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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.  

In my personal opinion the only positive to come out of the 2015 earthquakes was that many young people went into different villages around the country for the first time. They saw for themselves how people live in rural areas and hopefully came to realize how privileged they were in their homes in Kathmandu, Pokhara, etc. Where we stand now, it’s hard to see any positives from Covid-19 other than we all know how to wash our hands!

Flippant and ridiculous as it seems, earlier we did not know how to properly wash our hands despite our mothers telling us over and over.  And for decades now development organizations have been pushing hand washing as part as their water and sanitation (WASH) projects in villages and communities around the world. The biggest challenge is that water resources are often limited and most communities have shared water taps.

So it was with interest I learned of an innovative yet simple hand washing station which involves no touching of the water ‘tap’.

A few years ago I met Sonia JM when we both worked on the communications team for Jazzmandu. After a couple of years our paths diverged and it was only recently we bumped into each other again.  Sonia was excited to explain about a low-tech hand washing technique she had come across called Tippy Tap. In these days where washing our hands may save our lives, it seemed too good an idea not to share. 

Tippy Tap is particularly useful at community level where one central tap is used. What about using such a thing outside shops that are currently providing a bucket of water for hand washing before entering?  And when we emerge through this nightmare, it would be an excellent facility for village schools.

Sonia explains further: “I was looking through the Facebook page of a friend who works in Africa and came across Tippy Tap. Wow, I thought to myself. This technology would work so well here in Nepal.” Being that Tippy Taps have worked well at community level during epidemics, including the Ebola outbreak in Sierra Leone and in school settings, Sonia says she was surprised they were not being promoted here. And decided to take matters into her own hands (no pun intended).

Just a week prior to the lockdown in Nepal Sonia installed two Tippy Tap washing stations in a project community she is working with through UNOPS HQ and rural based offices of the organization have also been encouraged to set up these washing stations and to promote them to the communities they are working with.  

So what exactly is this great low-tech washing station device?  [JT1] Tippy Taps ensures no one touches any tap since a water-filled container is tipped up to enable hand washing by using your foot to tilt the container.  Soap is hung on a string next to the container. You can even mix disinfectant directly into the water in the container. But Sonia stresses if this is done where children will use it, the soap on a rope is a better idea in case the kids try to drink the water.

Designed and initiated by WaterAid, you can follow the link below to get instructions on how to build a Tippy Tap—which I am told takes only about 30 minutes. Sonia points out that in the longer term “this can lead to long lasting behavioral change in hand washing hygiene and also demonstrate that low cost initiatives can really work. Saves water too!”

Download the super easy instructions from WaterAid here https://www.wateraid.org/uk/sites/g/files/jkxoof211/files/schools-challenge-ks1-tippy-tap-instructions.pdf

The homeless people in Biratnagar Metropolitan City are struggling to ­­make their ends meet during the novel coronavirus lockdown. For the people in the Musahar settlement at Bakhari, Biratnagar-12, the lockdown has been tantamount to a famine. They survive on daily wages, which has stopped since March 24.

A few lucky ones are borrowing from friends and relatives to buy rations. But most of the others do not have anyone who would lend them money or rations.

Bedananda Rishidev, a resident of Bakhari, says his family is trying hard just to survive. “There is no food at home. I don’t know whom should I ask for help,” he says. He used to work as a mason and earned Rs 600 in daily wages. He and his wife have to look after three children. “I don’t have any saving. Nobody will even trust me with a loan.”

Such is also the story of Ashok Rishidev. “I used to work at a few places. But nobody will lend me any money. How am I supposed to look after my family?” He is the sole earner in the family of eight. “I asked for some rice at one place I worked. But they just ignored me,” he says.

Kamali Risidev, a single woman, tried getting help from the ward chairman and local leaders. “But they refused even to meet me. They gave masks to some people,” says Kamali. “I’ve heard we need to wash hands. But there is no soap. And no rice to eat. I fear I will die just like this.”

Another woman in the settlement, Rajkumari, complained that the police come and force them to stay indoors. “But how can I stay indoors? I am hungry,” she says. “We don't have a farm either. How do we feed our children?”

“Some leaders came and met the landowners. But they don’t come to this area,” she adds.

The Musahar people have never seen any elected representative visit their settlement. The last time they met party leaders was when they campaigned for elections. “Before elections, they had promised us they would solve the problems of the homeless and give us lalpurja [land-ownership certificates]. Forget that, they don’t even listen to us when we ask for food during the lockdown,” says Saraswati Rishidev. “Neither the winning nor the losing party leaders have come to our home after elections.”

The Musahars have been living on public land for four generations without land ownership certificates. They live under constant fear that authorities will come to remove them from the place.

“The one who promised us lalpurja has become a minister. But he has never set his foot in this area after elections,” says Bhagalu Rishidev. “They sat on our beds and listened to us before elections. But now we know they are big liars.” There are four Musahar settlements at Bakhari with 260 families. Drinking water pipes don’t go their houses. Nor do they have any toilet in the settlement.

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.