Over the past three and a half decades of political upheavals, Nepal’s healthcare system has remained in a prolonged state of transition. Governance has shifted from a centralized to a federal model. Financing has expanded from a mix of state-funded programs and out-of-pocket payments to include health insurance and growing for-profit incentives. The major scope of care has moved from predominantly preventive to hospital-based services, with increasing focus on chronic non-communicable diseases.
Political instability has delayed or inhibited reforms, yet the intervening profound societal transformations have made restructuring both urgent and unavoidable. Such transformations include a shift from a largely rural agrarian society to a predominantly urban and “modern” one, rapid evolution of formidable new challenges, such as climate change and ecocide, antimicrobial resistance, migration-related health issues, and the unchecked profiteering and commodification of healthcare. At the same time, the transitions in governance, financing, and professional capacity offer new opportunities to reimagine the health system.
Covid-19 exposed deep structural weaknesses in Nepal’s healthcare system. Unlike a few comparable low- and middle-income countries that fared better than Nepal during the pandemic, Nepal lacked a trusted and effective primary care network and a data-driven public health system rooted in communities. Socioeconomic and political factors that had been neglected for decades made it inevitable that the country would struggle to respond effectively.
With the above in mind, here are some changes that I would like to see in the healthcare arena in Nepal.
Bring health to the community through a robust primary care system
In Nepal, “healthcare” is still understood largely as treatment primarily provided in hospitals or smaller health centers. Preventive and public health services that normally can contribute far more in keeping the population healthy are not even considered by many as important health services. The scope of public health services is also largely limited to childhood vaccination programs, maternal and child health programs, and a few other programs run by poorly trained health workers or volunteers.
The services provided at health centers, which the state has prioritized, are naturally more focused on the diagnostic and therapeutic aspects. But real health is produced in households and in communities. Awareness related to hygiene, nutrition and education, the importance of public health services or of avoiding superstition and addiction, and the value of financial security are formed early and determine lifelong wellbeing. Strengthening these socio-economic determinants through family and community-level interventions is the most effective and least expensive investment the state can make in order to raise a healthy nation..
The focus of healthcare must therefore shift from hospitals to households. This requires systematic expansion of a public health system network that reaches every community and is led by well-trained professionals using data, science, and social engagement. Such a system would empower citizens to take ownership not only of their personal health behaviors and lifestyle choices, but also of broader determinants like pollution, food safety, the expanse of vegetation and public spaces, walkability and safety from road traffic in the neighborhood, and ecological sustainability. Only such a system would get the country out of the perennial clutch of food and waterborne illnesses. It would also allow the country to be better prepared for emerging mega-challenges such as atmospheric pollution and ecocide, mental health crises, antimicrobial resistance and novel pandemic threats.
A community-based primary care system, staffed by competent general practitioners, nurses, and health workers trained in community health, and supported by a strong referral network of secondary and tertiary hospitals, is essential for universal, affordable, and equitable care.
Create a National Health Service
Government-run healthcare in Nepal is largely confined to poorly managed and poorly equipped district hospitals and overcrowded provincial or federal facilities. As a result, an estimated one-third to two-thirds of Nepalis seek care from private, for-profit providers. The health market is driven by profit, rewarding overuse of tests and therapies, particularly intravenous over oral medications, unnecessary tests and procedures, including surgeries, frequent visits, and longer hospital stays.
There are no effective legal or regulatory checks on such conflicts of interest. Oversight bodies are weakened by regulatory capture, with for-profit interests deeply entrenched in professional councils, medical associations, education boards, and even government institutions. Over time, this erosion of ethics has spread to public hospitals as well.
Ordinary citizens ultimately bear the cost, facing information asymmetry, stark inequities in access and quality, unsustainable expenses, and a healthcare system that serves poorly for everyone everywhere.
These problems cannot be solved through technical or procedural tweaks alone. Real progress requires realigning incentives toward universal, high-quality, and equitable care, beginning with a planned, gradual phase-out of profit motives in healthcare, as was done in many Western nations where free market capitalism is otherwise idolized. The first step is to reform remuneration and financial policies so that all arrangements creating conflicts of interest in patient care are strictly prohibited.
State-run health institutions suffer from chronic inefficiency, poor management, and lack of direction. There are at least several examples of comparably situated and funded non-government hospitals delivering far better care and higher patient satisfaction with similar resources. Basic protocols for safety and quality—standard elsewhere for decades—are often missing, despite requiring minimal technology or cost.
The health bureaucracy shows little capacity to assess population needs, anticipate future challenges, or use available expertise effectively. It remains overly dependent on I/NGOs to set agendas and even run programs. Weak systems for workforce management, worker safety, and fair remuneration further undermine morale and performance.
This bureaucracy, built without a culture of continuous improvement, struggles to deliver even the basics, such as ensuring paracetamol availability during dengue outbreaks or keeping the population safe from easily controllable scourges like cholera. It cannot be expected to reduce financial barriers to health access, curb out-of-pocket spending, or achieve universal healthcare without fundamental reform.
Nepal’s healthcare system, both public health and clinical, needs a complete overhaul. A National Health Service should be established to realize health as a human right and provide universal care through a unified, adaptable system capable of meeting the evolving health challenges of the future.
Human resource and remuneration policies must be flexible and competitive to attract and retain expertise at all levels. Only such a system can deliver reliable community-based primary care, integrate public health with clinical services, uphold professionalism and accountability, realign incentives toward equity and innovation, and advance quality, efficiency, sustainability, and social justice.
Invest in health education and healthcare professionals’ education
To that end, the Health Education Commission should work with the government or National Health Service to assess system needs for human resources and guide public and private academic institutions accordingly. The immediate priority is to develop skilled human resources in primary care, clinical subspecialties, nursing, allied health, and laboratory sciences. The different levels of the government should financially incentivize both the training and post-training recruitment pathways of critical human resources, such as rural primary care specialists, that are not currently considered attractive careers.
Reorganize budget priorities and expand healthcare investment
The healthcare budget should be increased to match the vision of health as a public good, not a commodity. Health financing must be made more efficient, sustainable, and focused on continual improvement of the standards, scope and accessibility of the services, and on reduced financial burden for citizens and the state. Nepal can learn numerous lessons from other low- and middle-income countries that have built robust healthcare systems through effective health financing. Health insurance should be reoriented for sustainability and impact - but it is only one part of the solution. The state must view healthcare as a long-term, high-return investment in national development rather than just a fiscal obligation.
Build a culture of research and innovation
Health research in Nepal suffers from poor awareness of priorities, lack of rigor and quality, limited funding in a “market” ecosystem, and weak institutional support or even bureaucratic obstructionism. The body assigned with the dual role of regulating research in the country as well as promoting and conducting research—the Nepal Health Research Council—is itself mired in serious conflicts of interest and needs urgent restructuring, retaining only the regulatory functions. Research should be embedded within Ministry divisions, academic institutions and major hospitals and public health units to generate evidence that drives reform. Building such internal research capacity within the government health network (or the National Health Service) is essential for an accountable, self-learning, adaptive, and independent healthcare system.
In conclusion, Nepal’s healthcare reform must be guided by one principle: health is a human right, not a commodity. A unified, science-guided, community-rooted health system—free from perverse incentives and powered by research, education, and public trust—can finally deliver health and dignity for all.
