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It’s hard to predict how the corona crisis will unfold in Nepal when the extended deadline of the lockdown expires on April 15. Chances are, the lockdown could be further extended as Nepal is yet to widely test people for the virus, and as India is also looking likely to extend its own nationwide lockdown beyond April 21. This could be for everyone’s good, and a much better option than rescinding the lockdown and letting the contagious virus free to follow its natural and potentially deadly course.

Yet the fear that aspiring autocrats could misuse the pandemic to cement their rule, and to undercut civil liberties, also continues to grow. We already see this in Russia and Hungary. Even in India and Nepal, the respective governments have been accused of catering to the whims of the middle and upper classes even as the poorest of the society disproportionately suffer from the near lockdown. There is also a tendency of governments to discredit any voices of opposition to their anti-corona measures. Opposing voices everywhere stand accused of trying to ‘politicize’ the pandemic.

“Around the world, measures to contain the coronavirus are threatening liberal values and basic principles of democracy,” as political analyst Shreekrishna Aniruddh Gautam puts it. In Nepal too the ruling party leaders, from the prime minister down, have been trying to discredit the opposition parties and the media, which have rightly raised their voice against the mismanagement and corruption seen in the government’s anti-corona measures. This, however, has not dispelled doubts that many ruling party leaders will not think twice about enriching themselves on the pretext of controlling the pandemic.

As dangerous have been efforts to tinker with online media content that portrayed senior government officials in a bad light for their involvement in corona-related corruption. This suggests that the government could get more and more draconian as it tries to control the narrative of its fight against the dreaded virus. And the Oli government does look likely to come under some criticism, given its mismanagement of the crisis and given Nepal’s lack of resources to fight the unseen enemy.

Thankfully, PM Oli is slowly regaining his health and is now reportedly leading the corona response, something he had delegated to lower-level government officials till date. This will hopefully open up clear channels of communication and minimize the involvement of unscrupulous middlemen in the import of vital kits and medicines. With him in charge, the government will also be in a better position to track the flow of cash from the center to the provincial and local units. The prime minister doesn’t like the criticism leveled against his government. He now has the chance to prove his critics wrong.

Countries the world over, including Nepal, are opting for lockdowns to contain the spread of novel coronavirus (Covid-19), often with considerable public support. Many governments have assumed emergency powers to do so. This in turn has fuelled fears that rulers with autocratic bent could use the pandemic to cement their rule and silence critics.

For instance, to contain the contagion, Hungarian Prime Minister Victor Orban has assumed extraordinary powers to rule by decree. The decree, among other things, allows the prime minister the power to control the media. Rights groups warn the country could be headed towards a full-blown dictatorship.

“Around the world, measures to contain the coronavirus are threatening liberal values and basic principles of democracy,” says political analyst Shreekrishna Aniruddh Gautam. “The other tendencies in evidence during the pandemic are further cementing of nationalist sentiments and emboldening of anti-globalization forces.”

In Nepal, some government decisions have already raised eyebrows. It decided to let Nepal Army import essential materials to fight coronavirus, after a private company assigned the duty failed to do so. Why do we need an elected government, many question, if all vital government duties are to be passed on to the army?

Even top leaders of the ruling Nepal Communist Party are unhappy with lack of consultations in dealing with Covid-19 and with the prevalence of security forces on vital national issues, which, they reckon, could threaten civilian supremacy. Prime Minister KP Sharma Oli is yet to summon a joint meeting of ruling and opposition leaders, which belies his assertion that the anti-corona measures of the federal government have broad political support.

Missing scrutiny

The government has also stalled the parliament’s winter session, which is known as the bills session. In the absence of parliamentary scrutiny, it can now issue decrees to get things done. The next session of parliament is the budget session. As corona is an urgent issue, the government can summon a special session of parliament before that. And if big gatherings are a problem, the parliament can meet virtually, as is being done in some other countries. The Oli government has thus far refrained from such innovative measures.

Tara Nath Dahal, executive director of Freedom Forum, a think-tank on civil, political and media rights, says he has repeatedly drawn the attention of the Speaker of the federal lower house Agni Sapkota that there should be continuous and consistent parliamentary oversight over government functioning during the pandemic.

“Now, the country is operating on the basis of government decrees. There is also a question-mark over the constitutional validity of the lockdown, even though it maybe justified from a public health perspective,” Dahal says. “It is vital that the parliament continues to function, especially during a national crisis.”

The judiciary can help with check and balance but its functioning too is limited. Currently, all courts (Supreme, High and District) are hearing only urgent cases. Similarly, the National Human Rights Commission, a constitutional rights watchdog, has been almost comatose during the coronavirus lockdown.

In such a void, it is easy for the government to try to accumulate power and suppress dissent, according to Dahal.

Dangerous precedents

Take the recent fiasco with the online news portal Kathmandupress.com. The portal’s developer remotely accessed the website’s backend and deleted an article critical of the prime minister’s advisors. Reportedly, the PM’s inner circle had put pressure on the IT company to delete the article, even though this has not been independently verified.

In another development, Press Council Nepal has blocked over a dozen online news portals on the ground that they were publishing fake news and misleading the public. Though some of those portals did indeed post news of questionable nature, observers say the press council does not have a right to block them, which sets a dangerous precedent. 

In his address to the country on April 7, PM Oli doubled down on critics, arguing that some people were trying to mischievously defame the government even though it was doing a good job in controlling the spread of coronavirus.

Freedom House, a US-based global think-tank, has called on governments across the world to protect civil, political and media rights during and after the pandemic. “Criminal penalties for distributing false information are disproportionate and prone to arbitrary application and abuse. Instead, governments should counter any falsehoods by delivering clear, accurate, and up-to-date information,” advises the think-tank in its guidelines.

But over the past two years, there have been multiple efforts to curtail media freedom in Nepal. Three laws—Media Council Bill, Information Technology Act, and Special Services Act—have provisions that curtail media freedom and civil rights.  

In the name of controlling the pandemic, experts fear governments could also snoop on people’s private information. “China reportedly contained the coronavirus with the help of its overarching surveillance mechanisms,” says Gautam, the political analyst. “One upshot of such sweeping surveillance could be spying on and preying upon the government’s adversaries. This will be a big threat to democracy.”

Naradevi Gurung, 52, who had elevated blood pressure and high fever, died on March 31 after private hospitals in Biratnagar of eastern Nepal refused to see her/ AMN ARCHIVES 

“Every citizen shall have the right to basic health services from the state, and no one shall be deprived of emergency health services,” states Article 35 of the new constitution. Despite the constitutional provision, in reality, there is no assurance of people’s access to even basic health services in many parts of Nepal. After the government announcement of a lockdown to contain the possible spread of the novel coronavirus, the public right to basic health services has been even more restricted. There have been instances of deaths of patients presenting themselves with corona-like symptoms after private hospitals refused to admit them.

This callous behavior of private hospitals and clinics during the coronavirus pandemic has sparked a debate on the kind of health policy the country needs. There are also voices that private hospitals should be nationalized, temporarily during the corona crisis, if not permanently. Spain recently nationalized all its private hospitals and healthcare service providers after they were deemed uncooperative in the country’s fight against the coronavirus. 

Nepal opened its door for private investment in health with the start of the era of economic liberalization in 1990. The National Health Policy 1990 advocated the role of the private sector, and led to the opening of private hospitals and other health related services. Private sector is now involved mainly in two areas of healthcare: first as service providers, and second as producers of medicines and equipment. But has time come to revisit Nepal’s privatization policy?

Regulate, don’t close 

Former multiple-time finance minister and central working committee member of Nepali Congress Ram Sharan Mahat, who is thought of as one of the architects of the new era of liberalization and privatization, says there is no need to rethink the current policy. “It is also untrue that the government has pulled back from the health sector. In the past three decades, there has been rapid expansion of government hospitals in districts and rural areas,” he adds. Since the private hospitals complement rather than compete against government hospitals, they should be better regulated rather than closed, he advises. 

Mahat says those with little knowledge are questioning the rationale behind the privatization of health. “People should get to choose which hospital, private or government, they want to go and get treated. Some may even opt to go abroad for the same purpose. It is their right,” he adds. 

Madhusudan Subedi, a Professor at Patan Academy of Health Sciences, says the issue of rethinking Nepal’s health policy came to the fore mainly after Dr. Govinda KC’s recent campaigns for drastic reforms in the health sector. “The demand for nationalization of private hospitals is emotional and impractical. The problem again is that after 1990 successive governments failed to regulate the health sector properly, and not necessarily that our private hospitals are not working,” he says.  

On the coronavirus pandemic, Subedi says what is missing is coordination between government agencies and private hospitals. “And before accusing them of callousness, the government should provide Personal Protective Equipment (PPE) to doctors and nurses in private hospitals. But even the doctors working in government hospital don’t have these basic protective gears,” Subedi says. 

Nay, involve the state

But according to Khagaraj Adhikari, former Health Minister and central committee member of the ruling Nepal Communist Party, this is the perfect time to rethink the post-1990 health policies. “The private hospitals have done some good. But their response to the coronavirus pandemic suggests they will be accountable to the public and the state only when it suits them and not when they are most needed. There is thus a strong rationale for greater government involvement in healthcare,” he says. 

Many private hospitals are also openly flouting set criteria. For instance, they must set aside 10 percent of their total beds for free treatment of the poor and marginalized communities. But according to last year’s Auditor General’s report, most private hospitals are not implementing this provision. Similarly, the facilities they provide to senior citizens are also short of the legal requirements. The same report says private hospitals have not hired the required number of doctors and nurses; nor do they have adequate labs, equipment and beds. 

Says Uma Kanta Chaudhary, another ex-health minister: “The state should be bold. If private hospitals shy away from their responsibly during a health crisis, they should be penalized. Yet it is not just their fault. Traditionally, the Nepali government has also failed to effectively monitor and take action against those who violate rules.” He advises that the private hospitals be made “more service-centric rather than purely business-centric”.
 

The neglected lot 

In the past three decades there has been insufficient investment and effort in improving the state of government hospitals and decentralizing them. Right now they are desperately short on vital staff and equipment, and disproportionately concentrated in urban pockets. 

There are four types of hospitals in Nepal: public hospitals (known as government hospitals), private/NGO hospitals, nursing homes, and medical colleges. Around 700 big and small private medical establishments are in operation, along with 19 medical colleges. In terms of government hospitals, there are three federal level hospitals, seven regional hospitals, and 77 district hospitals, in addition to smaller health and sub-health posts in local units.  

Lockdown is considered the most effective way to contain the community spread of the novel coronavirus (Covid-19).

Countries like Italy, the United Kingdom, France, India, among others, are under complete lockdown. Japan and South Korea are under pressure to implement it in toto. “When it comes to containing the novel coronavirus, there really is no other viable option,” says Dr Khem Karki, a public health expert at Ministry of Health and Population while urging all Nepalis to strictly follow lockdown rules. Thankfully, compared to India, other South Asian countries have witnessed relatively fewer infections.

Initially, Nepal had announced a week-long lockdown, which has now been extended by another week. People are starting to question: Will this lockdown be extended indefinitely? Government sources do not have a definite answer. They say the lockdown will be under constant review and will be relaxed if the corona risk drops. Says Deputy Prime Minister and Minister of Defense Pokhrel who is leading Nepal’s fight against Covid-19, “We are closely following developments. We cannot actually say how long it [the lockdown] will go.”  

The duration of Nepal’s lockdown will also depend on how the situation evolves in India. With China well on its way to containing the virus, and given its strict travel restrictions, there is less of a threat to Nepal from the north. But due to the open border and the provision of free movement of people across it, Nepal will have a harder time controlling the spread of the coronavirus from India.

“If the number of cases remain static, Nepal might think of easing the lockdown. But that too will take around a month. Also, if there is an increase in cases in India, Nepal would be bound to keep the borders shut and prolong the lockdown,” says Pramod Jaiswal, Research Director at Nepal Institute for International Cooperation and Engagement (NIICE). “I also don’t see any possibility of resumption of international flights to major affected countries anytime soon.”

In the worst-case scenario in India, more and more Nepali migrant workers will look to enter Nepal, lockdown or not. Conversely, if India can keep the number of positive corona cases low, most of them are likely to stay put there and thus the pressure on Nepal will ease considerably.

But what kind of indications are we getting from India? On current evidence, could its lockdown be extended beyond 21 days? According to the Press Information Bureau of India, the country’s official press agency, “There are rumors and media reports, claiming that government will extend the lockdown when it expires. The cabinet secretary has denied these reports, and stated that they are baseless.”

Earlier, the research of Ronojoy Adhikari and Rajesh Singh of University of Cambridge had shown that India’s 21-day lockdown was inadequate and that it could go up to 49 days. Indian officials, however, say they currently have no plans to extend the 21-day window. However, they have not completely ruled out an extension as well.

Usually, the symptoms of the novel coronavirus emerge within 14 days after people get infected. So if those with the virus have already entered the country, they will show some symptoms within this period. If not, there is no risk from them. As Nepal has already banned all international air travel until April 15, the bigger challenge will again come from the porous land borders with India.

Infectious disease physician Dr Anup Subedi says removal of lockdown depends on the progress on testing, isolation and contact tracing. “Additional testing kits and logistics have just arrived. Now we will do more tests, which in turn will help us determine the gravity of the matter,” he say. “But no, I do not think two weeks will be sufficient to contain the novel coronavirus in Nepal. Yes, what we can do is take additional measures to ease people’s daily lives should there be an extension of the lockdown deadline.” 

Dr Subedi also says there is a strong case to be made for continued restriction on the movement of people across the border and to allow only essential supplies.

Despite the request of the Nepal government to stay put wherever they are, Nepali migrant workers continue to flock just across the border. Many of those who have gotten to enter the country have not implemented the 14-day isolation rules either. Even for the stranded ones, the government of Nepal has no option but to allow its citizens to enter their country.

“It is insensitive on the part of both Nepal and India not to take back their citizens stranded along the Indo-Nepal border,” says Uddhab Pyakurel, an assistant professor at Kathmandu University and a researcher on India-Nepal border. Yet that could pose a huge challenge if those who enter cannot be quarantined.

Additionally, thousands of Nepali migrant workers in various parts of India are struggling. The Indian government has pledged to provide them with basic necessities. But they are not convinced and want to get back to their homeland as soon as possible.

No one should be surprised if the complexities of people-to-people ties and an open border between Nepal and India lead to a further extension to Nepal’s novel coronavirus lockdown.

From Donald Trump in the US to Narendra Modi in India, government executive heads are leading their respective country’s Covid-19 response. They drive the virus response, make important announcements, and try to keep the public morale high.

British Prime Minister Boris Johnson had also been at the forefront of his country’s corona response before he himself contracted the disease. Should he become incapable of working, Foreign Secretary Dominic Raab will take over important responsibilities, including the corona response.

But here in Nepal, even though Prime Minister KP Oli is recuperating from a kidney transplant operation, and could need rest for at least another six months, he has designated no heir-apparent to take up his responsibilities in his absence. He refuses to even temporarily hand over his responsibilities. Former Chief Secretary Bimal Koirala says it will be difficult for the government to make timely decisions without the prime minister’s active participation.

Since the corona outbreak, the prime minister has addressed the country just once. Last week he issued a short message on social media asking people to work from home as he was also working from his Baluwatar residence. Although PM Oli has tasked a committee led by Deputy Prime Minister Ishwar Pokhrel to deal with the corona crisis, the prime minister has not delegated decision-making to the deputy prime minister or any other minister.

PM Oli’s advisors say the executive head is still presiding over cabinet meetings when necessary and giving needed instructions. So there really is no need to worry.

In an interview with Nepalkhabar.com earlier this week, Prime Minister’s Political Advisor Bishnu Rimal ruled out any possibility that the kidney transplant would keep the prime minister away from work for long. “The prime minister has no problem holding cabinet meetings and coming to quick decisions,” he says.

But at the time of his discharge from hospital following the transplant, the prime minister’s medical team had said that Oli could take around six months to be active again and had advised complete rest. Some days later, PM Oli was admitted at the Tribhuvan University Teaching Hospital after having difficulty with his breathing. He was discharged after 24 hours.

Doctors have already said that even limited activity is bad for Oli’s health. Yet there does not seem to be much coordination among other top Nepal Communist Party leaders on filling Oli’s perceived void.  

According to political analyst Puranjan Acharya, even in normal times, a country like Nepal without robust state mechanisms needs a strong executive head—and even more so during crisis. Even with the active corona response of other prime ministers and presidents around the world, he says, “they are still failing. In our case, the PM is almost inactive and state mechanisms are not working. Making things worse, those in the government are involved in blame games.”

Acharya reckons cabinet members are ineffective in the absence of clear directions from the top. If things continue this way, the Oli government “will not be able to handle the escalating corona crisis.”

The absence of the prime minister’s strong command has already been felt in the past three months since the coronavirus started spreading around the world. Nepal found itself without test kits, protective equipment for healthcare workers and basic medicine. Vital supply chains were broken. Lack of coordination has been apparent both within the ministry of health as well as between the provincial assemblies and local governments.

“The lack of PM’s direct and active leadership has already been seen in the fight against coronavirus,” says Krishna Pokhrel, another political analyst. “Before going for kidney transplant, the PM had formed a committee led by DPM Pokhrel. But the committee failed to list out necessities and buy them from abroad. Similarly, there was no preparation to set up test labs outside Kathmandu valley.” Pokhrel thinks the mechanism Oli has in place to deal with the corona crisis is not working.

Acharya says the absence of the prime minister’s active leadership has led to anarchism in the bureaucracy and complete non-cooperation by private hospitals.

“In this time of crisis, we have to work at war-footing, with the bureaucracy, the security forces, the opposition parties and the civil society working together. But that is not happening. The trust in cabinet ministers is dwindling, which is a matter of worry,” he says. As worrying, Acharya adds, even the kind of international support Nepal received in the aftermath of the 2015 earthquake has been missing. 

Alternatively, Sajha Party led by former journalist Rabindra Mishra has submitted a memorandum to the government proposing a joint political mechanism to fight coronavirus.

Since the outbreak, there has been just one all-party meeting chaired by DPM Pokhrel. All political parties support the government’s fight against coronavirus. But they would also like to see more initiative and direction from the top.

The federal government has instructed local governments to arrange food for the poor people dependent on daily wages. The high-level Covid-19 Prevention and Coordination Committee led by Deputy Prime Minister and Minister of Defense Ishwar Pokhrel urged local governments to identify those people, and provide them with relief packages. 

The streets are empty. Industries are closed. Construction-related works and public transport have been halted. These sectors provide employment to a large number of daily-wage workers. There are also other vulnerable groups such as farmers, senior citizens, widows and those with disabilities who need immediate relief packages.

Earlier, issuing a press statement, Nepali Congress President Sher Bahadur Deuba urged the government to bring immediate relief. “I urge the government to bring relief package to low-income job holders, other workers and students living in rented apartments in Kathmandu,” said Deuba. 

The Kathmandu Metropolitan City has started the process of collection of data of poor people in the city. According to the KMC, all ward committees have been instructed to collect data of daily-wage workers, people living in the street, and those without shelter.  According to Namaraj Dhakal, chief of Administration Department of the KMC, they will provide relief packages to those people after they collect data from all wards. Other some local governments have already started relief packages for the poor. 

Much of the world was unprepared for the Covid-19 pandemic. Nepal wasn’t either. But we could have been better prepared had the federal healthcare system not been botched right from the start. In the old unitary set-up, there was a clear chain of command. As Dr. Sushil Nath Pyakurel, former Director General of the Department of Health District, put it to APEX, under the old set-up, “health offices directly supervised health posts and sub-health posts. Regional health offices supervised and monitored district health offices. The Ministry of Health and Population and its departments in turn monitored the regional health offices.” 
In the federal set-up, there are just 6-7 hospitals under the direct supervision of the federal government and the rest are divided between the federal and local governments.

As there is no clear chain of command, there is a lot of duplication of work. For instance, instead of cooperating to build robust coronavirus quarantine facilities, the provincial and local units have now built their own ramshackle ones. The provincial and local healthcare facilities are understaffed, and short of ideas. Even when they have budget they are incapable of procuring medicines and vaccines without federal-level supervision.  

This is why, argues Dr Pyakurel, all healthcare systems should be centrally commanded. He proposes establishing Centers for Disease Control as well as well-equipped medical labs at the center, and in each of the seven provinces. For this, he emphasizes, there is a need for clear political commitment.

In the view of Nepal’s former Health Minister Gagan Kumar Thapa, a change in mindset is vital. “The 2015 earthquake taught us that we were short on long-term disaster planning and in dealing with health issues in such cases.” Thapa thus proposed a Mass Causality Center under the ministry, which would be operated with the help of security agencies. The proposal was forwarded to the finance ministry. “But nothing happened thereafter,” Thapa laments. “Such a center could have simultaneously treated thousands of patients.” 

Perhaps regional cooperation is a better idea in dealing with this kind of cross-border problems? Indian Prime Minister Modi called a special video-conference of SAARC leaders to chalk out common strategies on the coronavirus. Nepal pledged $1 million to the emergency SAARC fund set up after the conference. Yet the lukewarm response of Pakistan suggests the initiative will struggle to take off. Yet there is also no alternative. If there cannot be wholesale cooperation at the SAARC level, the eight countries can perhaps work together on select issues like climate change and pandemics that impact them all alike. 

More pandemics are likely in the days ahead. The Ebola in West Africa earlier this decade prompted many countries to take steps to fight large-scale epidemics but when the outbreak was controlled, their preparations were shelved too. As a long-term measure, Prime Minister KP Sharma Oli has instructed the Ministry of Health to start the process of building a separate hospital to deal with pandemics. 

But piecemeal solutions won’t do. Modern-day health challenges call for innovative and collaborative ones. There is a desperate need to coordinate the response to infectious diseases both at national and regional levels.  

How would you evaluate Nepal’s healthcare system in the new federal set-up?

Previously, we had a central ministry under which various department and offices functioned. There were five regional centers overseeing district health offices. At the grassroots level, there were health post and sub-health posts. Then there were health volunteers and Aama Samuha (‘mother's groups’) at the grassroots to deal with general health issues. We used those entities for both preventive and curative measures, and there was a lot of coordination among them. We have now adopted a federal structure, which is good in principle. Yet we have failed to ensure robust health structures under it.

How has Nepal’s healthcare system changed in the new set-up?

Earlier, district health offices directly supervised health posts and sub-health posts. Regional health offices supervised and monitored district health offices. The Ministry of Health and Population and its departments in turn monitored the regional health offices. There was a robust chain of command from the center to the grassroots. This helped maintain order in the healthcare system. In the federal set-up, we have a three-tier government. Health posts, PHCs and hospitals with fewer than 15 beds are now under the local government. Under the federal government, there are just big 6-7 hospitals. 

Are you suggesting Nepal’s healthcare system has been facing problems since the country was declared a federation?

A couple of things have created problems. First, the federal government has failed to properly manage human resources. The adjustment of civil servants has not been completed even in over three years; there is either over- or under-staffing. In rural areas, human resources are scant. In a centralized system, we could have forced staff to go to rural areas. We are allocating more and more budget to the provinces, but they are unable to instruct local units to work. That’s the crux of the problem. There is no coordination between provincial and local units. This weakness was also evident during the Dengue fever outbreak last year. 

Second, management of logistics and infrastructure has been faulty. For example, we gave provincial governments budget to buy necessary vaccines and medicines. Of the seven provinces, only Sudur Paschim was able to buy Vitamin A capsules for children. Finally, the federal government had to itself purchase Vitamin A and provided them to other provinces. The bodies authorized to buy vaccines—provincial social development ministries—cannot even make such simple purchases. There is no proper supply-chain for it. Provincial governments have failed to buy and manage other medicines also. There are instances of corruption while purchasing medicines. At the same time, provincial and local units are unable to spend their health budget. And when they spend, they do it unnecessarily.

What about management of information on various diseases? 

The management of information related to diseases is also problematic. Previously, there was a system of proper reporting to the ministry and Department of Health when there was even a minor outbreak of a disease at the grassroots. This reporting process has been disrupted in the federal structure. Local units are not reporting to the upper levels about diseases and health problems in their areas. If we fail to pass the information to the concerned agencies, we cannot handle new diseases. Again, we saw such problems during the outbreak of Dengue in Kathmandu last year. But we seemed to have learned little from our experience.

What could have been done to avoid such problems? 

When I was the Acting Secretary at the Ministry of Health and Population in 2018, we had recommended establishing testing labs in each of the seven provinces because we have only one lab for infectious diseases in Teku, Kathmandu. Labs are needed to immediately test suspected patients at local levels. They also minimize overload at the center. If there were labs in all seven provinces, testing for Covid-19 could have been much easier. But the provincial governments did not take any initiative towards this end. We see coronavirus samples of suspected patients being sent to Kathmandu for a test. There are qualified people outside the government. We can hire them for the provincial labs. 

Do we need a specialized body to tackle epidemics and pandemics? 

Yes. There has been a lot of discussion on it but no progress. We should immediately set up a Center for Disease Control (CDC). We see such entities in countries like the US and India.  Such a body at the central and provincial levels can do research on how to deal with new viruses like corona, as well as train healthcare workers, and inform the public. Additionally, they will empower health workers in dealing with new viruses. Such centers can also conduct research on future pandemics.

Nepal may become an epicenter of other infectious diseases in the future. Before the coronavirus, there was an outbreak of common cold in Humla and Jajarkot districts but we failed to study them. The diseases may also be different in the mountains, hills and plains. A center like the CDC can help prepare us. We are now totally dependent on the World Health Organization since we don’t have an independent research center. After the outbreak of Dengue, we had prepared a plan of action about the CDC. 

Are you suggesting that even in the federal structure, the healthcare system should be centralized? 

Certainly. There should be some sort of centralized system in public health. When we deal with an epidemic or pandemic, there should be a proper chain of command because qualified professionals are concentrated in Kathmandu. We can hand over the duties to provincial levels once they get qualified manpower. But unless provincial and local governments are capable, a proper chain of command should be maintained. Currently, there is a lack of coordination among the three tiers of government. 

Health is a fundamental right of every citizen. There should be universal health coverage. All governments shoulder equal responsibility to provide health services to the people. But the performance of local bodies in health services is dismal; even the health workers are deprived of basic facilities. Our federal structure has failed to ensure the constitutional provision of mandatory healthcare to all citizens. 

Can you share the experience of other countries with federated healthcare systems? 

Different countries have different systems so there cannot be a perfect comparison. But we can learn from others. Consider Pakistan, whose federal model is similar to Nepal’s. They had to centralize some of their health systems when their federally administered programs failed. The provinces of developed countries are resourceful so they can make their own infrastructure. But that is not the case in Nepal. For instance, the Kathmandu Metropolitan City has far more resources than a rural municipality. In some places, there is a lack of technical manpower, while in other places logistics are missing.

We adopted federal health structures without sufficient homework and thinking. There was a hurry. The problem is that non-medical people dominate provinces and local units. Instead of having provincial social development ministries look after health-related issues, we need separate health ministries at the provincial level. You cannot expect good output when you break the chain of command. 

So the existing healthcare system should be totally revamped? 

Definitely. First, all systems should be centrally commanded. Instead of social development ministries at the provincial level, there should be health ministries. There should be CDC in all seven provinces. There should be well-equipped labs in all seven. For this, we need political commitment. All political parties should understand the flaws in our current system. If these flaws are not corrected immediately, we can neither guarantee universal health coverage nor ensure health as a fundamental right. We have to make federal and provincial structures coordinate effectively. 

Why was the federal healthcare system botched even though there was a lot of time to get it right?

There was a lot of discussion about the healthcare system suited for a federal set-up. To be frank, higher authorities of other ministries were dominant in decision-making. The constitution allows deployment of necessary manpower to provide health services. But this did not happen because people who were in decision-making process did not take strong stand when it was needed.  

Nepal also seems to have learned little from the experiences of other countries.

You are correct. We shared the experiences of other countries with our bosses. We prepared a blueprint of the healthcare system suitable for Nepal. However, certain people acted like they knew everything and ignored our suggestions. There was dissatisfaction with the new structure, and some health workers threatened to protest. But people in decision-making simply ignored them.

How do improve communication and coordination between the three tiers of government?

There is coordination in some places but only due to individual efforts. The system as a whole is not working properly. There is a sort of vacuum but no one is paying attention. Until we have separate health ministries at the provincial level, there will continue to be a void. The current provincial health departments cannot give orders to peripheral health posts under local units. You see that both local units and provincial governments are now building corona quarantine centers and temporary hospitals on their own. There is no coordination. It would be more efficient for the two tiers of government to combine their efforts and resources.