Reimagining Nepal’s healthcare
Over the past three and a half decades of political upheaval, Nepal’s healthcare system continues to undergo transition.
Governance has shifted from a centralized to a federal model. Financing has evolved from a mix of state-funded programs and out-of-pocket payments to include health insurance and growing for-profit incentives. The scope of care has moved from preventive services to hospital-based treatment, with increasing focus on chronic non-communicable diseases.
Political instability has repeatedly delayed or obstructed reforms. Yet profound societal transformations have made restructuring both urgent and unavoidable. These transformations include a shift from a largely rural, agrarian society to a predominantly urban and “modern” one; the rapid evolution of new challenges such as climate change and environmental degradation, antimicrobial resistance, migration-related health issues, and the unchecked commercialization of healthcare. At the same time, ongoing transitions in governance, financing, and professional capacity present opportunities to reimagine the health system.
The COVID-19 pandemic exposed deep structural weaknesses in Nepal’s healthcare system. Unlike some comparable low- and middle-income countries that managed the crisis more effectively, Nepal lacked a trusted primary care network and a data-driven public health infrastructure rooted in communities. Longstanding neglect of socioeconomic and political determinants of health made it almost inevitable that the country would struggle to respond effectively.
With this context in mind, here are the 10 changes that I would like to see in the healthcare arena in Nepal.
1. Bring health to the community: build a robust primary care system.
2. Develop a dynamic public health system from the ground up.
In Nepal, “healthcare” is still largely understood as the treatment provided in hospitals or smaller health centers operated by various levels of government or by non-government entities. Preventive and public health services, which can contribute far more to keeping the population healthy, are often not even recognized as important health services. The scope of public health is narrowly confined to childhood immunization, maternal and child health, and a few other initiatives run by inadequately trained staff or untrained volunteers.
Because state priorities have long centered on health centers, services are naturally focused on diagnosis and treatment. Yet real health is produced not in hospitals, but in households and communities. Awareness and habits formed early in life—regarding hygiene, nutrition, education, the importance of preventive care, the rejection of superstition and addiction, and the pursuit of financial security—determine lifelong wellbeing. Strengthening these social and economic determinants through family- and community-level interventions is the most effective and least expensive investment a state can make to build a healthy nation.
The center of gravity of healthcare must therefore shift from hospitals to households. This requires the systematic expansion of a public health network that reaches every community and is led by well-trained professionals who combine 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 the broader determinants of health—such as pollution control, food safety, green spaces, walkability, traffic safety, and ecological sustainability.
Only such a system can free the country from the persistent grip of food- and waterborne diseases that continue to plague Nepali households—illnesses that most of the world eliminated decades ago using the most basic public health tools. It would also better equip Nepal to confront emerging mega-challenges such as air pollution and environmental degradation, mental health crises, antimicrobial resistance, and future pandemic threats.
A community-based primary care system—staffed by competent general practitioners, nurses, and community health workers, and supported by a strong referral network of secondary and tertiary hospitals—is essential for achieving universal, affordable, and equitable healthcare.
3. Create a National Health Service.
4. Prohibit all financial conflict of interest among healthcare provider organizations and professionals.
5. Phase out profit motives in healthcare.
6. Reform and professionalize the health bureaucracy; improve governance and enhance resilience and adaptability of the healthcare centers.
7. Develop health ministry departments or divisions into centers of expertise and innovation, and end reliance on INGOs and international agencies for health policy and programs.
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 the overuse of tests and treatments—particularly intravenous over oral medications—and encouraging unnecessary procedures, including surgeries, excessive follow-up visits, and longer hospital stays.
There are no effective legal or regulatory checks on such conflicts of interest. Oversight bodies have been weakened by regulatory capture, with for-profit interests deeply embedded 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 burden—facing information asymmetry, stark inequities in access and quality, unsustainable expenses, and a healthcare system that fails to serve anyone effectively.
These problems cannot be solved through technical adjustments or procedural reforms alone. Real progress requires a fundamental realignment of incentives toward universal, high-quality, and equitable care—beginning with a planned, gradual phase-out of profit motives in healthcare as seen in many Western nations where free market capitalism is idolized. The first step must be to reform remuneration and financial policies so that all arrangements creating conflicts of interest in patient care are strictly prohibited.
State-run health institutions are suffering from chronic inefficiency, weak management, and a lack of direction. There are numerous examples of comparably 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 cost or technology.
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, occupational safety, and fair remuneration further undermine morale and performance.
Built without a culture of continuous improvement, this bureaucracy struggles to deliver even basic functions—such as ensuring paracetamol availability during dengue outbreaks or protecting communities from preventable diseases like cholera. Without fundamental reform, it cannot be expected to reduce financial barriers to care, curb out-of-pocket spending, or achieve universal health coverage.
Nepal’s healthcare system—both public health and clinical—requires a complete overhaul. A National Health Service should be established to realize health as a human right and to deliver universal care through a unified, adaptive system capable of meeting the country’s evolving health challenges.
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.
8. Reinvest on, and ensure the highest quality of, health education and healthcare professionals’ education.
Education must target both the public and the healthcare workforce:
For the public: awareness of healthy diet and lifestyles, disease prevention, and ecological health.
For professionals: training in evidence-based public health and clinical medicine, quality improvement, and patient-centered, systems-based care.
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 currentlyconsidered attractive careers.
9. 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.
10. 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.
