Keynote Address by Kul Chandra Gautam at Inaugural Conference of
Nepal Public Health Foundation
Kathmandu, 30 June 2010
Let me start by congratulating, most sincerely, our Chairman and other founders, advisors and Executive Committee members of the Nepal Public Health Foundation. It is an enormous honour for me to be invited to deliver an inaugural keynote address on this auspicious occasion.
As I look around the conference hall, I see many great leaders of public health in Nepal. Some of this country’s most renowned and respected medical doctors are here with us. Some of our national policy makers and planners are also with us, as are our key external development partners and civic leaders involved in public health. I feel humbled and awed to be addressing such a distinguished audience.
Public health is defined as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations and individuals.”
There are 2 distinct characteristics of public health:
Mass vaccination is, of course, the most well-known and effective of all preventive public health measures. But many non-medical methods, involving healthy life-styles and behaviour change are central to improving public health. Breast-feeding, hand washing, physical exercise, use of latrines, collection and disposal of garbage, use of condoms or mosquito nets are among the most effective public health measures.
So, how are we doing in terms of public health in Nepal?
Well, we have both good news and bad news. But since we hear so much about the bad news all the time, let me start with some good news, first.
Progress in Public Health in Nepal:
In the field of public health, Nepal has made some significant progress, and it is on track to achieve – and even exceed – quite a few of the Millennium Development Goals – such as reduction of child mortality, maternal mortality, fertility, access to drinking water supply, and basic education.
Under-5 mortality, which is a very sensitive indicator of broader socio-economic development, has been reduced in Nepal by 80% from 250 to 50 per 1000 live births in the past half century. Let me remind you that it took most European countries two centuries to achieve such reduction.
In 1970 Nepal had the 12th highest child mortality rate in the world. By last year, we had moved ahead of 50 other countries, to rank 62nd. Four decades ago, 400,000 children were born every year, but 100,000 of them died before reaching their 5th birthday. Last year, 730,000 children were born, but less than 37,000 died.
Now, that may sound like Nepal has done a good job in child survival, but a bad job in family planning. But actually that is not so. Behind these figures there lies another deep truth – not widely understood: that parents tend to have many children when child mortality rates are high. And they begin to voluntarily reduce their family size only when they feel confident that their first children have a good chance of survival.
In Nepal, we began to see this parental confidence that their first children will survive, around 1990 when child mortality rate had declined by 50 % compared to that of the 1960s. Then, we started seeing a steep decline in both fertility and mortality rates.
Thus, a typical family had 6 children in 1960, 5 children in 1990, 4 children in 2000 and less than 3 children by 2009. Steady decline in child mortality rate, therefore, had quite a direct, though slightly delayed, impact on fertility rates.
What is especially remarkable is that during the last decade, when we had a terrible civil war, with thousands of civilian deaths each year, destruction of infrastructure and interruption of many basic services in rural areas, both child deaths and child birth rates, and even maternal mortality rates, continued to decline sharply.
Yes, we still have huge challenges in public health, but the achievements made so far should not be under-valued.
Some of the greatest success stories in preventing deaths and disabilities in our life time in Nepal have been eradication of smallpox, virtual eradication of polio, virtual elimination of iodine deficiency disorders (IDD) and Vitamin A deficiency, and significant reduction in iron deficiency anemia affecting large numbers of women and children.
As a result of massive distribution of iodized salt, we have seen within a single generation the disappearance of goiter and cretinism, and protection of thousands of children from brain damage and learning disability.
Nepal has one of the best programmes of Vitamin A distribution in the world, reaching 95 percent coverage all over the country. This has led to a significant reduction in night blindness and infant mortality.
Thanks to the very successful polio eradication programme, we no longer have hundreds of children being crippled every year. Leprosy, another debilitating disease, has been virtually eliminated. Iron deficiency anemia which leads to large number of women and children being anemic, lethargic and unproductive, has been drastically reduced.
Overall progress in childhood immunization, including against the deadly disease measles, has helped protect the health and promote the well-being of millions of children.
While we rightly lament the poor functioning of many of our public hospitals and health centres, we must celebrate the exemplary role played by Nepal’s 50,000 female community health volunteers. It is largely because of them, that our Vitamin A, de-worming, polio campaigns, and other public health services have had a massive outreach, even in the middle of conflict, contributing so significantly to good progress towards achieving MDG 4 and 5.
In modern public health, we often speak about the need to address the social, economic and environmental determinants of health across a population, rather than just dealing with a single disease or individual behaviour change. We recognize that our health is affected by many factors including where we live, our genetics, our income, our educational status and our social relationships.
In many of these respects too, there have been some impressive positive developments in Nepal.
Children of Nepal today are healthier, more educated, and more knowledgeable about the world, than in any previous generation. And there has also been much progress in women’s health, education, and their overall status in society, which is so vital for national development.
That is the good news. Now, let me list some bad news.
Disparities and Inequality:
Perhaps the worst of the bad news is that, while we have made good progress in terms of national average, there are huge inequalities and disparities among various population groups. Some of our historically marginalized and disadvantaged communities and population groups lag seriously behind the more privileged communities.
For example, child mortality rate among Dalit, Moslem and non-Newar Janajatis, is twice as high as among Newars and Brahmins. Maternal mortality rate among Moslem women is three times that of their Newar counterparts.
Most of the inequalities and disparities relate directly to levels of poverty. Our most successful public health programme – immunization – has a respectable national coverage of nearly 94 %. But EPI coverage among the poorest quintile of our population is only 68 %.
80% of the wealthiest quintile of our population has access to a health facility within 30 minutes walk, but only 50 % of our poorest quintile has such access.
Narrowing the gap in coverage of essential health services among people of different caste and ethnic groups, different geographic regions, between male and female, and between the rich and the poor, ought to be a high priority for public health in Nepal.
In light of this mixed picture of relatively good progress in expanding essential health services, but major problems of equity – and I might add, of quality – in the provision of health care, what are the biggest challenges and promising prospects for promoting public health in Nepal?
We have all heard of the 10+2 system in education. Today I would like to propose for your consideration a 10+2 agenda for public health in the coming decade in Nepal.
1 Scale-up Essential Health Care
2 Focus on Equity
3 Tackle Malnutrition
4 Prioritize Non-Communicable Diseases
5 Prevent Accidents, Injuries and Disabilities
6 Promote Environmental Health
7 Harness the Power of Education and Communication for Behaviour Change
8 Strengthen Health Systems
9 Foster Public-Private Partnership
10 Capitalize on International Health Partnership
Normally, these 10 action points would be enough to promote strong public health in most countries. But in the current historical juncture of Nepal, I see the need to add 2 other critical actions, outside the health sector, that are vital for our nation’s public health.
The Plus2 elements we need to add in our public health agenda are:
11 Institutionalize a Culture of Non-Violence
12 Consolidate Genuine Democracy
Let me elaborate briefly on each of these 12 points.
While we have made much progress in public health, it is unacceptable that in this day and age, we still have periodic epidemics like the outbreak of diarrhea in Jajarkot and surrounding districts last year. The progress we have made in reducing child mortality is wonderful, but it is of little comfort to the 37,000 mothers who lose a child, and 6000 of them who lose their own lives while giving birth every year.
To have half the country’s children chronically malnourished; two-thirds lacking basic sanitation; and nearly half a million children becoming blind, deaf or otherwise disabled every year is a real tragedy, especially when we know that the majority of these deaths and disabilities can be prevented or treated at relatively low-cost.
We must redouble our efforts to scale-up all of our essential health services – substantially increasing the number of trained health workers, ensuring that there is no stock-out of essential medicines, upgrading health facilities, and even offering conditional cash grants for vulnerable populations to avail of basic health service, as has been done successfully with the safe delivery incentive for pregnant women.
Luckily, Nepal has some good models of health care that can be scaled-up. We have the highly effective network of our legendary FCHVs. The Community-based Integrated Management of Childhood Illness (CB-IMCI) has now been introduced in all 75 districts. Institutions like Tilganga Hospital and Netra Jyoti Sangh are providing eye care services on a massive scale.
Nepal’s new National Health Systems Plan (NHSP-II) outlines in considerable detail how further progress can be made to reduce maternal and newborn deaths, to control communicable diseases, to promote nutrition and food security, to deal with new, neglected, and reemerging diseases, and to find affordable ways of responding to non-communicable diseases.
What we need now is to implement this plan diligently with strong partnerships, enhanced human resources, essential supplies, sufficient funds and reliable monitoring.
I already spoke about inequality and disparity as being major flaws in Nepal’s overall development, including in the health sector.
On the positive side, according to NHSP-II, some significant gains have been made in the last decade in reducing inequalities in access to and utilisation of family planning and child health services between different castes and ethnic groups, as well as between poor and wealthier citizens of Nepal.
There is virtually no inequality among ethnic groups in the incidence of diarrhea or respiratory infections. Disparities in the use of immunisation services have decreased between caste and ethnic groups over the last decade. Except for the Muslim community, inequalities have fallen among other castes/ethnic groups in the use of contraceptives.
Among other factors, elimination of user-fees for certain basic health services has progressively reduced barriers to access by the poor and marginalized communities. Today, essential health care at the sub-health and health posts and Primary Health Care Centres are free of charge to all. At district hospitals, regular as well as emergency services, including medicines, are free of charge to the poor, vulnerable, and marginalized groups, while 40 essential medicines are free of charge to all.
Institutional deliveries are now free of charge to all women nationwide. In addition, payment by the government of transport costs as part of the safe delivery incentive programme is encouraging more women to opt for institutional deliveries.
But some disparities persist. Disparities based on geographic location, gender and levels of poverty are higher and persistent across all ethnic, caste and social divides. We still have a long way to go to ensure equitable access to quality health care across the board.
In this context, I note with some satisfaction that the new NHSP-II contains specific objectives to reduce cultural and economic barriers to accessing health care services by the poor, Dalits, Janjatis, Muslims and deprived Madhesi communities.
I sincerely believe that if we implement NHSP-II faithfully, the health sector can be in the forefront of fulfilling our dream of building a New Nepal of equity and social justice.
Malnutrition poses a huge public health problem among women and children of Nepal. With half the children stunted, 40 percent underweight and 13 percent suffering from acute malnutrition, improving their nutritional status would be the best foundation for public health, as well as for education and overall national development.
A key strategy to improve nutrition is to ensure household food security. But beyond food, control of infections and good caring practices are equally important.
Recognizing this, the Government of Nepal has adopted the targets of MDG 1 and the “World Fit for Children” goals on micronutrients as top priorities. Pilot schemes have been initiated to improve maternal and child nutrition. Evidence-based, cost-effective, community-based interventions have been identified and are ready to be taken to scale.
Improvement in women’s nutrition and health before and during pregnancy; timely and exclusive breastfeeding, quality complementary feeding, provision of vitamins and minerals through fortified foods and supplements, and community-based treatment of severe acute malnutrition ought to be priority interventions. Improved hygiene and sanitation also contribute to tackling infections which exacerbate malnutrition.
Besides causing infection and illness, malnutrition damages the cognitive and physical development of children. It reduces their educational achievement and future earning ability, and thus perpetuates the intergenerational cycle of poverty. On the other hand, investing in nutrition and early child development can unleash a virtuous cycle of human development. Tackling malnutrition should therefore be considered a key, sustainable, poverty reduction strategy.
Historically, and quite understandably, communicable diseases have been at the top of global health priority. But both the global and our national health systems now need to find a way to give greater prominence to non-communicable diseases.
Nepal is now going through an “epidemiological transition” from communicable to non-communicable diseases, such as heart and kidney diseases, cancer, asthma, diabetes, obesity, allergies and stroke. Accidents and injuries, and mental health problems are other growing concerns.
The risk factors for many of these diseases are environmental and lifestyle-related choices such as drug, alcohol and tobacco use, diet, lack of exercise or stress management.
NCDs are now responsible for more than 44% of deaths and 80% of outpatient contacts in Nepal. Most medical doctors and private hospitals dedicate the bulk of their time and generate most of their income from treating NCDs.
The main response to the challenge of NCDs is likely to be behaviour change and adoption of healthy life-styles. Prevention, early detection and control of hypertension and diabetes alone could greatly reduce the burden of the most common non-communicable diseases.
Mental health problems are grossly under-recognized but of growing concern in Nepal. Gender-based and domestic violence, the legacy of conflict, the stresses and strains of modern life, including prolonged family separation because of large-scale migration of labourers for foreign employment, are causing growing psychological stress and mental illness in our society.
There has been a dramatic increase in suicides among women of reproductive age – accounting for 16 percent of all deaths in this age group – and making it the leading single cause of their death. This ought to be a matter of grave concern not just for health professionals, but also for women’s rights activists and national policy makers.
The Government is slowly introducing a mental health component in our national health and social welfare programmes. But the efforts so far are far from commensurate with the magnitude of the problem.
The World Health organization (WHO) estimates that globally 10 % of people in developing countries are disabled. Given Nepal’s poverty, difficulty in accessing health services, poor ante-natal care and high incidence of traffic accidents, and more recently, the consequences of a decade-long violent conflict, Nepal probably has a higher incidence of disability than the global average.
There have been some great success stories in prevention of disabilities through immunization, salt iodization, and Vitamin A supplementation. But much more needs to be done in terms of treatment, rehabilitation and special education
While our traditional child survival efforts have met with much success, accidents and injuries have become increasingly prominent, now accounting for 11% of total deaths, and the leading cause of disabilities.
As we all know from daily news reports, road traffic accidents have grown to alarming proportions. The legacy of 10 years of civil war has led to increasing incidence of violence to resolve not just political disputes but all kinds of local and community-based conflicts – leading to more deaths, disabilities and injuries.
In response to the rising concern regarding accidents and injuries, NHSP-II aims to expand measures including safer driving, wearing of seatbelts and helmets, and improving the capacity to handle injuries from road traffic accidents.
Further prevention, treatment and rehabilitation of people with disabilities merit increased priority commensurate with the magnitude of the problem.
Safe water, clean air, basic sanitation and hygiene are key determinants of public health in any country. These are of critical importance in Nepal as diseases associated with environmental factors such as respiratory infections and diarrhoea are the leading preventable causes of mortality and morbidity in the country.
Ensuring universal access to safe drinking water, sanitation and hygiene ought to be our urgent national priority. In particular, we must ensure that our children grow up in a sanitary environment. Accordingly, besides our households and neighbourhoods, all of our schools must have access to clean water, separate sanitary latrines for boys and girls, and hygienic atmosphere in the vicinity of schools.
Indoor air pollution poses great risk in our smoke-filled rural households. So we must invest in clean energy for cooking, heating and other chores in our households.
Proper hygiene and sanitation is of even more critical importance in urban areas, because of the danger of epidemics in densely populated and congested slum settlements. Urban areas also face great risk of pollution from road traffic and industrial pollutants, piling up of garbage, contamination of rivers and sewerage, chemical effluents and all kinds of other waste materials. To protect the health of urban dwellers, we need to pursue a deliberately eco-friendly urban development policy.
Global warming and climate change are already beginning to negatively impact public health. We must use many policy instruments to tackle these health challenges, including tax incentives and even subsidies for vehicles and machineries that use non-polluting energy sources which minimize carbon emission and greenhouse gases.
Our children should be taught good environmental citizenship. We must protect our environment to save our children, and empower our children to save the environment. We must strive to build a carbon-neutral Nepal for our children and future generations.
The greatest gains in public health in the 21st century are likely to be derived not from medical breakthroughs but from people’s behaviour change.
I recall a remark in the 1980s by a great champion of public health and former Director of the US Centers for Disease Control, Dr. Bill Foege, that it would cost more than $10 billion annually to add a single year to the life expectancy of an average American through medical interventions.
But he said, we could add 11 years to their life expectancy through 4 virtually cost-free actions: a) stop smoking, b) moderate alcohol consumption, c) change certain dietary habits, and d) do moderate amount of exercise regularly.
To these, one could add a few more behavioural changes, especially relevant in developing countries like Nepal, such as: practice exclusive breastfeeding, hand-washing, safe sex and following basic traffic rules. These could immensely help improve public health outcomes.
None of these require sophisticated medical technology, highly trained manpower or huge investments. What they require is attitudinal and behaviour change which can be fostered through today’s amazing information and communication technologies, now penetrating even the poor, remote communities of Nepal.
Let us recall that the greatest and most effective health care provider in the world is the mother. The more we can do to empower her with basic knowledge and skills in good nutrition, care and stimulation of the young child; hygiene, sanitation and better birth spacing, the better the health outcomes for the child, and the family.
Teachers are another group of potential health workers that we tend to under-estimate. Most children spend many years as captive audience of their teachers. A strong school-based health education programme could do wonders to promote public health.
We must harness the enormous power and outreach of radio, TV, newspapers, mobile phones and SMS technology, and the voices of our artists, singers, comedians, sports personalities and other celebrities to disseminate public health messages.
A successful “Health for All” campaign requires the efforts of “All for Health”.
To back up the health-seeking efforts of people themselves, we must have a strong public health system in the country. In recent decades, Nepal has built up a work force of trained health professional and para-professionals, and developed a network of sub-health posts, health posts, primary health care centres, district hospitals and referral services.
Currently, many of these health professionals and institutions perform sub-optimally, and it is our duty to strengthen our health systems to make them more effective.
Nepal has already exploited many of the most cost-effective interventions for reducing mortality and morbidity, and much of its small but rapidly growing budget has been wisely used to finance essential health care services. Further improvements will require a better functioning health system that is able to respond to emergencies 24/7, which, of course, will be more expensive and more difficult to achieve.
Community-based IMCI and other successful programmes are expected to increase demand for referral to higher levels of the health system. To cater to increased demand, strengthening of the health system must command a high priority and increased resources.
There is a critical need to strengthen district hospital services to respond to referral requests from peripheral health units as well as to cater to the increasing demands for basic curative care. Services, such as eye care, dental and mental health care will need to be added and expanded in district hospitals, along with the required human resources, drugs and essential equipment.
Although the Government of Nepal and donors invest heavily in health, some 56 percent of total health expenditure in Nepal comes from private sources. Out-of-pocket household expenditure accounts for 50 percent of total expenditure on health.
Non-state investment in the health sector is quite substantial, although it is concentrated almost entirely in urban areas. Currently there are 13 privately run medical colleges, 17 NGO run hospitals, 17 eye hospitals, 87 private research centres and nursing homes; and hundreds of privately run pharmacies.
The private health sector owns and operates two thirds of Nepal’s hospital beds, and employs around 20,000 people. By reducing the need for Nepalis to go abroad for medical education or for specialist care, the sector is estimated to save Nepal more than NRs. 500 million per year in foreign exchange.
Thus it is clear that private sector plays a very important role in the provision of specialized health care, especially of the curative nature. It is, therefore, important that we foster a more productive partnership between the public, philanthropic and for-profit private sector.
There is considerable room for mutually beneficial partnership between the private and public sector to secure more benefits for ordinary Nepalis. One area crying out for urgent action is to enact and enforce clearer norms and regulations, without the Government becoming involved in micro-managing these institutions.
The not-for-profit sector offers some good examples of public-private partnerships. NGO management of some Government hospitals, NGOs offering family planning, safe motherhood, TB, and HIV/AIDS services, and the prevention and treatment of uterine prolapse, and certain disabilities, are examples of some effective partnerships.
As in many other countries, there are good prospects for contracting out certain service provision and management functions of public health facilities to private sector providers as part of public-private partnership in the future. Another area would be to develop innovative health insurance schemes suitable for Nepal’s needs.
We need to develop a clear policy framework for PPP, to regulate and encourage the private sector to expand services to underserved communities, but without the government being involved in micromanagement. The Nepal Public Health Foundation might take a leadership role in some of these areas.
External Development Partners finance nearly half of Government spending on health. On the whole, the contribution of donors in the health sector has been quite effective. It has produced measurable results of which both Nepalis and donors can be very proud.
Recognizing Nepal’s needs, good performance, and potential for further progress, Nepal was invited to be a founding partner of the International Health Partnership, and signed the IHP Global Compact in London in 2007. I was privileged to be a signatory of the IHP Compact, representing UNICEF at the time, but proud to see that Nepal was one of the few chosen countries.
Nepal’s performance and potential is recognized positively in a number of other global health partnerships such as the Global Alliance for Vaccines and Immunization, the Global Fund to Fight Against AIDS, Malaria and TB, the Micronutrient Initiative, the Catalytic Initiative for Child Survival, etc.
At the heart of the International Health Partnership, there is a mutual commitment to get better results by increasing support for national health strategies and plans in a well-coordinated way. There is also a strong emphasis on shared accountability for results, including through stronger partnership with civil society organizations like the Nepal Public Health Foundation.
Some of our external donor partners help us through concerted efforts to pool their resources and coordinate their actions under the SWAP planning and monitoring processes. Still, there is much room for ensuring greater aid effectiveness to which both Nepal government and EDPs have committed themselves.
Some of the areas for improvement that need to be prioritized are:
– Better guidance by MOPH, and perhaps by NPC, on where non-pool EDPs should focus their support.
– Better alignment of EDP planning and approval cycles with the Nepal Government’s budget cycle.
– Reduction in transaction costs and greater reliance on the SWAp planning and monitoring processes to minimise additional bilateral reporting requirements.
– Agreement to conduct more joint missions, co-financing or “silent partner” arrangements.
– Improved longer term indications of donor support to facilitate planning through periodic informal consultations between GoN and EDPs.
– Stronger commitment by the Government to ensure more rational staff deployment, more vigilant control of corruption and mismanagement.
Under normal circumstances, the above 10 action points should be enough to build the foundations for strong public health in Nepal. However, we live in abnormal times. It is difficult to promote public health when the whole body politic of the country is sick and unhealthy. Hence we need:
11. Institutionalize a Culture of Non-Violence
Today Nepal suffers from a new disease of epidemic proportion – it is called the “culture of violence”. None of our medical schools or schools of public health teach us how to diagnose and treat this disease. Yet, all of us, including medical professionals, are its victims.
We are all familiar with the deplorable kidnapping of high-profile doctors and their family members. Less publicized but more widespread are the daily acts of threats, intimidation, and extortion that affect all segments of Nepali society.
Schools and hospitals are supposed to be “zones of peace”, off-limit for violent and militant activities. But in Nepal they often become hubs of violent political activism.
Whether it is to settle minor local disputes, or partisan issues blown out of proportion, or even genuine grievances that require thoughtful debate, the first and instinctive recourse of our youth and political activists is to call for strikes, demonstrations, shut-down of public transport, disrupting public services, instilling a sense of fear, and inconveniencing innocent people.
Public health services inevitably become victims of this virus of violence that has engulfed our society.
In a democracy, people have the right to protest, engage in collective bargaining, and press their demands peacefully. But rationalization of violence as a legitimate, revolutionary method of political change to justify generalized bandhs, indiscriminate closure of schools, hospitals and businesses that inconvenience innocent people, who are not party to any conflict or dispute, are a blatant violation of citizens’ human rights.
A most tragic development is the widespread availability and use of small arms across the landscape of Nepal. It is estimated that 55,000 small arms and light weapons are in the hands of armed gangs, criminals, private militia, and ordinary citizens.
This is leading to criminalization of politics and politicization of violent crimes. Institutionalization of such a culture of violence and impunity will haunt Nepal for many years to come.
Now, we all acknowledge that ‘structural violence’ of poverty, inequality, exclusion and marginalization has long persisted in Nepal, but widespread physical violence in public life is a recent phenomena and a by-product of the decade-long armed conflict.
Yes, we must fight to end the deep-rooted structural violence in our society, but that does not justify the current wave of indiscriminate physical violence, as two wrongs do not make a right.
As champions of public health and people of goodwill, we must reject this cancer of violence as an acceptable means for achieving any worthy goals.
Most importantly, we must inculcate in the minds and hearts of our children and youth the values of non-violence and peaceful pursuit of all worthy goals. Our children must not be socialized in an atmosphere where political and physical violence is accepted as a part of everyday life.
The World Health Organization defines health as being “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Such well-being is only possible in a full-fledged democracy with a thriving economy in which people can live a long, healthy, productive and creative life offering them many choices in accordance with their needs and interests.
Like so many other countries, Nepal is very far from such an ideal, but the path we seek must lead us in that direction.
To get to that destination, we must learn from our own experience and the experience of others. We must avoid the mistakes of the past and learn from lessons of history – our own and that of others.
For lasting peace and progress of our people, we have no choice but to cast our lot in favour of pluralistic democracy, respect for universally agreed human rights, resolution of conflicts and disputes through peaceful means, and pursuit of a just and equitable society and economy.
Democracy does not produce instant results, and in our impatience and frustration, let us not be tempted to look for other non-democratic short-cuts. We must certainly be open to innovations and experimentation, but let us be careful not to embrace solutions that have been tried elsewhere and have failed.
Above all, let us guard against demagogues who tend to emphasize what divides us rather than what unites us as Nepalis. Let us always look for win-win solutions, and uplifting common ground, rather than trying to radicalize and divide Nepalis into enemy camps as agragamis and pratigamis.
Through our two relatively peaceful People’s Movements, Nepalis have shown that they will not tolerate for long dictatorial and authoritarian regimes. While Nepal is obviously not immune to political extremism and out-dated ideologies, let us search for solutions that will establish Nepal as a mature, egalitarian democracy and a respected member of the international community in a rapidly globalizing world of mutual inter-dependence and human solidarity.
As the level of education and sophistication of our people grows, and as democracy takes deep roots, we can expect the people of Nepal to attain the state of health as envisaged in the WHO definition.
Better health in turn will unleash a virtuous cycle of greater productivity and prosperity, and peace of mind that we all cherish.
I wish the Nepal Public Health Foundation great success in pursuing this noble cause.
Published on Nepali Times