Costly consultation
At a pharmacy in Tripureshwor, Kathmandu, the number of people coming with complaints of flu, skin rashes, stomach aches, and other common ailments has doubled in the past year. The pharmacist there says that people skimp on doctor’s consultation fees whenever they can, especially since a less than five-minute visit sets them back by almost a thousand rupees. Sarina Lama, 45, who was at one of the pharmacies in the area to buy some antidiarrheal medicine for her teenage daughter, says she hasn’t been to a hospital in the past five years or so. Every time someone in her family of five falls sick, a local pharmacist is consulted. She also has a nurse in her neighborhood whom she sometimes asks for advice when a fever shows no signs of abating or a cough won’t go away. Rai realizes how risky that is. The last time her nine-year-old son was ill she was up all night, for several nights in a row, as he was ‘making strange noises’ in his sleep. She was contemplating taking him to the hospital, wondering if she could ask her employer for an advance, when the wheezing stopped and she heaved a sigh of relief. “A doctor’s appointment would have created havoc in our monthly budget since he would have run ten different tests. We would, most probably, have had to cut back on some basic things like eggs, meat, or petrol for my scooter,” says Rai, a salesperson who works from ten in the morning to seven in the evening six days a week at a retail store in Mid-Baneshwor, Kathmandu. In February 2021, the Nepal Medical Association (NMA) doubled doctor’s fees. It shot up to Rs 825 from Rs 450 per consultation. It’s likely to go up again. The NMA and the Association of Private Health Institutions of Nepal released a joint statement informing people about the increment due to inflation. According to the government’s rules, doctor’s fees can be revised every two years. Most people ApEx spoke to said going to the doctors is expensive. At most hospitals, they will order a battery of often unnecessary tests, sometimes even asking patients to repeat a few blood works for confirmation. People also say that as the prices go up, the quality of the service deteriorates. The wait is long, and doctors spend just a few minutes with each patient, sometimes even openly discussing their case in front of other patients. A reputed hospital in Thapathali, Kathmandu, is notorious for sending people inside the doctor’s office in droves. Though this violates the medical code of ethics, doctors can be seen talking to and examining patient number one while patient number two waits for his turn on the bench right behind him and another lurks by the door, ready to step in as soon as patient number one gets up from the stool. Sanjit Chaudhary, pharmacist at Alka Hospital Pharmacy in Jawalakhel, Lalitpur, says people seem to rely on over-the-counter medication rather than visiting a doctor. Sometimes, the condition worsens and they are left with no option but to spend thousands on treatment. This, he says, wouldn’t be the case if healthcare was affordable and people didn’t have to shell our hundreds of rupees for a two-minute chat with a doctor. “People tend to adopt a wait and watch approach when they are ill. If their condition worsens, they spend a few more days trying out different over-the-counter medications. There is this hesitation to go see a doctor right away,” says Chaudhary. This, people ApEx spoke to at a few hospitals in Thapathali, Kathmandu, and Jawalakhel, Lalitpur say, is because of how expensive a hospital visit is as well as the fact that the testing process before the actual treatment is tedious. Despite how expensive private hospitals are, they lack proper facilities. You are made to go from one building to another and the queue is long. Everywhere you go, you are told to wait. “You don’t want to come to a hospital unless you absolutely have to,” says a 62-year-old resident of Kupondole who was at a hospital in Thapathali, Kathmandu, for his annual checkup. He confessed he wouldn’t have come if his son and daughter in-law hadn’t been after him. He, on the condition of anonymity, says he has been coming to the hospital for five years and while it has always been expensive, it’s even more ridiculous now. “Worse, the hospital charged around Rs 700 extra during the Covid-19 pandemic. Apparently, it was for all the precautionary measures they were taking,” he says. Hospital and physician prices are often extremely high and vary across institutions. These arbitrary high prices are a major driver of the increasingly unaffordable health care costs. For example, a Vitamin D blood test costs Rs 4,500 at a hospital in Jawalakhel, Lalitpur, while the same costs Rs 2,700 at a reputed lab a two-minute walk away from it. Forty-two-year-old Goma Raut, who has been running a retail store in Battisputali, Kathmandu, for the past eight years, says everything is expensive and healthcare even more so. “If we fall ill, we have no option but to surrender to our fates,” she says. Raut laments that the government only takes from its people and doesn’t provide anything in return. “There are rules we must follow and taxes that we must pay while the government does as it pleases,” she says. “Is it even monitoring how private hospitals are run?” Renuka Thapa, 49, who works as a maid, took up two additional jobs after her husband’s death due to Covid. This means she has to work at five different homes every day. She doesn’t have a single day off. Though she has managed to pay off the loans she took to foot her husband’s medical bills, she has no savings. The money she makes is spent on rent and food. She struggles to pay her children’s school fees. Her eldest son has asthma and she worries about what she will do if he falls ill and she has to take him to the hospital. “I can’t afford healthcare on top of all our daily expenses. It’s way too costly,” she says, adding most doctors don’t even attend to their patients properly. Government-run hospitals are poorly managed and private hospitals seem to bill you for the air you breathe while you are there, she adds. An ophthalmologist who has been practicing for over 40 years refused to hike his fees when it went up from Rs 450 to Rs 850 in 2021. Many of his patients wouldn’t be able to spend an additional Rs 500 per visit, he said. Six months ago, he started charging Rs 650 but he says that is as high as he will ever go, even when he spends at least 10 minutes with a patient. But not all medical practitioners think that way and that’s perhaps where the problem lies.
Accelerating digital service coverage in Nepal
Nepal can leapfrog legacy technology and networks and follow many emerging economies to rapidly improve digital connectivity across the country. In fact, several efforts from both the government and the private sector are underway to expand digital connectivity, provide customers with more value, and encourage more technology-enabled innovation and entrepreneurship. The regulatory and policy environment must reflect these aspirations and goals. Reforms and institutional design need to focus on methods to expand and maximize consumer welfare. How can Nepal improve connectivity to benefit more people at the base of the pyramid? I discuss three priority areas to start with, focusing mainly on the end consumer and a human-centric perspective. Coverage and quality Nepali companies and the government have made considerable progress over the past decade to improve internet connectivity. Telecommunication services grew over the pandemic and the government, through the Rural Telecom Development Fund (RTDF), began investing to expand coverage to households and institutions such as government offices, schools, and hospitals. Households subscribing to fixed broadband increased from 7 percent in 2018 to 33 percent by the end of 2021; almost 90 percent of those were fiber optic connections. According to the 2021 census data, 73 percent of households have a phone, 38 percent have internet access, and 15 percent have a computer or a laptop. At the same time, differences in telecom coverage and device ownership between urban and rural areas are stark; women and other vulnerable members in households typically have less access to a phone, leave alone the internet. Nepal is yet to meet its goal of 90 percent broadband penetration. Infrastructure sharing is one area that can improve coverage and quality of broadband networks, while maximizing citizen welfare. In the same way, the Nepal Telecommunication Authority (NTA), Nepal’s telecommunications regulatory authority, has introduced and set interconnection charge and protocol among wireless voice operators and enabled voice interoperability, similar regulations are now vital. Rather than engaging in costly tower building, regulations can encourage wireless operators to lease and share tower infrastructure with each other. They can then improve the coverage and quality quickly and cheaply. If fixed broadband players share their infrastructure, they can collectively invest in high-speed fiber optic networks in more areas of the country. A new telecommunications act may open pathways to enabling these new models, while also mobilizing private investment. With the guiding principle of consumer welfare, this can have a massive impact on accelerating high-quality internet coverage. Affordability When it comes to entry-level data plans, Nepali telecommunication and internet services are within the affordability standards of the UN Broadband Commission at 5 percent of average monthly income (GNI per capita). The commission has introduced 2025 targets for entry level plans (at least 1GB) to be less than 2 percent of monthly GNI per capita. According to the Alliance for Affordable Internet, Nepal is within the affordability threshold for fixed and wireless broadband, but the country can do better. If operational issues and costs hampering the sector are reduced, savings could be passed directly to end-consumers. However, mobile broadband data costs are relatively higher per unit in comparison to fixed broadband. If Nepal is to achieve wireless data affordability targets, we need to incentivize more competition and investment into the wireless telecom sector. Importantly, the government must accept that telecommunications infrastructure, unlike large projects in energy, require regular investment and upgrade because of the advancements in the underlying technologies that enable the network. Policy reforms related to local ownership requirements and licensing fees must reflect goals to expand competition and encourage foreign direct investment (FDI) to help improve the country’s wireless network, service quality, and next-generation capabilities. These upgrades will help Nepal to hit the UN Broadband Commission’s 2025 goals. In fixed broadband, on the other hand, data costs have been driven lower because Internet Service Providers (ISPs) have been able to piggyback off affordable equipment and the Nepal Electricity Authority’s (NEA) established electricity distribution infrastructure. However, investments have been overlapping. Industry players point out that existing fixed-broadband service coverage in Nepal could have been achieved with half or even quarter of the current accumulated aggregate level of capital expenditure. Again, savings made through sharing of infrastructure could be passed to consumers. Two other features of Nepal’s internet sectors are the relatively high international internet costs because of insufficient collective bargaining from our service providers, as well as excessively high government taxes on internet service providers. Both are contributing to creating a sector that may be characterized with low financial viability and little incentive for innovation. Value-added services (VAS) While the overarching investment focus of the government is currently on hardware infrastructure and connectivity, value-added services can further advance the goal of internet coverage. I am referring less to the legal definition of VAS under the telecommunications act, a category under which most ISPs fall into, but in general to services that can complement internet and voice telecom services. VAS are enhanced or improved services provided over telecommunication networks other than core network services. These are services from content providers, network aggregators, application providers, etc. In Nepal (rural areas and urban peripheries in particular), there is a need for services that contribute toward socio-economic development. With greater internet access, more people have signed on to social media and now have better access to information. By producing and monetizing online digital content, many Nepalis have also started doing well in the Creator Economy. However, connectivity goals must also focus on enhancing financial literacy and cybersecurity, better health and educational outcomes, and more opportunities for entrepreneurship. Rural broadband programs currently under execution in Nepal provide free physical broadband connections and free internet access; they are great starter programs to digitally connect more of the population. But Nepal needs internet access to improve tangible socio-economic indicators and contribute to economic prosperity. It is remarkable that the average 35-year-old woman in Nepal's mid-hills can go online and use Facebook, TikTok, and YouTube today. However, she and her family should also be able to use digital financial services, tele-health services, online education for the children, and improve marketability of whatever the family produces. Conclusion In the past few years, significant effort in Nepal has gone toward improving access to internet connectivity. This is a welcome effort, and one that needs to continue. Policymakers and regulators exploring reforms to the telecom sector and other sectors focused on service-delivery must place consumer welfare as the guiding principle for these reforms. Such focus can make regulations more dynamic and forward-looking, especially for industries prone to disruption. The author, a Senior Fellow with the Nepal Economic Forum, leads Digital Chautari, a platform to facilitate conversations on creating a Digital Nepal
Govt brings ordinance to punish loan sharks
The government has brought an ordinance to take action against loan sharks. President Ram Chandra Paudel issued the ordinance presented by the government on Wednesday. The President’s Office said that Paudel issued the Ordinance to Amend Some Nepal Acts Related to the Civil Code 2080. A cabinet meeting on Tuesday had decided to send the ordinance to the president to resolve the problems of loan shark victims. The government has introduced an ordinance to criminalize loan sharking and make it legally punishable. Bringing the ordinance, the government is amending the Criminal Code, Criminal Procedure Code, Civil Code, and Civil Procedure Code. The government has already formed a commission to address the loan sharking issue. A cabinet meeting on April 3 had formed the commission under the leadership of the former Chairman of the Special Court, Gauri Bahadur Karki. Former Assistant Inspector General of Nepal Police Uttam Bahadur Subedi and former Deputy Attorney General Ganesh Babu Aryal are the other members of the commission. The Karki-led commission has recently requested that loan shark victims submit their applications to the commission. Issuing a notice last Thursday, the commission requested the victims of predatory lending to file their applications within 15 days starting from Sunday. The commission has said that victims can register their applications online or through district administration offices with the necessary proof. The commission, formed as per a five-point agreement reached with loan shark victims on April 1, has been given three months to prepare a report and recommend solutions to resolve the problems of loan shark victims. The commission has opened its office in Janakpur, the capital of Madhesh Province, as it will be easier for the victims to share their problems. Most of the loan shark victims are from districts of the Terai region. The government and the victims on April 1, had also reached an agreement to expedite the process to amend the laws to criminalize unscrupulous lending. Currently, loan sharking is essentially categorized as an offense under the civil code. In this condition, the victims have to fight the deep-pocketed loan sharks alone. However, the acts of blackmailing, extortion, and other exploitations in the guise of loan sharking fall under criminal offenses. A report prepared by a task force formed by the government last year after a similar agitation launched by loan shark victims pointed out how the case filed by the loan sharks against the borrowers put the borrowers at a disadvantage.
New forces deserve a chance to transform Nepal
We, the people of Nepal, now disown all socially misfit, politically dogmatic and morally degraded individuals donning the garb of politicians. The landslide victory of political novelty, charismatic leadership and the individuals, who have the good of the people and the country at heart, is what we expect in the 2027 general elections. That victory will be a landslide rejection of bygone-era dogmas and gospel of socialism so that the haters and dividers will never rise again. It’ll have to spearhead against the mañana mentality—the regular tendency of putting off until tomorrow what can be done today. We know the politics of our geopolitical, geostrategic and geo-economic contexts, and what best politics can produce. We now need to categorize and showcase the actions into social, political, cultural and economic folders. Current governance politicizes every citizen’s concerns—it’s a political immaturity that always misleads, misguides, deceives and distorts our spirit of change, hope for political novelty and noble need of good governance. Political patriarchs and their swarms of henchmen perform no meaningful action for the commoners. Leaders follow leaders; some are bad, others are very bad. Most state organs and their services are wobbly, wonky and unsteady. Neither they put national priorities on the frontburner nor do they strategize national strategies. Sickening scenes have been staged as alliances are made and broken—the undignified path of collusion for short-term gains. Unprecedented political choreography can be seen in Nepali politics—a Leftist party forges alliance with the Rightist one striving to get the political benefits of state’s power buttons, defeat rival factions within organizations, devouring opposite parties across the aisle in the parliamentary melodrama, crushing the coalitions so as to exercise de facto power without being in power; these racketeers must be voted out. Regressive, revisionist and extremist ideas through religious fanaticism are steadily gaining strength—as the last local, provincial and general elections have shown—and lurking to plague those inclusive and accommodative socioeconomic and political achievements tossing all the progressive forces aside. Despite their many names, most of the political forces in Nepal have proven themselves as center-left parties. The new custodians of the nation must, therefore, exercise accountability, responsiveness and direct link to the people upholding meritocracy in every move. They should intervene into politics for reforming the education system, public service delivery system and prepare state mechanisms to combat pandemics, climate crises, growing inequalities, rising debt burdens, economic shocks and many other crises that can eventually morph into a greater humanitarian crisis. Other crucial actions for making the state resilient are addressing the recurrent problems of long-standing infrastructure gaps, structural socioeconomic challenges and enormous development needs. They must address challenges of foreign policy priorities resulting from a land-locked geography and encirclement of nuclear powers. Nepal's independence, sovereignty, territorial integrity, freedom, protection of national interest, and promotion of national respect and dignity must always top the list. Additionally, they must internalize the values of sovereign equality, Panchsheel, mutual respect and benefit, among others, something which the existing leadership has largely failed to do. Then comes justice, equality and accountability accompanying the spirit of democracy, human rights and the rule of law. Economic progress and prosperity, ecological balance, human security and conservation of the planet complete Nepal’s foreign policy pantheon. Apart from that, these forces need to comply sincerely with Nepal’s foreign policy priorities so as to shape their foreign policy behavior. A member of the UN’s Peacebuilding Commission, Nepal’s troop contribution to UN peacekeeping missions is the second largest. Nepal was an elected non-permanent member of the UN Security Council twice, in 1969-1970 and 1988-1989, and is now a member of the UNHRC for the second time (2021-2023). What’s more, it’s role is enlarging. Given this context, these forces need to act simultaneously on foreign policy priorities for the neighborhood, South Asia, Northeast Asia, Southeast Asia and the Pacific, Central Asia, West Asia and Africa, Europe and the Americas, regional cooperation—SAARC, BIMSTEC, BBIN etc—not to mention multilateral affairs. They must acknowledge the norms of Non-Alignment while dealing with IPS, BRI, QUAD, RCEP and other strategic and economic global alliances. Nepal is soon graduating from LDC and the nascent leaders must grasp this. To graduate from the LDC category, according to the UNCTAD 2022 report, it must meet the established graduation thresholds of at least two of the three criteria for two consecutive triennial reviews—the Income Per Capita, an Index of Human Assets and an Index of Economic and Environmental Vulnerability. A myopic socio-political vision further worsens the nation’s image. So, pragmatic approaches for enhancement of strong economic diplomacy, promotion of soft powers, jobs for youths in the country, protecting industrial sector, export-oriented industrial policy, modernization of agriculture, promotion of tourism and protection of Nepalis at home and abroad are immediate actions to be taken to get rid of ever yawning socio-economic gaps. It is evident that the government's legitimacy relies on trust of sovereign people. When the people stop believing in it, a government loses legitimacy. People are not like Newton’s ‘mass’ that remains at rest or motion until external force is applied; people regenerate their needs and aspirations, and forces of circumstances create their able leaders to mobilize them. The credibility of established institutions and leadership also are questioned. Presently, widespread distrust toward government mechanisms and state institutions have come to light. Words like democracy, government, service delivery, justice, free press, economic growth and welfare have so far become discredited. We cannot deny pro-public features of democracy. Fascinatingly, public opinion expressed through the recent by-election is a genuine expression of mass frustration and anger. Such consequences reveal distrust and legitimacy gaps in the community. Therefore, we must apply democratic forces for the abrupt collapse of stagnant political dogmas, erratic populism and victory of democracy, multiplicity, inclusiveness, and ultimately the triumph of We the People through a sovereign voting right.