries                 4.2   4.5   4.2 9                              Enteric infections                       3.6   2.5   4.9 10                            Neurological disorders                   2.3   1.9   2.8

Do you snore while sleeping? Is your sleep disturbed and you feel lazy during the day? Are you looking for treatment for sleep disorders? There is good news for you. Bir Hospital, the oldest state-run hospital in the country, has come up with a sleep laboratory. First of its kind in the government health center in Nepal, the sleep lab is a center where a comprehensive test is used to diagnose sleep disorders. Dr Prajwol Shrestha, chest specialist at Bir Hospital said: “Sleep labs are beneficial for those suffering from sleep disorders. Though the exact number of people suffering from sleep disorders in Nepal is not available, the number is increasing across the country, per Dr Shrestha. The most common one is sleep apnoea, a kind of sleep disorder in which breathing stops and resumes while someone is sleeping. Intake of junk food, sedentary lifestyle, smoking and consumption of alcohol, mental stress are some of the reasons behind sleep disorders, per the health expert. What happens in the lab? Patients’ sleep is monitored in the lab. There is recording of the brain waves, oxygen level in blood, heart rate and breathing of the patients when she or he is sleeping. Eye and leg movements are also recorded during the study to check how the patient’s sleep is. Dr Shrestha said: “During the test, surface electrodes are put on the face and scalp of the patient. The electrical signals generated by the brain during 6-8 hours are recorded and sent to the measuring equipment. An electrocardiogram is used to record electrical activities of the heart.” The hospital conducts electromyography—a procedure to test the electrical activity in muscle for patients who suffer from sleep apnoea. According to a research by New York Medical College and Department of Surgery, Westchester Medical Center, USA, worldwide, 969m people aged 30-69 years may be suffering from OSA with many more people undiagnosed. People with sleep apnoea are treated through the continuous positive airway pressure (CPAP) approach, says Shrestha. This approach involves wearing a mask over the nose of patients or mouth while asleep. The mask directs pressurized air from a small bedside pump to the airway of patients to keep it open during sleep. CPAP eliminates snoring and is most often used to treat snoring associated with obstructive sleep apnoea, per Shrestha. “Through CPAP treatment, patients get snoring treated, have a sound sleep, and do not have drowsiness during the daytime. Blood pressure and diabetes also come under control through this treatment.” Types of sleep A sound sleep makes one feel refreshed and active the next day. Sleep is segmented into two cycles—non-rapid eye movement (non-REM) and rapid eye movement (REM) sleep. Non-REM sleep happens first and includes three stages. During the first stage there is a transition from wakefulness to sleep. The brain slows down, heartbeat, eye movements and breathing slow and body relaxes. In the second stage, one enters light sleep. Eye movements stop, breathing and heart rate become regular, body temperature drops. One becomes less aware of his or her surroundings. In the third stage, muscles are completely relaxed, breathing slows, one progresses into deepest sleep. Dr Shrestha said: “During the REM stage, the body is immobilized and dreams occur. This stage occurs during the morning. REM sleep happens about 90 to 120 minutes. These cycles get disturbed when you snore or are disturbed when you are asleep. People have difficulty going back to sleep again. According to the National Institute of Neurological Disorders and Stroke, during deep-sleep (stage three) and REM, the cells repair and rebuild, and hormones are secreted to promote bone and muscle growth. The body also uses deep sleep to strengthen one’s immunity so that she or he can fight off illness and infection. Disturbance in these stages causes difficulties in sleeping. Dr Shrestha said, “People feel lazy and lethargic and can’t concentrate on their work. There is a feeling of heaviness and a patient wants to sleep during the day time. There is also short-term memory loss.” Long-term health problems such as high cholesterol, raised body weight, heart attack, stroke, paralysis and sudden cardiac arrest can occur when one can’t sleep properly. That’s why the cause for the sleeping disorders should be identified and treated.” The patients are asked to visit the laboratory taking someone along with him or her. They should take a bath in the afternoon before coming to the hospital and carry a night dress with them. They should not wear any kind of hair oil or apply cream on their face. They should sleep after 8 pm in the lab bed. Eight hours of sleep is recorded by a sleep technician. The sleep pattern is then interpreted. Dr Shrestha said: “We advise medical treatment or behavioral changes depending upon the interpretations for a person to have a sound sleep.” “We can subject only one patient to these tests in a day.” The hospital charges Rs 3000 for the service. The test is non-invasive. How long should people sleep? The National Sleep Foundation has recommended sleep durations as follows: 14-17 hours for new-borns, 12-15 hours for infants, 11-14 hours for toddlers, 10-13 hours for preschoolers, 9-11 hours for school-aged children, and 8-10 hours for teenagers. Seven to 9 hours is recommended for young adults and adults, and 7-8 hours of sleep is recommended for older adults. All for a sound sleep The normal sleeping patterns of the people are disturbed. Sleep disturbance causes multiple health problems. When a person snores heavily in his or her sleep there is obstruction of breathing. This affects one’s sleep. Lack of proper sleep degrades one’s work performance and makes one suffer from various health problems. “This lab has been established to help people get medical services for their disturbed sleep and improve health quality.” As per Shrestha, most sleep apnoea patients, who visited the hospital within these four months of launch of the service in the hospital, required treatment through CPAP. Most of the visitors were young people, he adds. The hospital charges Rs 3000 per night for treatment for sleep apnoea through CPAP. For better sleep Don’t take stress Maintain mental peace Create a proper environment. It should be well-ventilated and peaceful. Avoid bright lights in the bedroom Avoid tea, coffee, alcohol and cigarette two hours before sleeping Do some physical exercise Take a bath with lukewarm water before sleeping Treat any medical health condition such as infections Avoid using mobiles and laptops Listen to the music or meditate

Police on April 30 arrested Sanjay Regmi from Lazimpat, Kathmandu, on charge of swindling three million rupees from a person with a false assurance of sending him to Australia. On the same day, police also nabbed Man Bahadur Kumal from Samakhusi, Kathmandu. Like Regmi, Kumal too was accused of defrauding a man of Rs 350,000 on the pretext of finding him a well-paying job in Dubai. More recently, police on May 2 arrested one Raju Shrestha for luring a man into paying him Rs 700,000 for a job placement in Cambodia. Incidents of people being conned by fraudulent foreign employment agencies and agents are nothing new in Nepal. Authorities say the cause for concern is that there has been no let up in such cases. This is primarily due to the attractions of foreign jobs among Nepali youths, who see no job prospect or future in their own country. Thousands of Nepalis migrate to several countries for employment on a daily basis. The Government of Nepal has approved 111 countries for labor migration through recruitment agencies. Between 2008/09 and 2021/22, more than 4.7 million labor approvals were issued to Nepali migrants wanting to work abroad, the Department of Foreign Employment says. Nearly all migrant workers from Nepal are young adults and from the economically most productive age group of 18 to 44. As per the Nepal police daily bulletins, the people who are cheated in the name of foreign employment too fall in the same age category. Cheating on a rise The cases of police arresting people on charge of foreign employment fraud has been increasing of late. A total of 1,516 such fraud complaints have been registered in the Department of Foreign Employment so far this year as opposed to 695 complaints last year. ‘Cheating’ is a broad category mostly involving deception and fraud by private recruitment agencies during the pre-departure phase, the department defines. The department gets at least 12 fraud cases per day; some days, it receives up to 80 cases against fraudulent overseas job recruitment companies and agents. On May 7, police arrested Sitaram Bastola for conning 101 people. The 68-year-old is accused of swindling Rs 35.6 million from these people by promising to send them to the US, Germany, the UK and Japan. Nepal Labour Migration Report 2022 explains that the skill of migrant workers is an important determinant for better opportunities, higher salaries and benefits, and stronger bargaining power in the international labor market. Officials suspect many people who end up being cheated by foreign employment companies and agents are those who do not possess the qualifications or the skill sets to apply for overseas jobs through a legal channel. “If you are competent then there is no need to be lured by the cheaters,” says Umakanta Acharya, director general at the Department of Foreign Employment. Migrant workers unwilling to file complaints The task of overseas job recruitment firms, which are popularly known as manpower companies in Nepal, is to connect job-seekers with employers abroad and support them in the overall process of migration such as documentation, obtaining visas, and acquiring labor approvals, among other services. But many aspiring migrant workers are being cheated either by manpower agencies or fraud agents, because there are so many of them for a person to figure out their legitimacy. Officials say despite being conned, many victims are often unwilling to file complaints owing to threats and the fear of retaliation. Where to register? In Nepal, the Department of Foreign Employment and the Foreign Employment Tribunal are responsible for handling disputes related to foreign employment. The department’s Complaint Registration and Investigation Section receives cases against individuals and private recruitment agencies from migrant workers or their family members. Complaints against fraudulent agencies are handled by the department itself, while complaints against individuals are forwarded to the tribunal. The tribunal’s records show that 441, 548, and 316 cases were filed in the fiscal year 2019/20, 2020/21, and 2021/22, respectively. There are also migrant resource centers in 39 district administration offices across the country, where migrant workers can get counseling at the time when they take their passports. The foreign employment department officials suggest people to visit them to verify the legitimacy of the manpower companies and agencies, but such a recourse is rarely taken by an individual applying for an overseas job. “People should not give money to someone. If they have to give money then they must take receipts which many don’t do,” says Acharya. “Many of the transactions are not done through the banking channel. And even if they are, there are no explanations about the reasons for transactions. This is why many people end up being conned.” Since the victims do not always have actual receipt or contract, Acharya adds the lack of evidence makes it nearly impossible for people to substantiate their claims. If someone is transferring money via the banking channel, the department requests them to explain the transfer or the bank deposit as foreign employment. Krishna Prasad Bhusal, information officer at the department, says:“It is not that people are unaware of fraud incidents. They are aware but they still give their money to the agents and manpower companies. “It is difficult to handle the cases and verify the verbal communications because it is difficult to substantiate claims made.” This is why authorities strongly recommend aspiring migrant workers to learn skills, be competent and verify the agencies and people involved in facilitating them. Chiranjivi Baral, National Network for Safe Migration, vice-president  Reason Many Nepali people opt to visit foreign countries for jobs to earn money, because the country does not have enough job opportunities. But what most of them don’t know is that they can go in foreign employment without spending money. Unscrupulous foreign job recruitment agencies and agents take advantage of this ignorance and con people. Solution People must be aware and have knowledge about the process of foreign employment. They should know that they can opt for foreign jobs without spending a single rupee.