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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.

Lorenzo Viviani’s ‘Leadership and Democracy: A Political Sociology of the Personalization of Leadership’ examines how political leadership is transforming in contemporary democracies. He argues that power is increasingly personalized, shaped by the charisma, image and populist styles of individual leaders. These developments, Viviani explains, redefine leadership, legitimacy and democratic institutions. To understand modern leadership, he emphasizes, one must analyze how the relationship between leaders and voters is evolving and what factors shape perceptions of legitimacy and trust (2024). 

Nepal’s recent political developments can be interpreted within this framework. The youth-led protests of Sept 8–9 raised profound questions about leadership, legitimacy and governance. A major turning point came earlier that month, when the government imposed a social media ban on Sept 4. The subsequent protests not only forced the government’s resignation but also fundamentally reshaped Nepal’s political discourse. A lack of transparency, declining charisma among political leaders and the rise of populist rhetoric were central to this crisis.
Thousands of young people mobilized against the Oli government, accusing it of authoritarian behavior and widespread corruption. Tragically, security forces killed a number of protesters and injured many others on the first day. The government’s response was marked by indifference; no cabinet minister resigned or expressed remorse. 

Instead, officials used harsh language against demonstrators, exposing the regime’s authoritarian tendencies despite its democratic mandate. Public anger intensified, and by the second day, the protests had turned violent. Government and private properties, including the Prime Minister’s Office, the Supreme Court and residences of political figures, were set ablaze. Unable to control the situation, the Oli government resigned, and the prime minister was evacuated under military protection. Prominent figures, including Nepali Congress leader Sher Bahadur Deuba, were assaulted by crowds in an unprecedented display of public outrage.
In the aftermath, an interim government was established under former Chief Justice Sushila Karki, with a mandate to conduct parliamentary elections within six months. From a conflict studies perspective, this transition offers valuable insights into the erosion of democratic legitimacy and the interplay of leadership, governance and populism. 

The Oli administration had failed to meet public expectations, relying on nationalist rhetoric as a political survival strategy rather than pursuing genuine reform. His government’s verbal attacks, manipulative politics and outdated economic vision alienated the public. Instead of strengthening institutions, it punished opponents selectively and used the justice system for retribution. Transparency collapsed, and bureaucratic inefficiency appeared to serve as a shield to corruption.
The decline of charisma among Nepal’s political elite further deepened the crisis. Charisma, in this context, refers not to personal appeal but to visionary leadership and moral authority. Long-standing political leaders failed to articulate a compelling national vision. The traditional rhetoric of democracy, development and prosperity no longer inspired the youth. Dominated by aging figures with conventional mindsets, major parties have struggled to deliver tangible progress, leading to public disappointment. When leaders lose moral grounding and credibility, authority inevitably weakens. 

Figures such as KP Oli, Sher Bahadur Deuba and Pushpa Kamal Dahal saw their influence erode as perceptions of self-interest and moral decay grew. Their visible wealth and comfort contrasted sharply with public hardship, reinforcing cynicism. The resulting collapse of charisma contributed to governance instability and accelerated democratic erosion.
Neo-populist trends also played a critical role in Nepal’s recent upheaval. Both emerging and established leaders adopted populist strategies to gain influence. Within the Nepali Congress, Gagan Thapa’s campaign for youth leadership directly challenged the establishment authority of senior figures such as Sher Bahadur Deuba. While the movement mobilized younger voters, it often prioritized personal ambition over institutional reform and civic education. 

Although frustration with the older generation’s corruption and stagnation is understandable, turning to populist shortcuts risks further democratic erosion. Leaders propelled by populist appeal frequently weaken institutions, restrict civil liberties and centralize power, even when elected through democratic means. Consequently, Thapa and his allies, despite their electoral legitimacy, risk undermining Nepal’s fragile democratic foundations if populism continues to define their political trajectory.
As Viviani observes, political power has become increasingly personalized. Nepal’s youth movement and subsequent political transition exemplify how populist manipulation of public discourse can disrupt democratic stability. 

Fueled by technology and vast, often misleading information flows, young protesters demanded instant transformation and prosperity. 

However, the absence of civic education and unrealistic expectations led to frustration and destructive outcomes. The violence and instability that followed severely damaged Nepal’s international standing. Foreign investors, already cautious, became even more hesitant. The destruction of historic landmarks, private enterprises and public infrastructure symbolizes not renewal but regression. Ultimately, the crisis has left Nepal more polarized, ego-driven and fragile, posing serious challenges for the nation’s democratic future.
Nepal’s recent political crisis reflects the growing personalization of power that Viviani describes in Leadership and Democracy. The 2025 youth-led protests, sparked by government repression and corruption, exposed the collapse of transparency, moral leadership and public trust. As traditional leaders lost credibility and populist figures rose, Nepal’s democracy weakened further, marked by violence, institutional decay and deep generational frustration with unfulfilled promises.

The Supreme Court  has begun preliminary hearings on more than a dozen writ petitions challenging the formation of the interim government led by Sushila Karki and her subsequent decision to dissolve the House of Representatives (HoR) before the end of its term.

The Constitutional Bench of the Supreme Court will hear a total of 16 writ petitions. Chief Justice Prakash Man Singh Raut has already given his consent to forward all cases to the bench. The petitioners have argued that Karki’s appointment as interim prime minister is unconstitutional, as Nepal’s 2015 Constitution does not allow non-members of Parliament to assume the prime ministerial position.

Furthermore, while appointing her as prime minister, no specific constitutional article was cited. The Office of the President has argued that Karki was appointed under Article 61 of the Constitution, which relates to the president’s duty to safeguard the Constitution. However, in 2015, all provisions related to the formation of government were clearly outlined under Article 76. Karki was appointed interim head following the GenZ protests on Sept 12.

Another argument raised by the petitioners concerns Article 132(2) of the Constitution. Lawyers Bipana Sharma and Ayush Badal contend that a former chief justice cannot hold any government office except within the National Human Rights Commission (NHRC). Article 132(2) states: “No person who has once held the office of Chief Justice or a Judge of the Supreme Court shall be eligible for appointment to any government office, except as otherwise provided in this Constitution.”

This means that, except for roles in the NHRC, former chief justices and Supreme Court judges cannot assume any other government positions. However, those in power argue that the current government emerged from the GenZ revolution, and therefore, its constitutionality and legality should not be judged through the lens of “normal times.”

Nepal had faced a similar situation in 2013, when then–Chief Justice Khil Raj Regmi led an interim government. His appointment was also challenged in the Supreme Court, but the court delayed its hearing until after Regmi stepped down upon completing the elections. Later, Supreme Court judges were divided over the verdict. Interestingly, current Prime Minister Karki, who at the time was serving as a senior justice, had expressed that Regmi’s appointment went against the spirit of the interim constitution. Now, legal observers are keen to see how Karki will defend her own appointment.

Karki faces three major constitutional challenges: A non-parliamentarian assuming the office of prime minister; the lack of any cited constitutional article in her appointment by President Ramchandra Paudel; and the restriction under Article 132(2), which bars former justices from holding government office.

Similarly, several writs have been filed against the dissolution of the House of Representatives. Shortly after taking office, Karki recommended to President Poudel that Parliament be dissolved. Reports suggest that Karki believed she could only serve as prime minister after Parliament’s dissolution. Media sources also claim she faced pressure from Kathmandu Mayor Balendra Shah to dissolve Parliament immediately. Legal experts, however, argue that Karki’s appointment was justified under the “doctrine of necessity.”

Still, constitutional experts point out that, under Article 76(7), the prime minister can recommend dissolution of Parliament only after all attempts to form a new government have failed. On this very basis, the Supreme Court in 2020 and 2021 had reinstated the Parliament dissolved by then Prime Minister KP Sharma Oli, ruling that the House could still produce a new government. The current House of Representatives, elected in 2022, is set to complete its term in 2027.

As the Supreme Court prepares to begin hearings on the 16 petitions, the prospects of the March 5 elections look increasingly uncertain. Dialogue between the government and political parties has begun, but it has not helped rebuild trust. Political leaders continue to raise concerns about security, saying they still fear openly holding meetings and rallies. Nepal Police has yet to recover the 1,200 weapons looted during the Sept 9 protests, and more than 4,000 escaped inmates remain at large and reportedly involved in criminal activities.

Party leaders claim they are still receiving threats. In this context, if elections do not take place on March 5, the interim government may lose its legitimacy, creating a new political vacuum. Senior leaders of the Nepali Congress and CPN-UML argue that the only way to preserve the current Constitution is for the Supreme Court to reinstate Parliament.

They contend that restoring Parliament would provide a legitimate institution to address the demands of the GenZ protesters, including ending corruption, ensuring systemic reform, and curbing nepotism. NC and UML leaders also say that, as their party offices have been destroyed and many leaders have lost their homes, the current environment is not conducive to holding elections.

Devraj Ghimire, Speaker of the dissolved House of Representatives, is also strongly advocating for Parliament’s restoration. He is currently consulting with legal experts to create a constitutional and political pathway for the reinstatement of the House.

With less than 120 days remaining for the March 5 elections announced by the government, the political and security environments are far from ready. The country’s security situation remains fragile, and the morale of security agencies—particularly the Nepal Police and the Armed Police Force (APF)—is notably low. Half of the inmates who escaped during the Sept 9 jailbreak have yet to be recaptured, and the looted weapons remain untraced.

Tensions also persist between political parties and some GenZ groups, while party leaders continue to express doubts about the overall security preparedness. The government has yet to unveil a clear election strategy, and crucial talks between top political parties and the government have not begun. Prime Minister Sushila Karki remains hesitant to meet major party leaders, deepening the political uncertainty.

Of the three major parties, the Maoist Center has decided to contest the elections, the Nepali Congress remains undecided and the CPN-UML is demanding the restoration of Parliament. Relations between the Karki-led government and CPN-UML are particularly strained. Without securing the confidence of the main political forces, it will be an uphill battle for the government to conduct credible elections.

Since assuming office, PM Karki has taken a rigid stance toward major political parties. While public sentiment may favor leadership changes within those parties, it is not the government’s role to dictate internal party affairs. Reports suggest the government is reaching out to mid- and lower-level leaders rather than engaging directly with top leadership—a fundamentally flawed approach that undermines trust.

The international community is closely observing whether this government can deliver elections on schedule. The primary mandate of the Karki administration is to hold timely and credible elections. Failure to do so will raise serious questions about the government’s legitimacy and purpose.

We urge the government to act swiftly, initiate dialogue with political parties and foster a conducive environment for the polls. The Election Commission must also actively coordinate with parties to ensure preparation and confidence. Nepal cannot afford another cycle of political instability driven by ego and mistrust. Political parties must act responsibly, but the ultimate responsibility lies with the government to lead decisively and ensure elections are held on time.