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“Every day I lie to comfort my wife that everything is going to be fine but in reality things are falling apart,” says Babu Raja Rajthala. Rajthala had to spent nearly all his wealth when his wife, Kesari, 42, had to undergo renal dialysis for around two years before she could get a new kidney. In the two years, Rajthala had already sold all his properties back home in Hetauda for his wife’s treatment. The long stay in the expensive capital city compounded his financial woes. By the time of the transplant, Rajthala was penniless and he could not even buy post-transplant medicines.

The couple’s children are suffering too. “They can’t contin­ue their college education because I can no longer pay their fees,” Rajthala laments.

It could have been a different sto­ry if the Rajthala family had access to the government grant for kidney failure patients right at the start. His wife received the government grant only after seven months of the operation, by which time even her new kidney was damaged. To make the kidney fully functional again, she has to undertake another round of expensive treatment, and Rajthala family simply does not have the money.

The Rajthalas are far from the only sufferers. According to the Health Ministry, around three million Nepalis suffer from kidney-related diseases, and there are currently more than 30,000 patients whose kidneys have failed. That number increases by 3,000 every year.

Renal disease is considered dan­gerous in Nepal, as the patients can live only if they can afford the expensive treatment.

Limited options

Those diagnosed with kid­ney failure have only two options—to undergo dialysis for the rest of their lives or get another kidney. Both processes are costly. Dial­ysis—in which an exter­nal machine temporarily replicates the functions of healthy kidneys—doesn’t cure the underlying dis­ease. A patient has to undergo dialysis 2 or 3 times a week, depending on the severity of the problem. The procedure costs Rs 6,000-9,000 a week; whereas it costs around Rs 400,000-500,000 to transplant a kidney.

The government made dialysis and kidney transplant services free from 2016-2017 and the services are now being provided in over 50 private and government hos­pitals across Nepal. For a single patient, the government bears almost Rs 550,000 on kidney trans­plant and Rs 2,500 per dialysis. The total yearly subsidy comes to over Rs 1 billion a year.

“There have been no recent studies but I believe the government initiative has encouraged more people to seek treat­ment, which has saved many lives,” says Dr Pukar Chandra Shres­tha, Executive Direc­tor of Human Organ Transplant Center (HOTC) at Bhaktapur.

Many patients, few machines

But according to data from the Department of Health Services (DOHS), until May 14, 2018, there were only 410 dialysis machines pro­viding completely free services. The patients outnumber the machines by a huge margin.

“Every day, the number of patients is increasing whereas the number of machines remains con­stant,” says Dr Rajani Hada, Head of Kidney Department at the gov­ernment-run Bir Hospital. “Also, the existing machines are occupied by old patients who need continuous treatment, sometimes preventing the new patients from enrolling.” According to Hada, a dialysis session lasts around four hours and even if the hospital manages to work in three shifts on a single machine, only three people can receive the treatment per day.

Jung Bahadur Thapa Magar, a patient who recently got a kidney transplant at HOTC, chose to ignore the free service and opted to pay out of his own pocket so he could receive timely treatment.

“It takes around 1-2 months to complete the formalities for free services,” says Magar. “Even after that, there is no guarantee of timely service.”

Government officials corroborate his claim. “It takes a minimum of four months to pro­vide the money to the victim,” says Prakash Ghimire, an officer at the DOHS. “The decision-making is dismally slow in our health bureaucracy.”

There are currently more than 450 patients registered for free dialysis at HOTM, many of them on the waiting list. New enrollments have been can­celled as there are not enough dial­ysis machines to meet the demand. Many of the existing machines are not functional or only partly so. In Bir Hospital, 19 dialysis machines lie unused because there aren’t enough trained human resources.

The medi­cines are expensive too. The government provides almost Rs 150,000 to every kidney patient to buy medicines after a transplant. But often that is not enough. In order to protect the newly transplanted kidney, a patient has to rely heavi­ly on medicines. The monthly bill for medicines comes to around Rs 20,000-25,000 for a couple of years after the transplant. Gradually, the cost decreases to Rs 10,000-12,000 a month, which is still expensive considering that the patients have to consume medicines all their lives.

Bimala Basnet’s 14-year-old daughter Binisha has been under­going dialysis for two years. Basnet, who sells fruits inside the HOTC premises, has an unpleasant impres­sion of transplant. “I’ve only seen transplant end people’s lives. I don’t recommend it unless the patient’s family has at least Rs 500,000 in reserve,” she says.

Ghimire of DOHS feels providing medicines to hospitals would be more effective than giving cash to the victims, and says that a review of the existing mechanism is already underway.

Prevention is cure

Nephrologists are pushing the idea of kidney transplant as a per­manent cure, but lack of human resources and infrastructure and unclear rules are major hurdles. As per government rules, only relatives can donate a kidney to a patient.

“This limits the availability of healthy kidneys. Moreover, kidneys may not match even among rela­tives, and older people’s kidneys are not healthy enough,” says Dr Dibya Singh Shah, Professor and Head of Department of Nephrol­ogy at the Tribhuvan University Teaching Hospital in Maharajgunj. According to a DOHS report (July 16, 2016-May 14, 2018), only 203 could get new kidneys in the period.

Health prac­titioners in the field blame the government for introducing the free services without proper homework. Renal diseases can be easily cured if diag­nosed early, they say, and yet there is no initiative in early diagnosis and prevention.

The average cost for a kidney test is only Rs 300. Health practitioners believe that establishing health clinics across the country and pro­moting regular check-ups is the right way to go about it. Also, there is a need to decentralize dial­ysis services away from major cities.

“Those with dysfunctional kidneys need lifelong dialysis. How can a poor person afford it?” Shah asks rhetorically. “If only the focus shifted to prevention, things would be much better. Until then, it’s a vicious circle of medications and surgeries.”

With the number of kidney patients steadily rising in what is still a poor country, how long the government will continue to support kidney patients is also an open question.

Anil Chaudhari, the 23-year-old son of Gita Devi Chaudhari and Shyam Kishor Chaudhari, has been sentenced to death in Qatar. “Please save our son. We’ve heard he’s being executed. He’s our only son,” Gita Devi and Shyam Kishor beseech anyone who visits their home in Aurahi Municipality-1 in Mahottari, a district in the central plains. They frequently break down and weep, or make a plea to God. Besides Anil, Gita Devi and Shyam Kishor have two daughters, both of whom are married. The Chaudhari family is in profound anxi­ety ever since Anil, who went to Qatar three years ago as a migrant worker, was sentenced to death by firing squad on the charge of murdering and robbing a Qatari national Umair Mohammed Umair Al Ramzani Al-Nauimi. Anil used to work as a general laborer in a car wash company.

Just before his arrest 14 months ago, Anil was planning on returning home within a year. Before the death verdict, his family was under the impression that he had committed a misdemeanor. He had told his family that he hadn’t done anything wrong and that he had been held for investigation. Anil’s parents were therefore hopeful that he would be eventually be released.

He still talks to them on the phone. “I won’t live. I won’t be able to come home,” Anil tells his parents. “We don’t cry on the phone, because if we do, he will too. So we maintain poise and talk cheerfully with him to boost his confidence,” says Shyam Kishor. “He is our only hope for old age; we haven’t been able to think straight.”

“We pray to God day and night and implore the Nepal government to get our son free. In return, we are willing to give all our property to the government,” says a grief-stricken Shyam Kishor.

Shyam Kishor and Gita Devi had taken a loan of Rs 150,000 to send Anil to Qatar. The couple live in a rented room after their house was damaged. They have some land and run a small shop in a pushcart. But ever since Anil’s conviction, they have can neither focus on their business nor take good care of their health. The worry has made them emaciated.

They had dreams of building a new house after Anil’s return. They were also looking for a bride for him. Such dreams have been dashed. Shyam Kishor has already spent around Rs 60,000 on his trips to Kathmandu to knock on the government’s doors and beg for his son’s life. He is not ready to give up yet, even if that means he has to take more loans.

The Nepali embassy in Qatar is coordinating with the Ministry of Foreign Affairs to make an appeal on Anil’s behalf. The embassy has filed a case in Qatar’s appellate court.

The recent India-China rapprochement has been intrigu­ing to observe from here in India. Open a random news­paper or flip through the TV news channels, and there is bound to be a news story on how India and China have decided to ‘cooperate’ rather than ‘compete’. Most recently, Indian Prime Minister Narendra Modi, while speaking at the Shangri-La Dialogue forum in Singapore, made it clear that India pursues an independent foreign pol­icy and does not believe in joining any (read: pro-US) bloc. But in the next breath, he added that India is firmly in favor of unhindered and open navigation in South China Sea. This was in reference to what India and the West see as China’s ‘militarization’ of this vital global trade route.

Interestingly, the very next day, He Lei, a top Chinese general who was heading the Chinese delegation at the forum, termed Modi’s rather blunt statement on South China Sea ‘positive’. There clearly are renewed efforts to defuse old Indo-China tensions, even if the leaders of the two countries sometimes have to say provocative things to please their domestic constituencies. These efforts stem largely from the realization that only if the two Asian powers work together can they effectively counter Donald Trump’s protectionist tendencies.

As Prime Minister KP Sharma Oli is set to embark on his official trip to the northern neighbor, what does this thaw­ing of Indo-China ties entail for Nepal? If there is a level of understanding between Modi and Chinese President Xi Jinping on how to deal with other smaller countries in the neighborhood, it could mean India would have fewer qualms about Nepal reaching out to China.

But therein lies the danger. As happened with the 2015 Indo-China bilateral agreement on the Lipulekh tri-junction, vital issues of Nepal’s interest may increasingly be decided in Beijing and New Delhi. In the dealings between big powers, the interests of smaller players can often be ignored. This is why the Nepali foreign policy apparatus as well as PM Oli will have to be proactive in maintaining open and extensive channels of communication with both India and China.

In his second term as prime minister, Oli has been largely successful in performing the delicate balancing act between India and China. But unless our foreign ministry apparatus is also strengthened to quickly respond to emerging foreign policy challenges, and to come up with long-term strategies to back the prime minister’s international outlook, his efforts alone may prove inadequate o

The federal budget unveiled on May 29 by Finance Minister Yubaraj Khatiwada has expand­ed revenue base and emphasized job creation, with the ultimate goal of improving the lives of ordinary citizens. In other words, the budget attempts to make positive changes in the lives of low-income people by taxing high- and middle-income individuals. While individuals with annual income of over Rs 2 million have to pay a high tax rate, those earning below Rs 400,000 have to pay only 1 percent income tax. In fact, the budget tries to change other forms of taxation, not just income tax. Such amendments are aimed at bringing everyone into the tax bracket. This entails not just more transparency in financial transactions but also systematizing them through banking channels.

In a society with a huge infor­mal economy, the budget tries to convey another message as well: stop over-consumption. The hike in excise duties on motorbikes with engine capacity higher than 150cc and other vehicles over 1000cc capacity hints at this message. This has reinforced the old mentality that vehicles are luxury items.

The auto sector, which contrib­utes annual taxes worth some Rs 1 billion, had been slowly collapsing after the tightening of auto loans in 2017. The budget has dealt another blow to the sector. Anjan Shrestha, former chairman of Nepal Automo­biles Dealers’ Association, says, “We may not be able to rise again. This budget has wrecked our sector.”

Tightening the screws

The auto sector is but one exam­ple; the budget has caused many other entrepreneurs to lose sleep. The private sector in general will bear the brunt of the chang­es in tax­ation. The first hint of it came right after Khatiwada was appointed finance minister, when he issued an instruction to tighten customs pro­cedures. Implicit in his instruction was the intent to stop indiscriminate imports, which have increased sig­nificantly in recent times.

Khatiwada also made life diffi­cult for small businesses that were already in dire straits since the Goods and Services Tax (GST) came into effect in India in July 2017. The finance minister’s thinking is also reflected in his encouragement of the use of letters of credit. In other words, he wanted to curb import transactions carried out through other payment methods besides a letter of credit.

Finance Minister Yubaraj Khatiwa­da acknowledges that implementing the budget is a challenge. In a review session on May 30, a day after the budget, he said, “Businesses have to pay their due to the state. Those who don’t fulfil their responsibilities will be made to do so from now on.” He added that tax evasion has been categorized as financial crime and those committing it won’t be spared.

Despite many improvements in the taxation system, the revenue col­lection won’t be enough to finance current expenditure. This will exert heavy pressure on the government’s current account from the very first day of the upcoming fiscal. The cur­rent account is already strained as the national budget has to be allocated to three tiers of govern­ment. Data from the central bank indicate that in the first nine month of the current fiscal, the country is running a current-account deficit of Rs 171 billion. The economy will face further complications if rising imports cannot be curbed.

The production equation

Economist Madan Kumar Dahal thinks that the budget tries to incor­porate all sectors. Nonetheless, “the 8 percent growth target will be dif­ficult to achieve without a 40 per­cent capital expenditure. Because the revenue collection won’t be enough for even regular expenditures, high domestic and foreign loans will be necessary,” he says. The budget has set a target of 23.9 percent cap­ital expenditure for the next fiscal, 0.1 percent lower than the current fiscal’s capital expenditure.

In the review session, Khatiwada said that the budget rolls out red car­pet for investors in export-oriented industries. But although the finance minister stresses export promotion to reduce the country’s ballooning trade deficit, the task is easier said. Instead of focusing on export pro­motion, it might be better to raise domestic production in order to reduce imports.

In a meeting of the Nepal Commu­nist Party Parliamentary Committee held on May 30, Prime Minister KP Sharma Oli extolled the budget, claiming that it was the best-ever. “This budget will help the coun­try acquire a ship and will bring railway lines to Kathman­du.” He asked everybody to lend their support to the budget, which he argued paves the way for prosperity and, ultimately, socialism.

Others, however, are less san­guine.

Former vice-chairman of the National Planning Commission Govinda Raj Pokharel thinks that the budget has spoilt the country’s investment climate. “The taxation system is unreasonably harsh on the private sector. This won’t help boost private investment,” he says.

To increase investment, the gov­ernment, the private sector and the international trade organizations all have important roles to play. Attracting foreign investment calls for a favorable investment climate. Former finance minister Ram Sha­ran Mahat thinks the budget has completely failed on that front. He also thinks that an 8 percent growth rate is talk only.

Flying horse, crawling snail

Former Prime Minister Baburam Bhattarai derided the budget by comparing it to a famous children’s game (one in which they expect a fish but get a frog instead). Imme­diately after the conclusion of the budget speech, he tweeted, “In all respects, this budget is a continu­ation of previous ones. What was needed was structural change to make a leap toward prosperity. That was seen neither in revenue col­lection and domestic and foreign investments, nor in regional alloca­tion and devolution of authority to provincial or local levels.”

As Bhattarai claims, the federal budget incorporates even the tasks that the constitution has devolved to the local level government, such as the construction of zoos, tourist trails and handicraft exhibition cen­ters. Such provisions, coupled with frugal capital expenditures, indicate that the budget is populist.

Nepali Congress came down heav­ily on the budget. “On the cam­paign trail, the parties heading this government claimed that the NC’s economic policies were flawed. But this budget is a strange hodgepodge of NC’s policies and communist orthodoxies,” NC central working committee concluded a day after the budget’s announcement. “It prom­ises to be a flying horse, but one that delivers results at a snail’s pace.”

BY SHREEDHAR KHANAL | Kathmandu