11Aug2022

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Category: Policy Compendium

Policy Compendium

Evolving Roles of ICT in Nepal’s Education Sector

RUBIN Singh Maharjan

Abstract

Education is one of the most important aspects of human beings that drives human skills, art, and creativity. Without education, human values and ethics do not come along.  But since last March 2020, the physical classes have been completely closed due to the Covid-19 pandemic. As an alternative ICT (Information Communication Technology) came along creating an opportunity for online education that flourished around the world. An immediate shift from regular physical classes to online classes was a big jump for both teachers as well as students but there was no other alternative. Due to this the demand for internet users as well as mobile penetration has increased. The digital divide has been accruing since then as many students could not afford expensive mobile, television, and laptops of their own. From the government level, many policies related to ICT and different actions have been playing from the local level regarding ICT development. Technology has taken more control over our lives now as mobility is strictly prohibited. During this pandemic time, new policies related to ICT and different technological support have been taken to make sure that the flow of the teaching and learning process is not disturbed.

Introduction

Education has become one of the prime challenges for a developing nation like Nepal where poverty and bad governance are the crucial aspects that are keeping people away from education. Looking into the history of Nepal’s education system at the beginning from religious education in Temples, trusts, and monasteries literacy was started. Nepal did not have its education policy until 1939.  At the beginning of modern education itself, the Rana regime kept restrictions on education access in the education ordinance of 1939 manifested Rana policy made Nepalese people fall further behind in educating their citizens. In 1939 School Leaving Certificate (SLC) was recognized but still, the whole examination was conducted and controlled by Patna University in India which was slowly controlled by Nepal till 1947.  From 1951 to 1971 Liberal Policy of the government expanded access to education which brought a greater number of attendances in the education sector opening education for the general public. Focusing on School education in 1952 the Ministry of education was established. In 1954 National Education Planning Commission (NEC) was formed that reviewed the education situation and gave the suggestion to the government for the first time for financing in the education sector. This supporting information from the National Education Committee expanded access to education in 1961. The help of the United Nations’ technical cooperation for human resources and physical development for primary education by adopting the policy of partnership between government and the communities brought many changes in the education sector. The policy of School-based management was running during 1960.

In the area of education policy in Nepal, the congress government in 1959 adopted the policy to expand primary education by establishing one primary school in each election booth which supported more area coverage of schooling. By 1990 National Education System Plan (NESP) was formed but it lacked in addressing the nationalization of the education system. As soon as the Panchayat system prevailed NESP ended and in 1992 National Education Commission was appointed which gave a correction to the previous education policy. In 1998 a high-level education commission was formed and by 2008 the expansion of private education started booming around the country.

Nepal’s first education development plan was made in 1956 that focused on primary education and in 1971 National Education System Plan (NESP) was initiated that looked into school curriculum along with vocational education. From 1970 to 1990 the whole education system focused on giving equal access to education for both males and females and focusing on disadvantaged communities were the major target group. As it consisted of education for rural development (Seti Project) from1981 to 1991, primary education project from 1 983 to 1992, primary education development project from 1992 to 1998, basic and primary education project Part I and II from 1994 to 2004, and finally from 2004 to 2009 education for all program was started. So, we can see that expansion and maintaining access to education was the major focus area. Later in 1990, the Millennium Development Goals stated a global world target of education for all by 2015. (Consultants, 2009)

ICT (Information Communication Technology )

The term ICT is also used to refer to the convergence of audiovisual and telephone networks with computer networks through a single line system. There are expensive financial motivating forces to combine the phone arranger with the computer organize framework employing a single bound together framework of cabling, flag dissemination, and administration. Tools of communication like radio, TV, cell phones, computer and organized equipment, video conferencing, and remote learning. ICT implies the utilization of computer-based innovation and the Web to form data and communication administrations accessible to a wide range of users. (Tomar, 2021)

According to UNESCO, “Diverse set of technology tools and resources used to transmit, store, create, share or exchange information. These technological tools and resources include computers, the Internet (websites, blogs, and emails), live broadcasting technologies (radio, television, and webcasting), recording broadcasting technologies (podcasting, audio, and video players and storage devices), and telephony (fixed or mobile, satellite, Visio/video-conferencing, etc.) ” (UNESCO, n.d.)

General Objective:

To study the different provisions of ICT in the education of Nepal

Specific Objective:

1.      To find out the different policies made under ICT learning till now and its progress

2.      To find out about Government action during the covid-19 pandemic in the area of ICT development in the education sector

Methodology

The study followed a qualitative research design where means of secondary data from different research papers as well as newspaper articles had been taken to bring out different analyses from this research paper. The study area was specifically focused on Nepal as well as it has tried to compare with south Asian Countries and has brought different results from these authentic sources. Due to the Covid-19 pandemic situation, physically taking raw data was not possible so with the help of secondary data the following research took place. One of the metropolitan cities “Lalitpur” was taken for a detailed interview to get to know more about the grown reality of Nepal. 

ICT Policy Review

1st to 7th Plan of Nepal and its focused areas

From 1956 to 1990 the plans of Nepal in the area of education particularly focused on maintaining the quality of a school by funding a particular budget in the area of school staff, suppliers, services, and administration. With the increase in budget in a different year of planning. It also focused on power decentralization by giving authority to the district and preferred more local government schools. Provision of free education from 1 to 3 grade in all public schools. Also incorporated free education but did not play a good role. Another major objective was to increase access to school and this encouraged the private sector to open and operate the school and Early Childhood Education Development (ECED) centers. This also gave importance to female teachers to attract more female students to attend the school. Mainly poor and diligent students were focused on scholarship provision.

ICT and 15th Plan of Nepal

Curriculum-based on the development of human resources, infrastructure and technology, and life skills mainly digital learning materials will be developed to assist the teaching and learning process for English, Maths, Science, and technical subject. It also addresses ensuring life-long learning by connecting learned knowledge and skills with income-generating programs through informal education and alternative learning of electronic-library services at the local level.

In the area of the social sector in education, the 15th Plan mentions education and its technology-based learning where it says that the provision will be made for mobile programs on skills development and training to ensure the prescribed quality of technical and vocational education are focused. More technical stream education will be conducted in every community school. Innovative technology will be included in schools and university curricula as appropriate to utilize innovative technology.

ICT development In Education Policy of Nepal

Policy development from 1951 to 1990 there are some the areas where technical education and vocational training have been mentioned including non-formal education, distance education, and open learning as a starting phase for ICT development in the education policy of Nepal can be seen.

According to Master Plan 2013-17 in the part of Information and Communication Technology (ICT) in Education policy it says,

 ICT Policy 2010 states access to the Internet to all schools, national and international skilled human resources, promotion of Industry-Academia collaboration IT programmers focusing on students, teachers, and schools.

The School Sector Reform Plan (SSRP) states that ” ICT assisted teaching/learning will be implemented and expanded in all schools”. Alternative modes of schooling, distance learning by the Ministry of Education (MOE) is to develop learning support materials to enhance the quality of education through the use of ICT.

According to the three-year plan 2011-2013 of the government of Nepal policy related to ICT in Education: schools will be encouraged to use ICT in education to increase access to quality education in rural areas, the digital divide will be reduced and ICT will be integrated with all aspects of education.

Guiding Principles in developing a master plan,

1.      The first principle should be ICT for all students, meaning that the policy would act as an enabler to reduce the digital gap.

2.      The second principle should emphasize the role and function of ICT in education as a teaching and learning tool that would also encourage the utilization of all potential media and Technology.

3.      The third principle is to promote educational access and equity for all regardless of age, gender, ethnicity, disability, or location.

4.      The fourth principle is to emphasize the use of ICT to increase the efficiency and effectiveness of the management system in education. ICT will extensively be used to automatize and mechanize work processes such as the processing of official forms, timetable generation, management of information systems, lesson planning, financial management, and the maintenance of inventories.

According to this principle, there was action taken on the field on the part of skilled manpower development, and here are the key results and targets,

S. NTarget till 2017Achievement
1.218 Trainers Trained290 Trained till 2015
2.Teachers Trained for ICT20,000 teachers trained till 2017
3.Interactive Digital Content for students.All grades developed a total of 70 subject’s content till 2017

 Regarding different programs and activities, many committees are being formed like the functional National committee and coordination committee was formed in 2017.

·                       One E-government in the education sector was established in 2017.

So, looking at the master plan target and its achievement it shows really good progress till 2017. (MOE, 2013)

In-School sector Development Plan (2016/17 to 2022/23) by the ministry of education 2016 has shown the ensure equitable access to quality education for all that implies. Here ICT objective and improvement strategy and online course and material development and online self-learning method are mentioned that show more emphasis on remote learning strategy had been worked from the beginning itself.

The National Education system plan from 1971-76 by the ministry of education frames out a plan prepared/commanded by his majesty King Mahendra Bir Bikram Shah Dev. The provision of other educational materials like science and the vocational subject is better comprehended if films, firm-strips, and slides are used. Many other ways like education through radio and a basic requirement for school teachers training and teachers qualification are looked under. The education act 2028 (1971) also mentions opening school process, qualifications, mobile schools may be operated in remote mountain regions.

Digital Nepal framework 2019 is one of the latest events conducted in the area of Nepal’s ICT development programs. Open learning exchange (OLE) Nepal was established in 2007 which is one of the integrated technologies in classrooms. E-Paath includes more than 600 learning models for teachers. Her teacher’s training included 600 plus teachers trained in IT literacy. Technology infrastructure consisting of 5000 laptops in 100 schools was developed. Promoted digital inclusion and the smart classroom that was the focal agency of MOEST and supported agency by MOCIT (Ministry of Communication and information technology, MOF (Ministry of Finance), NDCL (Nepal Doorsanchar Company Limited). OLE Nepal in public schools focused, online learning platform in mostly rural and fewer facility people. Rent a laptop program, EMIS 2.0 (Education Management Information System) Mandatory for all public schools that integrate education management information system, as well as biometric attendance systems and CCTV comers including mobile learning centers in rural areas, are some of the ICT projects that had been in the planning phase.

ICT background of Nepal

ICT was never a priority before but providing equal opportunity for education for all was the main challenge. Due to not much implication of information communication technology used in Nepal, physical education was given more priority. Along with the changing scenario, the Covid-19 pandemic brought the necessity of online education where now technology is playing a huge role in the process of taking the quality of education forward. Due to this change, Nepal’s technological use has increased drastically. According to the 2019 Digital Nepal Framework, it shows that mobile penetration exceeded 100 percent whereas internet penetration reached 63 percent which shows great progress from 2012 which had only 62 percent and 21 percent respectively.  Here the government of Nepal also says that it is taking initiating steps to expand internet connectivity as part of its vision of a digital society that connects 90 percent of the population to broad services by 2020.   In the area of optical fiber cable coverage, 75 different locations in 45 districts are available (Telecome, 2021). Access to radio and digital television has reached 87 percent and 72 percent respectively according to the economic survey 2077-78 (Finace, 2020).

S. NParticularCoverage
1.                         Internet Penetration63%
2.                           Mobile Penetration100 + %
3.                           Optical Fiber Cable45 District
4.                           Radio Coverage87%
5.                           Television72%

Nepal in comparison with South Asian Countries in the area of ICT Development

Digital innovation in a developing country like Nepal has always been a huge challenge but every pandemic situation brings opportunity and this time it was digital innovation in education due to the Covid-19 pandemic.  Looking into the 2016 data of the ICT Development Index (IDI Index) it shows that the Maldives was first ranked in the Reginal IDI of south Asia in 2016, whereas Sri Lanka, Bhutan, India, Nepal, Bangladesh, Pakistan, and Afghanistan respectively ( Latif, et al., 2018). 2017 data from IDI shows the updated data where in the world ranking again the Maldives stand first with 85th ranked with 54.73 percentage among South Asian Countries where Nepal with 140th world rank with only 15 percent that has internet access. So, we can see the backwardness in the area of ICT (ICTdata, 2017).

Looking into internet penetration in mobile phones from 2014 to 2018 we can see the improvement of Bhutan with 33 percent, Bangladesh with 22 percent, Nepal with 33 percent, and Pakistan with 23 percent. On the other hand, we can see a huge increase in mobile internet perpetration in Nepal among other South Asian countries which shows good progress in the long run (GSMA, 2019) Overall, the increasing trend of Nepal in the area of ICT still lags in comparison to all the other countries of South Asia. But looking at the rate of increase in mobile as well as internet access it has given a good startup signal in the area of digital transformation in Nepal soon.

The covid-19 pandemic has become one of the worst crises hit around the world that not only affects human health but largely in the education sector. The immediate shift from physical education to online education was a hedge jump for a developing country like Nepal. As physical education was the prime process of teaching and learning. But with such a shift during the pandemic time, there was no other option. Depending upon ICT as a medium to connect with the students and having technological understanding was the main struggle for the teacher as well as for the students (Karki, 2020). To overcome this problem many strategies were used to connect the gap between the student and the teacher from the government side. The process of using radio, television, computer, and internet services was made for the schools that were facing problems to adjust new technology (Government, 2020). In Nepali university students who were involved in online education started having health-related problems and found online education not so effective were 55.6 percent of the teacher said that the classes were not so interactive whereas 41 percent of the students felt that the online classes were not effective (Dangal & Maharjan, 2021).  With a long lockdown physically teaching and learning activities were completely shut down and to reopen school the Ministry of Education, Science and Technology (MoEST) came up with a framework for reopening school based on the suggestions received from the province and local levels by reviewing the situation of Covid-19 pandemic at local and school levels (Ministry of Education, 2020). Going back to the lockdown again with the rise of the second wave giving more concern, especially for school-age children with no vaccine extended online classes. With this concern, the government started a process to obtain six million doses of Pfizer-BioNTech vaccine for under 12 children according to the Ministry of Health and Population (Republica, 2021). Along with the pandemic situation the students facing more problems in online education itself, with economic stress, parents not educated, internet access, fear of loss of the academic year as well as uncertainty in conducting physical classes and on top of that mental physical and social pressure on students (Dhungana, 2021). The digital divide in education started growing rise, especially for the students who are marginalized, students with disability, and low-income has detached from online education (Ojha, 2020). As the majority of the schools and students do not have access to a computer but government proposed online teaching which has created more gaps in education. To minimize such pressure on students during this pandemic Human Right Commission of Nepal had requested the Ministry of Education and private schools not to pressurize the students in the name of online education (Ghimire, 2020).

The shift from physical to online gave more pressure on parents, teachers, and educational institutions to continue the teaching and learning process. Parents balancing household work and jobs with their children’s online education gave more added role of guardians to educate their children. Due to this many parents lost their job squeezing the economic status that decrease to afford education.  This is just the situation in the urban area, but the guardian of the rural area is much more challenging.  In comparison to private schools, public schools are more technically backward and still need more support is needed to build technical knowledge. Looking into the data there is only 12 percent of public schools out of 30,000 have the information communication technology (ICT) delivery capability, with 30 percent having access to a computer and only 1 percent of public-school teachers can run online classes according to the Economic Survey of 2019-2020 (MOF, 2019-20). So, we can see from the data itself how the situation had been with the immediate shift from physical education to online. 

Interviewee Details

Name: Mahandra Bahadur Chettri

Post: Sichya Mahasakha Pramukh

Work Experience: High School Teacher for 3 years, After Lok sawa: worked in Education Monitoring Post (Sakha Adhikrit), worked in a different district like Baglung, Baitadi( Jila Sachiv), Kailali in (Upa Sachiv Post), Education Board (Upa Sachiv), District Education (Upa Sichaya Adhikari in Lalitpur Metropolitan City Office) and Now working in  Local Level Sichya Mahasakha Pramukh of Lalitpur.

Discussion and Recommendation

●     From Children’s development, pre-primary to class 12 school management responsibility is given to the local government. (Schools management: Teacher’s Salary, Appointment, Transfer, Holiday, estimation of the students) from School’s permission to primary to 11, 12-grade approval comes under our jurisdiction.

●     Education Procedure is made that has made education composition: Social Committee, Education committee (We discuss and make a decision mainly School education)

●      Before +2 different schools are different and now till +2 school. (Overall Management work is looked after us)

●     Support from LMC during this pandemic time: Computer lab establishment, ICT for long-term use has become more priority, ICT Knowledge more focused.

●     Last year a specific budget of Rs.12,000/- came from the Federal government along with internet services and the local government provided a subsidy to all the community schools and even this year at the rate of Rs 12,000/- subsidy was given to both school and +2 students. Before the subsidy was given to the only high school and from this year, they have provided it to all the basic schools. On top of the in addition for alternative online learning classes where for adhar bhut: Rs.15000/- and Mavi 25,000/- subsidy is given to all the community schools to implement the policy that they have made.

●     Result of the policy: Firstly, they have touched almost all the areas, access to education for all people especially for females, Dalit, differently able people, free textbooks

●     Due to the Covid-19 situation, some of the policies could not be that effective like the part of a monitoring mechanism for all the schools which was not at all possible.

●     Evaluation of these 14 policies: In a general aspect, all are a success but, in some parts, it is an only partial success like, Snack’s provision to school but the school did not open so this action also was not implemented, Sanitary pad distribution which also was not possible to give.

●     Firstly, needs were identified, Economic support from the Federal government and some from the Local government got little support. But in the area of alternative learning, they could not be addressed properly due to students having no access to online classes, and teachers having no skills in conducting online classes due to a lack of Budget. So, for this, they even gave some basic training to the teachers of public schools so that they can at least conduct classes from a mobile or any other device.

The local government not being able to work effectively in the area of ICT development with a lack of budget during the pandemic time. As a lesson learned we need more investment in ICT development and proper facilities for ICT-related training for both teachers as well as for the students is the most important priority for any kind of pandemic situation that may come in the future.

Most rural areas of Nepal are still deprived of proper technology as well as not aware of the importance of ICT policy. Sankhuwabha is one of them that still lacks trained teachers as well as skilled human resources as a major barrier to ICT in education policy. Not only this it has brought a big question on its proper monitoring and evaluation of schools regarding ICT development from the government working mechanism.  More awareness in the rural areas gives more concern according to Avinash Jha ( Jha,2021).

 Conclusion

The education sector needs immediate attention due to the Covid-19 pandemic and if we don’t bring changes in our teaching and learning process through online education the future of education quality will surely decrease leading to less enrollment rate of students. It’s been almost 2 years of a continuous shutdown of schools and as an alternative (ICT) Information Communication Technology played a huge role to fulfill this gap.  But challenges remain uncertain as all of a sudden change from physical to online has created many disparities. Lack of technical knowledge, lack of preparedness, and no proper online course design has made online courses more challenging for students. In the part of evaluating students through the examination process, we can see lots of confusion in deciding on how to take the examination for SEE, 11, and 12 classes. This has shown the dependency of the government on physical examination only and does not want to go for online examination as an alternative due to this pandemic situation. Using only one evaluation system for students is not at all good; it has to be improvised according to the situation.

Maximum use of technology due to this pandemic I would say has allowed us to do more things from technology. Not just studying from books but also studying from videos, online documents and different knowledge around the world can be our opportunity. But if we assume that if there were no Covid-19 pandemic then we would have never understood the importance of online classes. But now we can see the whole world is moving with online education with the help of ICT. This has boosted Nepal’s technological users’ knowledge and increased a greater number of mobile phones as well as internet penetration in Nepal. Even in comparison with South Asian countries, Nepal is slowly improving much better than other countries.

To look into a practical example of how local government bodies are working I took an interview with Mr. Mahadra Bahadur Chettri working as a Sichya Mahasakha Prakukh in Lalitpur Metropolitan City.  He has shared lots of information regarding ICT development in public schools and how they have been managing the current problem with different teaching-learning activities with the help of radio, small group teaching, documents, and giving monetary funds for internet access for all the public schools in Lalitpur. Looking at all the policies for this year and for the upcoming year they have planned different ICT-related development projects and more funding is allocated for ICT development in the education sector.  Local government bodies play a major role in the context of finding alternative education processes to education plays a major role.

In regards to different policies of Nepal related to ICT development in education, we can see lots of provisions since 1951. Distance learning and the use of technology training given to school staff were the basic approaches taken along with Master 2013-17 mentions different provisions of online education. But despite all those policies as well, planning while implementing during this pandemic time became a huge challenge for most of the school teachers as well as for the students. With the lessons learned and learning from our past now, we need proper planning regarding ICT for everyone and proper facilities are required for online oriented teaching-learning training for teachers with a proper evaluation system so that the flow of education is never disturbed even though there any short or pandemic situation.

Policy Recommendation

For a Quick-fix solution looking at the current situation supporting those students who are most vulnerable in the context of differently able or low economic status proper access to required reading materials should be provided. So that there is no case of digital divide seen in any area and for this, every school must keep the record of such students so that they can get immediate support so that the teaching and learning flow is not disturbed.

Secondly, preparing a separate syllabus during online classes as a backup so that the evaluation of the students can be determined accordingly and not in the same way as it used to in normal physical classes.

Establishing one technical team in each school that will be leading the teachers as well as students on online teaching and learning session. This will help in awareness regarding the importance of ICT development at the school level.

As we saw the mobile penetration rate of more than 100 percent we should also focus on mobile teaching and learning session packages as an alternative during the pandemic situation. This will help students as well as teachers’ continuity in the teaching and learning process. In some areas with no network as an alternative, required materials distribution should be managed by the local government itself.

As we saw in the pandemic the role of local government working efficiently so proper support and training related to ICT development is required so that if any such pandemic occurs local bodies are well prepared for anything. 

For a strategically long-term goal, the federal government itself should come into action for an ICT policies development for every school determining the requirements of internet services specification and proper budget allocation and distribution among all the local governments. Looking into the geographical area each Local government has its situation and requirements which are best for them. So, understanding the need and investing in specific ICT requirements would bring the best result.

References

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Policy Compendium

Vaccine Cooperation of LMICs across South and South-East Asia

ANKUR Shrestha

Abstract

SARS-CoV-2, commonly known as Covid-19, and its subsequent mutated variants have disrupted the entire world since the first virus case was confirmed in the Chinese city, Wuhan, in late December 2019. Though strict restrictions by governments worldwide have helped control the spread of the virus to some extent, vaccines are the only way to manage the crisis in the long run. As the virus does not discriminate against people based on their gender, age, race, or nationality, equitable distribution of vaccines needs to be at the forefront if we wish to minimize the damage from the ongoing pandemic. This paper compares the pandemic’s impacts on five LMICs and the efforts made by the respective governments to manage it. The document aims to learn from those LMICs and provide applicable and feasible policy interventions that Nepal can take better to manage the Covid-19 and other future public health crises.

Keywords

LMICs, COVID-19, vaccine, measurements, variants, response

Background

SARS-CoV-2, novel coronavirus or more commonly known as COVID-19, has devastated the world and held it in its firm grasp since the past year. On 30 January 2020, the World Health Organization Director-General declared the novel coronavirus outbreak a public health emergency of international concern (PHEIC), the World Health Organization’s highest level of alarm. At that time, there were 98 cases and no deaths in 18 countries outside China, among which four countries had evidence (8 cases) of human-to-human transmissions outside China (Germany, Japan, the United States of America, and Viet Nam) (Adhanom, 2020). The World Health Organization (WHO) reported that over 1 million cases of COVID-19 had been confirmed worldwide by 4 April 2020, a ten-fold increase in less than a month (WHO, 2020).

With the cases of COVID-19 rising, governments started to implement restrictions; in the beginning, barring international flights and later on also barring domestic travel. “Lockdowns”, restricting people from coming out of their homes for certain periods, became commonplace, as did mask mandates and social distancing. As the initial shock of the pandemic died down, and people got into living with these restrictions, the total number of cases started decreasing. The restrictions effectively controlled the pandemic to a certain extent, and as cases decreased, normalcy began to return with governments lifting restrictions.

The global economy, though, had been devastated due to the pandemic. Predictions made show that most countries posited a negative growth rate. The Global Economic Prospects on June 2021 estimated that the world economy shrunk by 3.5% in 2020, while a much worse decrease of -4.3% was estimated in January 2021. With everything shut down, the world moved into the virtual world. IT companies saw a large growth while the rest of the other industries posted losses.

In addition to restrictions, the fight against COVID-19 was helped by the excellent response of the medical community and the quick availability of vaccines. In July, China approved vaccines for limited and emergency use (Press Trust of India, 2020), while Russia approved them in August 2020 (Kramer, 2020). The United States FDA granted emergency use approval to Pfizer-BioNTech COVID-19 Vaccine on 11 December 2020 (FDA, 2021). The UK had already granted the vaccine temporary regulatory approval on 2 December 2020, becoming the first country in the Western world to approve the use of any COVID-19 vaccine (Reynolds et al., 2020). Similarly, other vaccines such as Oxford/AstraZeneca, Moderna, Janssen & Janssen all started rolling out, providing much-needed relief to the whole world and becoming a turning point for the fight against COVID-19. Vaccine rollout programs in the world also began massively, and although scepticism against vaccines remained around the world, vaccine mandates helped control the spread of the virus.

The arrival of variants was obvious. WHO has monitored new variants and marked any new dangerous variants as variants of concerns providing countries opportunities to be aware of the variant and try and restrict it before it spreads. However, these new variants have raised serious questions for the governments in how to deal with the pandemic. People have been hesitant to go back into lockdown as they face serious economic crises. At the same time, the rollout of vaccination programs has also begun to slow due to misinformation campaigns and the western model of “Freedom of Choice”. As of 31 October 2021, there were 247 million cases with 5 million deaths. Seven billion doses of the vaccine have been administered, while three billion people are fully vaccinated. Additionally, four variants of the SARS-CoV-2 virus have been deemed Variants of Concern (VOC), meaning those pose an increased risk to global public health. The new VOCs are named using the Greek alphabets with Alpha, Beta, Gamma, and Delta variants currently used for the four variants (WHO, n.d.).

It feels like COVID-19 is here to stay, and vaccines may be the only weapon that we have to fight the virus. Newer variants have called into question the efficacy of vaccines, but as we learn more about the virus, we can hope that more effective vaccines might be developed. The global economy is also forecasted to expand 5.6% in 2021, the fastest post-recession pace in 80 years, largely on strong rebounds from a few major economies. However, many emerging markets and developing economies continue to struggle with the COVID-19 pandemic and its aftermath (World Bank, 2021). If newer variants spread, this growth forecast will also surely shrink. Therefore, equitable access to vaccines through vaccine cooperation is the only solution in fighting this pandemic.

Vaccine Cooperation

Vaccine cooperation has been at the forefront of the response to the Covid-19 pandemic. LMICs have been fighting to win the vaccine battle in a battle to administer vaccines to everyone. Hotez (2014) argues that the historical and modern-day accounts of vaccine and vaccine diplomacy are remarkably great. However, these have not taken an overarching framework for its expanded role in foreign policy.

Vaccine diplomacy incorporates the crucial work of the GAVI Alliance and aspects of the WHO and other critical international organizations. It refers to nearly any facet of global health diplomacy that relies on the use or delivery of vaccinations (Hotez, 2014). What is happening today is a combination of exactly this, the COVAX initiative, bilateral donor agencies, donor countries, and vaccine manufacturing countries working directly to provide vaccines to LMICs. COVAX is an initiative coordinated by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI) and the WHO. COVAX, Gavi believes, will become a global solution to the pandemic, ensuring that people in all corners of the world will get access to the COVID-19 vaccines once they are available, regardless of their wealth (Berkley, 2020). Moreover, while donors and vaccine manufacturers usually have been found to use vaccines as a tool to enhance their diplomatic image, COVAX believes in ensuring equitable distribution to every nation.

Another important aspect of the global rollout of vaccines has been measuring the success of said rollouts. With vaccine shortages prevalent, high-income countries have invested and got priority to vaccines from manufacturing companies. In contrast, Low-Income countries and LMICs have continued to struggle in getting access. The consequences of unequal distribution of vaccines would be hundreds of thousands of deaths and huge economic losses globally due to a prolonged pandemic. Delays in vaccinating people in all the world regions bring the possibility of a resurgence of the virus, perhaps in an even stronger form, endangering the world once again (Dahal, 2020). Thus, measuring the success of vaccine cooperation in these countries becomes an important tool to understand what needs to be improved to get equitable access to the vaccines.

Study Framework

A study framework is necessary to understand the current situation of the COVID-19 pandemic and the subsequent status of access to vaccines and vaccine rollout plans of these countries. Understanding all these would help guide this study regarding the success of vaccine diplomacy in these countries.

For this study, LMICs have been chosen from South and South East Asia with comparatively similar economies. Five countries, three from South Asia and two from South East Asia, were chosen: Bangladesh, Cambodia, Lao PDR, Nepal, and Sri Lanka. These five countries have similar development status and are all in the LMICs categorical classification done by World Bank that met the criteria for this study. According to the IMF’s World Economic Outlook Database (2021), the average GDP and current prices for these countries for 2021 amount to 104.2406 billion USD.

The country with the highest Gross Domestic Product (GDP) among the five is Bangladesh at 352.908 billion USD, and the lowest is Laos at 20.44 billion USD. With the rise of new variants on a regularly occurring basis and the changes in data that occur every day, the study’s last date has been taken as 31 October 2021.

Identifying indicators to measure and assess the status is another important task in the study. With differences in the size of the population, access to health facilities, and quality of health services available among the five chosen LMICs, indicators have been divided into three different sections of measurement; Situational, Endeavour, and Prevention. According to their nature, some indicators have been reversed, meaning the higher the value of data, the worse the actual condition.

  1. Situational Measurements

Situational measurements provide an overview of the current situation of the COVID-19 pandemic in the country. The number of infections, number of tests, and deaths all provide an outlook of the country’s healthcare system while also implying the readiness and preparedness of the country to deal with a pandemic. Taken along with government policy decisions during the pandemic, such as lockdowns, or travel bans, it can show the effectiveness of the government to keep the pandemic at bay. The total number of tests that a country does is representative of its responses to the pandemic. The number of tests together with the number of infections reflect the true status of the country as, at times, the number of infections could be less as the number of tests is low.

  1. Number of Cases (R)[1]
    1. Number of Tests
    1. Number of Deaths (R)
  1. Prevention Measurements

Vaccinated population data is another important data source to measure the success of the country’s battle against the raging pandemic. Vaccination is the only solution to the current pandemic, and populations that have been partially vaccinated, fully vaccinated, and received booster doses provide different pictures. Partially Vaccination Population and Fully Vaccinated Population show vaccine willingness, and Booster Doses Administered can show countries’ ability to procure vaccinations and roll out vaccination programs.

  • Vaccine Doses Administered
    • Partially Vaccinated Population
    • Fully Vaccinated Population
    • Booster Doses Administered
  1. Endeavour Measurements

Measurements of the governments’ ability to procure vaccines show their proactiveness and international diplomatic strength. With shortages in vaccines due to time limitations, on top of the pressures faced by countries by the recurring waves and mutations in the COVID-19 virus, being able to procure vaccines is an important win. LMICs are also heavily reliant on donors to directly receive the vaccines through bilateral diplomatic efforts, facilities such as COVAX, or to get aid to buy the vaccines themselves. Thus, the number of vaccines received in donations compared to the number of vaccines secured through bilateral/multilateral agreements both become important measuring tools to evaluate the success of the LMIC’s vaccine efforts in battling the pandemic.

  • Number of Vaccines Procured
    • Number of Vaccines Received in Donations
    • Number of Vaccines secured through bilateral/multilateral agreements
    • Vaccines procured from unknown sources

Per capita measurements of all these indicators provide a basis for comparison between the five LMICs chosen for study (except for indicators 3.2, 3.3, and 3.4, which is measured in terms of the total number of vaccines procured). Similarly, the number of vaccines procured from unknown sources is a relatively unsafe indicator. With gaps in trusted data sources, adjustments had to be made to keep some vaccines procured in the unknown sources indicator.

Scale and Score Development

While constructing a scale for the indicators, the global average of each indicator is taken as the mid-point. Deviations of 33.33% on both sides would be considered the average, while each 33.33% deviation from that point would move the scale from 0 to +1, +2, or -1, -2. These scores generate a comparative scale that is extremely helpful for us to compare the progress of LMICs in these indicators with each other.

Global Average (Mid-point)

-2                                         -1                                         0                     +1                                              +2

Additionally, taking the same scale but considering the average of LMICs instead of the global average can provide another level of understanding in our comparison. The scale and indicator scores would remain the same. However, the scale would change slightly to:

LMIC Average (Mid-point)

-2                                         -1                                         0                     +1                                             +2

The scale would be helpful to measure the overall performance of the country. It can then compare the chosen LMICs on the various indicators and understand how well they are doing against one another compared to the global average.

The indicators each are weighted according to:

IndicatorWeightage
Situational Measurements3
Number of Cases1
Number of Tests1
Number of Deaths1
Prevention Measurements2
Vaccine Doses Administered1
Only Partially Vaccinated Population0.33
Fully Vaccinated Population0.33
Booster Doses Administered0.33
Endeavour Measurements2
Number of Vaccines Procured1
Number of Vaccines Received in Donations0.33
Number of Vaccines secured through bilateral/multilateral agreements0.33
Vaccines procured from unknown sources0.33

The total weightage combined with the total possible score would provide a range of -14 to +14 for the countries, with 0 considered the World Average or the LMIC Average in the two scales.


Overall Scores

  1. In comparison to the World,
IndicatorWeightageBangladeshCambodiaLaosNepalSri Lanka
1. Situational Measurements300+20-1
1.1 Number of Cases1+2+2+200
1.2 Number of Tests1-2-2-2-1-1
1.3 Number of Deaths100+2+10
2. Endeavour Measurements2-0.66+2.33-0.33-0.66+1.66
2.1 Number of Vaccines Procured1-1+20-1+1
2.2 Number of Vaccines Received in Donations0.33+0.66+0.66+0.66+0.66+0.66
2.3 Number of Vaccines secured through bilateral/multilateral agreements0.330+0.33-0.6600
2.4 Vaccines procured from unknown sources0.33-0.33-0.66-0.33-0.330
3. Prevention Measurements2-2+3-1-2.33+0.66
3.1 Vaccine Doses Administered1-1+20-1+1
3.2 Only Partially Vaccinated Population0.330-0.33-0.33-0.330
3.3 Fully Vaccinated Population0.33-0.33+0.660-0.33+0.33
3.4 Booster Doses Administered0.33-0.66+0.66-0.66-0.66-0.66
Total Scores (World)-2.665.330.66-31.33

The World comparison scores show a definite winner in responses to the pandemic. While Cambodia seems to be doing excellent in most of the indicators compared to the world, Bangladesh and Nepal seem to be struggling in all aspects. Specifically, among the worse two performers in Bangladesh and Nepal, Bangladesh has performed well in managing the number of Covid cases among its population. At the same time, Nepal does slightly better in testing and providing better health care to its infected population, as shown by the low number of deaths. Sri Lanka is towards the higher end of the scale, while Laos has a very similar score to the World Average. 

Looking at specific indicators, Laos has performed significantly better in controlling the number of cases and subsequently reducing the number of deaths. While, in the measurements of endeavours and preventions, Cambodia considerably outperforms the rest of the countries. It presents a great picture of the Cambodian government’s efforts in procuring vaccines and rolling them out to the general population, which has also been appreciated by UNICEF (UNICEF Cambodia, 2021).

  1. In Comparison to LMICs,
IndicatorWeightageBangladeshCambodiaLaosNepalSri Lanka
1. Situational Measurements3-10+3-2-2
1.1 Number of Cases1+1+1+2-1-1
1.2 Number of Tests1-2-1-1-10
1.3 Number of Deaths100+20-1
2. Endeavour Measurements2+1+2.33+1.66+0.66+2.66
2.1 Number of Vaccines Procured10+2+10+2
2.2 Number of Vaccines Received in Donations0.33+0.66+0.33+0.66+0.66+0.33
2.3 Number of Vaccines secured through bilateral/multilateral agreements0.33-0.330-0.66-0.33-0.33
2.4 Vaccines procured from unknown sources0.33+0.660+0.66+0.33+0.66
3. Prevention Measurements2-1+2.66+0.66-1.33+1.66
3.1 Vaccine Doses Administered10+2+10+2
3.2 Only Partially Vaccinated Population0.33-0.33-0.66-0.33-0.66-0.33
3.3 Fully Vaccinated Population0.330+0.66+0.660+0.66
3.4 Booster Doses Administered0.33-0.66+0.66-0.66-0.66-0.66
Total Scores (LMICs)155.33-2.662.33

Compared to other LMICs, the results are pretty similar except for Laos. Laos performs excellently and ranks among the best in the group compared to other LMICs. While the situational measurements are similar, Laos fares comparatively well in endeavour and prevention measurements compared to other LMICs. Cambodia ranks second among the five while Bangladesh ranks among the bottom two, albeit with improved overall scores.

Only Nepal performs substantially worse off than the average LMIC country among the five chosen countries. Looking at specific indicators, Nepal is slightly better off only in endeavour measurements while it is performing poorly in situational and prevention measurements. It shows that although the government has been active in procuring vaccines through various sources, it fails miserably in testing, controlling the pace of infection, and rolling out an effective vaccine program to administer it among its populous, in comparison to other LMICs.

Policies during COVID

The scores, representative of the efficiency of government responses in controlling the pandemic, show a huge variation among the five chosen countries. The policies implemented by the respective governments during the COVID-19 pandemic might explain why this is the case. The Oxford Covid-19 Government Response Tracker is a reliable source to understand the policy responses of different governments. Coded into 23 indicators, with four indices that aggregate the data into 0-100, the tracker provides an insight into how the overall government response was during the various pandemic stages. Among the indices, while other indices look at particular indicators, the Overall Government Response Index is important in understanding how the response of governments has varied overall indicators in the database, becoming stronger or weaker throughout the outbreak (Blavatnik School of Government, n.d.). The indices record the number and strictness of government policies. Although they cannot be interpreted directly as the appropriateness or effectiveness of a country’s response, they can provide some semblance of understanding.

The data from Oxford shows that the measures taken by the various governments during the pandemic were successful in helping them control the effects of the pandemic. However, learnings can be taken on where the interventions occurred. Through the policies taken, the governments can be categorized as either responsive, actively taking policies to limit the effects of the virus, or reactive, taking out policies only after the number of cases is drastically high. Additionally, more policies do not particularly represent better governance as the implementation of the policies matter. Therefore, the comparison of both of these provides an understanding of if and when policies were taken and if policy implementations were successful in decreasing the impacts of the pandemic.

Bangladesh and Nepal showed a high rise in COVID-19 cases throughout the measured period. Nepal has a distinct first-wave and second-wave period, while Bangladesh’s COVID-19 cases do not seem to have dropped significantly before rising again to new highs during the second wave.

The Overall Government Response Index in Nepal showed a general trend of greater response when the COVID-19 pandemic started, with a gradual decline in policy responses as the number of cases decreased during the first wave. The second wave seems to have caught Nepal unawares, with the number of cases rising dramatically in a very short period. The government subsequently took out policies to counter its effects. The response trend seems similar to the first wave, where the response index decreased as the number of cases in the second wave decreased.

Bangladesh seems to have dealt with the pandemic similarly to Nepal, wherein the first wave was controlled better with a high response from the government. In contrast to Nepal, the government response index does not decrease during the decreasing phase of the number of cases in the first wave. The second wave similarly seems to begin with an increased response leading to a slight decrease in cases. However, after a slight decrease in response, the pandemic raged massively, and the number of cases dramatically increased, reaching around 16,000 cases per day. The government response seems to have worked in the later parts bringing the number of cases down towards the end of October.

Source: (Hale et al. 2021)

Notes: The scale for the total number of cases is different for each country. The time and scale for Government Response Index for all the countries is the same.

Cambodia, Laos, and Sri Lanka were excellent in controlling the first wave of the pandemic in their respective countries. The graphs show that the government response was timely, high, and properly implemented. Cambodia seems to have taken stricter measures beginning from February 2021 as the number of cases began to increase, reaching an all-time high of around 1100 cases per day. The government response has remained similar after then while the number of cases seems to be fluctuating but decreasing towards the end of our measuring period.

Laos is similar to Cambodia, with very strict measures taken at the beginning of the pandemic, which helped limit its number of cases during the first wave. Even during the second wave, when the number of cases started to rise, immediate actions were taken to try and prevent the spread, which did control the spike. However, as government response dwindled, the number of cases increased again. With the number of cases reaching a record-high of 952 cases per day on 25 August 2021, the Laos government has again responded with stricter measures, but the pandemic does not seem to be currently stopping.

Sri Lanka was excellent in responding to the first wave, but the second wave has taken it by storm. Cases started rising to highs of 3,000 around May and June 2021 while the government responded to the increase. Even with a higher government response, Sri Lanka could not control the pandemic. The pandemic reached an average of around 3000 cases per day from April to September, with daily cases sometimes reaching upwards of 11,000. The second wave seems to be slightly subsiding as daily cases have fluctuated around 500 to 1,000 in October.

Policy Recommendations and Way Forward

The presented data provide a bleak outlook into Nepal’s situation and its response to the COVID-19 pandemic compared to the world, other LMICs, and the five chosen countries. The policies taken during the pandemic by the other chosen countries can be a reflection and learning into what Nepal can do to respond to the pandemic, in the beginning, during, and after the pandemic waves. With the new variant, Omicron, starting to spread worldwide, lessons learnt can be used to deal with the potential new wave.

  1. Address issues of liquidity crisis going on in the current economy. Nepal Rastra Bank has issued Repurchase Agreements (Repos) to increase liquidity (Fiscal Nepal, 2021). However, other additional measures are also required as Nepal still faces a liquidity crunch even after the pandemic has receded.
  2. Engage the community to increase citizen participation in COVID prevention as well as increase vaccine acceptance
  3. Address pre-existing inequities and the disproportionate impact of COVID-19 on marginalized and vulnerable populations (WHO, 2021).
  4. Increase preparedness in taking localized measures such as movement restrictions, mask mandates or, in extreme cases, short-period lockdowns.
  5. Allocate budget for prevention, control, and containment measures and health emergency funds.
  6. Limit outward remittances while providing exemptions for inward remittances to maintain the balance of payments.
  7. Provide stimulus packages and tax exemptions to affected industries, salary support to the public and private workers, deferral of tax payments, and temporary reduction in prices of government services (IMF, 2021).

References:

  1. Adhanom, T. (2020, January 30). WHO Director-General’s statement on IHR Emergency Committee on Novel Coronavirus (2019-nCoV).  https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov)
  • Hale, T., Angrist N., Goldszmidt, R., Kira, B., Petherick, A., Phillips, T., Webster, S., Cameron-Blake, E., Hallas, L., Majumdar, S., Tatlow, H.. (2021). A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nature Human Behaviour. https://doi.org/10.1038/s41562-021-01079-8
  • Hasell, J., Mathieu, E., Beltekian, D., Macdonald, B., Giattino, C., Ortiz-Ospina, E., Roser, M., Ritchie, H.. (2020, October 8). A cross-country database of COVID-19 testing. Scientific Data 7, 345. https://doi.org/10.1038/s41597-020-00688-8
  1. Hotez, P. J. 2014. Vaccine Diplomacy: Historical Perspectives and Future Directions. PLoS Negl Trop Dis 8(6): e2808. https://doi.org/10.1371/journal.pntd.0002808
  1. International Monetary Fund. (2021, April). World Economic Outlook Database. https://www.imf.org/en/Publications/WEO/weo-database/2021/April/weo-report?c=512
  1. International Monetary Fund. (2021, July 2). Policy Tracker. Retrieved December 17 2021, from https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#C
  1. Kramer, A. E.. (2020, August 11). Russia Approves Coronavirus Vaccine Before Completing Tests. The New York Times. Retrieved on 24 December 2021 from https://www.nytimes.com/2020/08/11/world/europe/russia-coronavirus-vaccine-approval.html
  1. Mathieu, E., Ritchie, H., Ortiz-Ospina, E., Roser, M., Hasell, J., Appel, C., Giattino, C., Rodés-Guirao, L. (2021, June 17). A global database of COVID-19 vaccinations. Nature Human Behaviour, 5, 947-953. https://doi.org/10.1038/s41562-021-01122-8
  1. Nepal Press. (2021, September 17). 4.4 million doses of Vero Cell vaccines arrive in Nepal. Retrieved 24 November 2021, from https://english.nepalpress.com/2021/09/17/4-4-million-doses-of-vero-cell-vaccines-arrive-in-nepal/
  1. Press Trust of India. (2020, August 24). China Approves Emergency Usage Of COVID-19 Vaccines: Official. NDTV. Retrieved 24 December 2021 from https://www.ndtv.com/world-news/china-approves-emergency-usage-of-covid-19-vaccines-official-2284069
  1. Reynolds, E., Halasz, S., Pleitgen, F., Isaac, L.. (2020, December 3). UK becomes first country to authorize Pfizer/BioNTech’s Covid-19 vaccine, first shots roll out next week. CNN. Retrieved 24 December 2021 from https://edition.cnn.com/2020/12/02/uk/pfizer-coronavirus-vaccine-uk-intl-hnk/index.html
  1. UNICEF. (2021). COVID-19 Vaccine Market Dashboard. Retrieved November 23 2021 [9:22 PM], from https://www.unicef.org/supply/covid-19-vaccine-market-dashboard
  1. WHO. (n.d.). Tracking SARS-CoV-2 variants. Retrieved 24 December 2021, from https://www.who.int/emergencies/what-we-do/tracking-SARS-CoV-2-variants
  • World Bank. (2021). Global Economic Prospects, January 2021. Washington, DC: World Bank. DOI: 10.1596/978-1-4648-1612-3.
  • World Bank. (2021). Global Economic Prospects, June 2021. Washington, DC: World Bank. DOI:10.1596/978-1-4648-1665-9.

Annexe:

The following things need to be considered before taking a look at the data used in the report:

  1. Sri Lanka and Laos Data are from 28 October 2021, while other data is from 31 October 2021. The latest data for October has been used in all cases.
  2. For Vaccinations,
    1. Total Vaccinations means the total number of doses administered.
    2. People vaccinated means the total number of people that received a dose of a vaccine (1 or 2)
    3. People Fully Vaccinated means the total number of people that received a full dosage of a vaccine (1 or 2 depending on the vaccine)
    4. People Only Partially Vaccinated = People Vaccinated – People Fully Vaccinated.
  3. Wherever doses administered (plus wastage) is greater than the total number of reported deliveries for a country, the difference between the doses administered (plus wastage) and the doses delivered (through COVAX, AVAT, donations, and/or bilateral/multilateral agreements) is categorized as “Unknown”.
  4. Vaccination Data Source:
    1. Mathieu et al. (2021) and UNICEF (2021).
    2. For Nepal, missing vaccination data was added from Nepal Press (2021) and WHO Nepal (2021).
  5. Testing Data Source: Hasell et al. (2020)
  6. For Cambodia, the Number of Test Data was taken from Cambodia Coronavirus Situation Report #70 (WHO Western Pacific Region, 2021).
  7. Data for the Total Number of Tests for the World and LMICs is missing as every country does not report the number of tests done. Therefore, available data were aggregated to get an approximation. The indicator, therefore, may not truly represent the actual status of tests.

Data and scores for the various indicators:

1 Situational Measurements

1.2. Number of Cases

Type: Reserved

Unit: Percentage of population

Weightage: 1

 DataScale (World)Scale (LMICs)
World3.14%0
LMICs1.86%0
Bangladesh0.94%+2+1
Cambodia0.70%+2+1
Laos0.52%+2+2
Nepal2.74%0-1
Sri Lanka2.51%0-1

1.2. Number of Tests

Type: Normal

Unit: Percentage of population

Weightage: 1

 DataScale (World)Scale (LMICs)
World43.67%0
LMICs23.47%0
Bangladesh6.21%-2-2
Cambodia13.50%-2-1
Laos9.58%-2-1
Nepal14.90%-1-1
Sri Lanka25.46%-10

1.3. Number of Deaths

Type: Reserved

Unit: Percentage of total cases

Weightage: 1

 DataScale (World)Scale (LMICs)
World2.02%0
LMICs1.78%0
Bangladesh1.78%00
Cambodia2.35%00
Laos0.15%+2+2
Nepal1.40%+10
Sri Lanka2.54%0-1

2. Endeavour Measurements

2.1. Number of Vaccines Procured

Type: Normal

Unit: Percentage of population

Weightage: 1

 DataScale (World)Scale (LMICs)
World110.20%0
LMICs72.21%0
Bangladesh58.71%-10
Cambodia220.20%+2+2
Laos108.92%0+1
Nepal62.18%-10
Sri Lanka150.97%+1+2

2.2. Number of Vaccines Received in Donations

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World7.27%0
LMICs17.06%0
Bangladesh39.36%+2+2
Cambodia26.35%+2+1
Laos78.91%+2+2
Nepal40.44%+2+2
Sri Lanka23.48%+2+1

2.3. Number of Vaccines secured through bilateral/multilateral agreements

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World48.18%0
LMICs72.26%0
Bangladesh37.79%0-1
Cambodia65.66%+10
Laos0%-2-2
Nepal43.46%0-1
Sri Lanka43.72%0-1

2.4. Vaccines procured from unknown sources

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World44.54%0
LMICs10.69%0
Bangladesh22.85%-1+2
Cambodia7.99%-20
Laos21.09%-1+2
Nepal16.10%-1+1
Sri Lanka32.80%0+2

3. Prevention Measurements

3.1. Vaccines Doses Administered

Type: Normal

Unit: Percentage of population

Weightage: 1

 DataScale (World)Scale (LMICs)
World90.06%0
LMICs59.29%0
Bangladesh42.40%-10
Cambodia162.77%+2+2
Laos81.70%0+1
Nepal53.64%-10
Sri Lanka132.95%+1+2

3.2. Only Partially Vaccinated Population

Type: Normal

Unit: Percentage of population

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World10.83%0
LMICs18.05%0
Bangladesh7.85%0-1
Cambodia3.80%-1-2
Laos6.44%-1-1
Nepal4.79%-1-2
Sri Lanka9.04%0-1

3.3. Fully Vaccinated Population

Type: Normal

Unit: Percentage of population

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World38.78%0
LMICs20.67%0
Bangladesh17.27%-10
Cambodia77.10%+2+2
Laos37.84%0+2
Nepal24.43%-10
Sri Lanka61.96%+1+2

3.4. Booster Doses Administered

Type: Normal

Unit: Percentage of population

Weightage: 0.33

 DataScale (World)Scale (LMICs)
World1.09%0
LMICs0.08%0
Bangladesh0%-2-2
Cambodia10.98%+2+2
Laos0%-2-2
Nepal0%-2-2
Sri Lanka0%-2-2
Policy Compendium

Nepal’s Dual National Security Risks: COVID-19 and Climate Change

SAMJHANA Karki

Introduction

Arnold Wolfers says national security means the absence of threats to acquire values and subjectively the absence of fear that such values will be attacked  (Wolfers, 1952). Likewise, Barry Buzan says that traditionally, national security was focused on the military only but now it encompasses political, economic, environmental, and societal security as well (Buzan, 1997).

Security is the condition or means of protection from harm or threat. The protection of sovereignty, territorial integrity, and political independence are the fundamental security concerns of every state. It was in rigid form in the traditional state system and is equally important even in the modern world order (Baral, B.). The world is facing new security challenges in the 21st century that have forced global and national security actors to think differently. Unconventional security issues such as resource scarcity, climate change effects, livelihood insecurity, environmental insecurity, food and water insecurity, health insecurity, natural calamities and disasters, pandemic diseases, etc. are now an integral part of security going beyond conventional security issues of protecting sovereignty and territory of the state (Upreti, B.R., 2019).

COVID-19 is the name given to the disease associated with the virus SARS-CoV-2 (severe acute respiratory syndrome-Coronavirus-2), a new strain of coronavirus that has not previously been identified in humans (Fuentes, 2020). COVID-19 has turned the world upside down. Everything has been impacted posing an indirect threat to national security which includes the possible chance to encourage criminal activities such as corruption, black marketing, cyber terrorism, an increase in the number of rape cases, gender-based violence, and domestic violence resulting in the violation of peace and order of the society which is most likely to disrupt the country’s economic development and prosperity. People lost their savings and their livelihood remained at risk. COVID-19 has not just put many migrant workers and daily wage workers jobless; it has also widened the gap between rich and poor resulting in poverty and inequality. This coronavirus has created chaos in daily life and the collapse of the existing healthcare, putting huge stress and fear on people’s health along with the nation’s manpower and labor force.

In the era of great power competition, climate change is expected to amplify the existing security challenges by adding complexity, accelerating the intensity, and presenting new challenges such as the rivalry between the US, Russia, and China in the Arctic region (Rawal, S.S, 2021). The impacts of the climate crisis are already being felt around the world; lives and livelihoods are being lost to extreme events like drought, powerful tropical storms, excessive heat, and more (The Climate Reality Project, 2019).

Climate change has a direct relationship with national security, basically non-traditional security threats. It escalates climate-induced disasters like landslides, wildfires, and floods which are much more likely to cause government instability and bring chaos to internal security and stability. Obviously, there presents a resource scarcity as the demand for a natural resource is greater than its availability. This results in unsustainable growth and a rise in inequality as prices rise to make the resourceless affordable for low-income generating groups of people. This also shows the linkage between climate change and poverty. Those in poverty have a higher chance of experiencing the ill effects of climate change due to the increased exposure and vulnerability, resulting in the low living standards of people. They could not fulfill their basic needs and it ultimately impacts the livelihood system causing a threat to national security in a long run.

Hence, climate change can also be regarded as a critical non-military threat as it results in migration due to a lack of resources and extreme weather events, in both rural and urban areas, particularly in low-income developing countries, and has the potential to indirectly increase the risk of violent conflicts, such as civil war and inter-group violence, global conflicts, pandemics, decrease in livelihood, food insecurity- pose a significant threat to national security.

Climate change is a problem for the entire planet. It is global as it arises from greenhouse gas emissions, which are generated in all parts of the globe. Likewise, its impacts are felt in all world regions. COVID-19 is, in principle, a transboundary problem, because it is borne in one (or more) regions, but it rapidly expands to the whole planet, moving from an epidemic to a pandemic. Being currently a pandemic, COVID-19 is now a global problem like climate change. In addition, the two problems are global in different ways. Climate alterations and global warming are induced by increasing atmospheric concentrations of Greenhouse Gases (GHGs), regardless of the geographical location of the emissions. It follows that the impact of climate change on a specific country is to an extent independent of its own emissions, thereby creating an incentive to free-ride on mitigation. Not so in the case of COVID-19, where the impact is transboundary, more like NOx and SO2 emissions, but one affected country cannot benefit from coping policies undertaken in another country, if not to a limited extent (Fuentes, 2020).

Some of the similarities between COVID-19 and climate change is that both are emerging issues (in terms of urgency), and every nation is affected by its impact. And both issues require a global effort and coordination. COVID-19 and climate change both fall under non-traditional security threats. The main question is Why does the COVID-19 threat take more seriously compared to the threat of climate change?

The article argues that the level of perceived risk towards the COVID-19 is higher than the perceived risk of climate change. To make the argument on the above-mentioned statement COVID-19 and climate change are measured and compared through human cost, economic cost, and social cost.

Although both issues are equally serious and require a timely solution, climate change is not treated with the same urgency as COVID-19. While coronavirus is treated as an immediate danger, the climate crisis is still not treated seriously whose consequences are decades away. Unlike a health disaster, it is harder to visualize how climate breakdown will affect us. Comparing both threats, climate change has a larger impact on national security.

Addressing the threats created by coronavirus and climate change, it is significant to analyze and compare its impacts from the national security perspective and the level of risk perception. The first section of the article shows the comparison of the costs. The second section shows the theory of perceived risk and in the end, its relevance for the Nepalese security aspect.

In the following section, the cost is analyzed in terms of COVID-19 and climate change.

Human Life toll due to COVID-19

As of 28 November 2021, the worldwide Covid death toll crosses the 261,400,499 million cases with 5,213,720 deaths. The compulsory lock-down, for instance, might increase the risk of people having mental illnesses, or even worse, increase the rate of suicide. Another reason is that people have been denied getting routine medical care as they did before the pandemic, such as cancer care, hemodialysis, etc. or people may have to postpone their operations because of a shortage of medical resources and so on.

Human Life toll due to Climate Change Impacts

The World Health Organization found that between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhea, and heat stress (WHO, 2021).

Approximately 30% of the global population experiences deadly heat for over 20 days per year. By 2100, this will rise to 48% if Green House Gas (GHG) emissions are drastically reduced and 74% if they continue to grow (Parncutt, 2019). As a new study shows that climate change is linked to 5 million deaths a year, almost 10% of global deaths can be attributed to abnormally hot or cold temperatures, according to new research linking extreme weather to mortality (Lombrana, 2021).

Due to climate change-related food shortages alone, the world could see a net increase of 529,000 adult deaths by 2050. Climate change could force 100 million people into extreme poverty by 2030 and poverty makes people more vulnerable to health problems (Christensen, 2019).

World Bank estimates that climate change could push 62 million South Asians below the extreme poverty line by 2030. Now, changing weather patterns are expected to directly impact over 800 million people by 2050 and will continue to burden South Asian countries economies. (Fallesen, Khan, Tehsin, & Abbhi, 2019).

In a future with continued high emissions growth, climate change’s impact on temperatures will cause an additional 73 deaths per 100,000 in 2100 (Carleton, Tamma, & Jina, 2020).

 Economic Impacts- COVID-19

According to the data given by The International Civil Aviation Organization (ICAO) seating capacity dropped by about 50 percent in 2020, and passenger totals dropped by 60 percent with just 1.8 billion passengers taking flights, compared to 4.5 billion in 2019. The International Air Transport Association (IATA) also released full-year global passenger traffic results for 2020 showing a 65.9% decrease in demand (revenue passenger kilometers) compared to the full year of 2019 (Clark, 2021).

The travel restriction and lockdown have affected every sector such as travel and tourism, and business. It has impacted every stage of the supply chain in the market, including production and distribution creating a negative supply shock and resulting in the closures of factories. Significant reductions in income, a rise in unemployment, and disruptions in the transportation, service, and manufacturing industries are some of the major economic impacts of COVID-19 (Pak A, 2020).

Economic Impacts- Climate Change

Economic impacts of climate change are already seen. According to Morgan Stanley, climate disasters have cost North America $415 billion in the last three years, much of that due to wildfires and hurricanes (Cho, 2019). Climate change has increased competition for diminished land and water resources, ramping up tensions between livestock owners and others (OCHA, 2021).

A report from the World Bank on climate change, water, and the economy predicts that some regions such as the Middle East and the Sahel in Africa could see growth rates decline by as much as 6% of GDP by 2050 (World Bank Group, 2016).

In Asia, 3,454 disasters were recorded from 1970–to 2019, with 975 622 lives lost and US$ 1.2 trillion in reported economic damages. Asia accounts for nearly one-third (31%) of weather-, climate- and water-related disasters reported globally, accounting for nearly half of deaths (47%) and one-third (31%) of associated economic losses. Most of these disasters were associated with floods (45%) and storms (36%) (WMO, 2021).

Globally averaged precipitation over land has likely increased. Each of the last four decades has been successively warmer than any decade that preceded it since 1850. Global surface temperature in the first two decades of the 21st century (2001–2020) was 0.99 [0.84 to 1.10] °C higher than 1850–1900. The global mean sea level increased by 0.20 [0.15 to 0.25] m between 1901 and 2018. In 2019, atmospheric CO2 concentrations were higher than at any time in at least 2 million years, and concentrations of CH4 and N2O were higher than at any time in at least 800,000 years  (IPCC Report, 2021).  Human-induced climate change is already affecting many weather and climate extremes in every region across the globe. Evidence of observed changes in extremes such as heatwaves, heavy precipitation, droughts, and tropical cyclones, and their attribution to human influence, has strengthened since AR5 (IPCC Report, 2021).

The direct damage costs to health (i.e., excluding costs in health-determining sectors such as agriculture and water and sanitation), are estimated to be between USD 2-4 billion/year by 2030 (WHO, 2021). Over 930 million people – around 12% of the world’s population – spend at least 10% of their household budget to pay for health care. With the poorest people largely uninsured, health shocks and stresses already currently push around 100 million people into poverty every year, with the impacts of climate change worsening this trend (WHO, 2021).

Social Cost – COVID-19

Apart from this economic cost, there is also social cost in various fields that cannot be overlooked and need time to recover. Like health, education, the increase of inequality in society, increase in domestic violence, as many governments announced stay-at-home guidelines. Personal protective equipment (PPE), billions of worn masks, and sanitizer bottles, among other plastic-based, single-use items that must be disposed of internationally, could have a direct environmental impact. Besides, as people stay at home and increase their usage of online shopping, the increased waste of households from shipped package materials could also induce a serious environmental impact.

Evidence suggests that COVID-19 has exacerbated the food security problem in countries that already have them. In Sudan, for example, an estimated 9.6 million people (21 % of the population) were experiencing a crisis or worse levels of food insecurity in the third quarter of 2020, which is the highest figure ever recorded for Sudan (WFP, 2020).

Social Cost- Climate Change

Throughout the 21st century, climate change is expected to lead to increases in ill-health in many regions and especially in developing countries with low income. In urban areas, climate change is projected to increase risks for people, assets, economies, and ecosystems, including risks from heat stress, storms, extreme precipitation, flooding, landslides, air pollution, drought, and water scarcity. Rural areas are expected to experience major impacts on water availability and supply, food security, infrastructure, and agricultural incomes, including shifts in the production areas of food and non-food crops around the world. Climate change results in various patterns of inequality. As the impacts of climate change mount, millions of vulnerable people face greater challenges in terms of extreme events, health effects, food security, livelihood security, water security, and cultural identity (World Bank).

Cost to Mitigate COVID-19

The global economy contracted by 3.3 percent in 2020, where the majority of nations experienced negative economic growth due to the slowdown in global economic activities caused by the COVID-19 pandemic (Ministry of Finance, 2021). As the economic impacts of the pandemic have become salient, governments have begun to slash their budgets for mitigating other global risks, including climate change, likely imposing increased future costs from those risks.

According to the Nepal Public Economic Survey FY 2077/2078, the COVID-19 epidemic has affected Nepal’s economy and for the first time in the last two decades, the economic growth rate has been negative at 2.12 percent. This is even higher than the economic damage caused by the devastating earthquake of 2072. Nepal government had announced a stimulus package exceeding Rs. 210 billion in the budget for fiscal 2020-21 to help businesses cope with unfavorable circumstances created by the COV- ID-19 pandemic and to boost the economy (The Himalayan Times, 2020).

In China, the total estimated healthcare and societal costs associated with COVID-19 were 4.26 billion Chinese yuan (Jin & et.al, 2021). As of July 1, 2021, China has an estimated RMB 4.9 trillion (or 4.7 percent of GDP) of discretionary fiscal measures announced (IMF, 2021).

Similarly, the Indian government unveils ₹6.28 lakh cr. stimulus post-second COVID wave (The Hindu, 2021).

The World Bank has approved a fast-track $29 million COVID-19 Emergency Response and Health Systems Preparedness Project to help Nepal prevent, detect, and respond to the COVID-19 pandemic and strengthen its public health preparedness (World Bank, 2020).

According to a report by U.S. health data company IQVIA Holdings Inc, the total global spending on COVID-19 vaccines is projected to reach $157 billion by 2025 (Mishra, 2021).

Cost to Mitigate Climate Change

As of January 2021, the Global Environment Facility (GEF), has invested $1.9 billion in grant funding from the Least Developed Countries Fund (LDCF)and the Special Climate Change Fund (SCCF) for 386 adaptation projects in 98 countries (Bakarr, 2021). According to the UN Environment Programme’s Adaptation Gap Report 2020, adaptation cost is expected to be $140 – $300 billion annually by 2030.

In the context of climate change the cost to mitigate climate change the total global economic cost would be €200-350 billion per year by 2030 (Ritchie, 2017). When mortality costs around the globe are totaled, the researchers find that the present-day value of emitting an additional ton of CO2 is $36.6 per ton under a scenario of continued high emissions (Carleton, Tamma, & Jina, 2020).

Threat or Risk Perception

Threat or risk perception is the conscious or unconscious estimation that something is dangerous or there is a risk of a certain thing. Normally we respond to a threat when we feel it also, we tend to respond more when there is a larger threat and vice versa.

The below-mentioned 2*2 table shows the actual threat and perceived threat of COVID-19 and climate change respectively.

The table needs to be finalized …

 A2(Actual risk of CC)P2(Perceived risk of CC)
A1(Actual risk)A1=P1  A2=P2
P1(Perceived risk)P1<A1P2<A2
Table 1: Table showing the risk perception of COVID-19 and climate change

where, A =Actual Risk, P= Perceived Risk

A1= Actual risk of COVID-19 and A2= Actual risk of climate change

Similarly. P1= Perceived risk of COVID-19 and P2= Perceived risk of climate change

The above-presented data and explanation in the previous chapter also show that climate change is the actual threat to COVID-19. But its perceived risk is less than that of COVID-19. COVID-19 has been seen and perceived by most people as a “clear and present danger” to the entire world population. Attention has been focused on COVID-19 and people have paid comparatively less attention to the ongoing changes in our planet’s climate. We have got a vaccine for COVID-19, but we can’t place hope in finding a vaccine against climate change. Covid-19 will remain for more than 1-2 years, its impact will be less as compared to climate change. Climate change has been here for ages and will be here for a longer period. But we are not able to mitigate it.

Although climate change costs are high, their threat is perceived less. Reasons may be climate change impact could not be seen directly or has a regular impact as COVID-19. It is just like a slow poison. But in the case of COVID-19, we can see the live deaths in front of our eyes. Also, it is a public health compound that the government can control. On the other hand, climate change impact could not be handled by a single government.

The World Bank has already warned ‘that climate migrants will be in the tens of millions in three decades even if urgent action is taken. The UN has said that reduction targets are not being met and there is a rising likelihood the world will miss its Paris Agreement target of reducing global warming to 1.5C (34.7F) above pre-industrial levels  (World Bank, 2019). Despite the fact, that climate change is not treated with the same urgency as COVID-19.

Global leaders and governments are not taking urgent actions they should be taking to save the planet. The main reason is, that the coronavirus effect is visible, it immediately infects and potentially kills anyone exposed to it, whereas climate change impact is slowly destroying our planet, creating a major threat to our survival over decades of time. A leading climate scientist Hans Joachim Schellnhuber has also said – “If you do not stabilize climate change, you will actually destroy the good prospects for development.”

The actual risk of climate change is high as compared to the actual risk of COVID-19, but people are more concerned about protection from COVID-19 rather than climate change. Similarly, in the case of the government, climate change is given less priority. So, the perceived risk of climate change seems to be below. In such conditions, when actual risk is greater than perceived risk, the level of response should be high and rational policy-making is required. But the same part is missing.

Given the compressed time frame of COVID-19 and the perception of the immediate high risk involved, significant financial sources and public and private research institutions are activated to hastily find and produce a solution. In the case of climate change, research activity is admittedly facing a much more complex problem, one whose consequences are (mistakenly) perceived by policymakers and the public as less urgent and is more widespread and undertaken on a quite different financial, geographical, and temporal scale (Fuentes, 2020).

Implications for Nepal

Nepal’s Vulnerability to Climate Change

Climate change is already affecting every inhabited region across the globe, with human influence contributing to many observed changes in weather and climate extremes (IPCC Report, 2021). Nepal is one of the most vulnerable countries to climate change, water-induced disasters, and hydro-meteorological extreme events such as droughts, storms, floods, inundation, landslides, debris flow, soil erosion, and avalanches. Nepal’s mountainous and challenging topography and socio-economic conditions (ranks 145 on the Human Development Index, merely one-fourth of its population live below the poverty line) make it a highly vulnerable country to climate change.

Although Nepal has a negligible contribution to global greenhouse gases (GHGs), adverse impacts of climate change are already seen in many parts of the country on water, health, agriculture, forestry, biodiversity, and economy (Gautam, N., 2014). Nepal is more vulnerable to a changing climate compared to other South Asian countries. Its glacier lakes may burst and cause floods, destroying infrastructure and people’s lives in lower lands. Some of the effects are irregular rainfall change in intensity of snowfall and rainfall in higher Himalayas, flood and landslide, drought, water shortage, heat waves, mosquitos at high altitudes. These effects result in migration, poverty, malnutrition, civil wars due to scarcity of resources, political conflicts, and so on. All these indicators are connected to human security resulting in a threat to national security.

Nepal is facing the problem of snow melting, glacier blasting, soil fertility decreasing. The temperature has been increasing in Nepal in the past few decades.  The maximum temperature in Nepal increased at a rate of 0.06 °C/year between 1978 and 1994, with higher rates at stations located at higher altitudes (MOFE, 2019). Nepal’s diverse geo-climatic system, which combines heavy monsoons, steep terrain, and remoteness, renders the country vulnerable to natural disasters. A rapid increase in atmospheric temperature for the past few decades and climate-induced disasters like less precipitation, heavy precipitation, and drought triggered by it have been causing adverse impacts on Nepal’s Himalayan range and glaciers, and ecosystems dependent on them (Ministry of Forest and Environment, 2019).

Despite its negligible contribution to total global emissions of greenhouse gases, Nepal is one of the countries that have high risks of adverse effects of climate change. Topographical diversity, fragile geological structure, sensitive ecosystems, and diversity of climate and micro-climate zones are the main reasons for it. Furthermore, poverty, illiteracy, social disparity as well as high dependence of the community on natural resources for livelihood have made Nepal more sensitive to the impacts of climate change.  (Ministry of Forest and Environment, 2019). As climate change impacts increase, Nepal’s vulnerability continues to grow.  Globally, it is ranked fourth, in terms of vulnerability to climate change  (UNDP). Nepal has experienced changes in temperature and mean precipitation. Data on temperature trends from 1975 to 2005 showed 0.060 C rise in temperature annually whereas mean rainfall has significantly decreased on an average of 3.7 mm (-3.2%) per month per decade (GoN, 2016).

Under various climate change scenarios for Nepal, mean annual temperatures are projected to increase between 1.3-3.8°C by the 2060s and 1.8-5.8°C by the 2090s. Annual precipitation reduction is projected to be in the range of 10 to 20 % across the country (GoN, 2016). Based on the National Adaptation Programme of Action (NAPA) 2010, out of 75 districts, 29 districts are highly vulnerable to natural hazards such as landslides, 22 districts to drought, 12 districts to GLOFs, and 9 districts to flooding. According to the Global Report on Disaster Risk, Nepal ranks 4th position in terms of climate change. Such climate-induced disasters and frequent earthquakes have increased vulnerabilities and risks to water and sanitation security, food insecurity, poverty, migration and further made the country highly vulnerable to climatic hazards.

Changes in the hydrological cycle may significantly change precipitation patterns leading to changes in river runoff and ultimately affecting hydrology and nutrient cycles along the river basins, including agricultural productivity and human wellbeing. There are indications that the dry season is becoming drier and seasonal droughts and water stress more severe. The timing and length of the monsoon period also seem to be changing (E, Chettri, Tse-ring, Shrestha, & Fang, 2009).

Hence, climate change should be regarded as a top priority and mitigation approaches need to be taken.

What is Nepal doing?

Nepal is having some bold targets to mitigate climate change and achieve sustainability. Nepal is formulating a long-term low greenhouse gas emission development strategy by 2021 with the aim to achieve net-zero greenhouse gas emissions by 2050. The government has promised to make adaptation plans in all the 753 local governments  (Galimberti, 2021). In the annual budget plan speech, the government has announced a complete ban on the production, import, sale, distribution, and use of plastic bags thinner than 40 microns to reduce environmental pollution from plastic products. This is the third announcement towards this end made by the federal government as the previous two announcements were limited to paper (Ghimire, 2021).

The government is making environmentally friendly economic commitments in the form of Nationally Determined Contributions commitments such as the removal of tax hikes on electric vehicles. Commitments alone are worthless unless they are translated into real action. The Nepal Climate Change Support Programme (NCCSP) started with the aim to ensure the poorest and most vulnerable communities in Nepal can adapt to the effects of climate change  (MoSTE).

The Government of Nepal, UNDP, and the Food and Agriculture Organization had launched a new project to integrate climate change adaptation in the agriculture sector to address climate change impacts through adaptation initiatives in the agriculture sector and build Nepal’s capacity to mobilize funds for longer-term climate initiatives that are linked to Nepal’s Agriculture Development Strategy (FAO, 2016).

The Government of Nepal and its development partners endorsed the landmark ‘Kathmandu Declaration on Sep 23, 2021, to develop a strategic action plan for Nepal toward Green, Resilient, and Inclusive Development (GRID). Under the Kathmandu Declaration, Nepal’s development partners have identified up to $4.2 billion in potential future support, in addition to the $3.2 billion in previously committed resources to support GRID (World Bank, 2021).

The National Adaptation Plan was approved on 28 October 2021 by the Council of Ministers of the Government of Nepal.  The programs include adaptation actions that are best able to address climate vulnerabilities and risks in the short (2025), medium (2030), and long-term (2050); as well as adaptation actions that contribute to the achievement of national economic and development priorities (Public Health Update, 2021).

Nepal is also a party to the United Nations Framework on Convention of Climate Change (UNFCCC). Nepal has aimed to reinforce the implementation of an ‘Environment Friendly Local Governance Framework’ in municipalities and rural municipalities under the Nationally Determined Contribution (NDC) commitments to enhance climate change adaptation.

Nepal government is giving proper attention as it can, it has set targets, signed, ratified various agreements such as Paris Agreement, attended conferences,s and so on. However, in comparison to COVID-19, it is not giving the needful attention as it needs to be.

Hence, Nepal should capitalize on its pioneering and decade-long experience in the Local Adaptation Plans for Action (LAPA) process to effectively implement and achieve ambitious commitments of the NDC in action (Jamarkattel, 2021). Although climate activism from the grassroots has emerged, changing the discourse on the urgency of climate change adaptation, without the enactment of strategies regarding disaster risk management, waste management, use of green energy, and other frameworks, international coalitions will not come into fruition (Sharma, 2021).

Conclusion

This article argues that climate change is the defining crisis of our time, and it is escalating even more quickly than our expectations based on recent studies and research. It is a major threat to international peace and security. The major environmental threat, climate change, has widespread implications for Nepal, causing impacts to water availability, agricultural production, forestry, among many other detrimental effects (Adhikari, N.B., 2020).

Not only Nepal, but climate change is also a global issue, sooner or later every country must face the misery of its consequences. Every country either developed or developing, has the same need in climate change, impact mitigation, and adaptation. However, the developing countries lack inadequate preparation for the impact of climate change owing to their finances and technology and have limited capability while they become more vulnerable to climate change. They are believed to have less ability to climate change adaptation impact, less mitigation, and adaptation strategies dealing with climate change. The impact of climate change in developing countries absolutely outweighs that of developed countries and this situation has led to global inequality regarding the urgency to give the same attention to climate change action across the world (Wijaya, 2014).

Policy Recommendations

·         Developed countries must assist developing countries in all climate change-related solutions. Nepal, for example, needs international assistance since it is unable to address this global issue on its own.

·         As there are several diverse stakeholders or stakeholders with varied interests, the practice of collaborative leadership is required in this scenario. Hence, there is a need to practice a collaborative leadership approach during policy-making and implementation. Acting together, with urgency and without ego, helps us fulfill our commitment to impact and focus on what really matters.

·         Although COVID-19 has been given the higher priority as it is the present matter of concern, still there is also an urgent need to focus on climate change mitigation.

·         The climate crisis is providing the impetus we need to transition to a new industrial model based on renewable energy, recycling, and resource efficiency.Policies such as increasing the use of clean energy and improving energy efficiency should be practiced.

·         The counsel of indigenous groups must be heeded. They are also assisting in the preservation of forests and their resources in order to combat climate change.

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ANNEX

Figure showing the chronology of climate change adaptation governance in Nepal, Source: Extracted from Policy Alignment to Advance Climate-Resilient Development in Nepal, pg. no. 5

Policy Compendium

Need for Inclusion of Telemedicine in Private Health Insurance in Nepal

ANUSHRUTI Adhikari

LITERATURE REVIEW

Quality health care delivery system in a community is a vital factor for economic development. In the case of people from rural areas, when one has a condition that cannot be treated by a local primary care doctor and is referred to a specialist 3 to 4 hours away then those who can’t afford to take day off of work tend to put it off or don’t go to the specialist until their condition gets even worse which at time ends up being much more expensive to treat. People also tend to not make the follow-up visit again because of the transportation and financial issues. This is when telemedicine becomes an efficient alternative. It equalizes the quality of health care internationally so that everybody, regardless of where they live, can have a similar quality of healthcare (Klonoff, Joseph, Poropatich, et al, 2009).

Starting with reimbursable telemedicine services will help assure that administrative leadership, at the highest levels, is committed to the strategic and financial support of telemedicine implementation. Unlike just a few years ago, most healthcare executives are investing in telemedicine programs (Waller and Stotler, 2018 ).

Nationwide healthcare insurance plans and private insurers are reimbursing telemedicine as a part of health insurance programs, but their credibility against the physical consultation is still being reviewed. The fundamental question is how services delivered through telemedicine compare with those delivered through alternative means (Sisk and Sanders, 1998). The cost of telemedicine and lack of reimbursement for it are among the major barriers in the development of telemedicine (Kruse, Karem, Shifflet, et al 2016). Another impactful barrier to the implementation of telehealth solutions has been whether the amount allowed for payment is enough to create an economic incentive for doctors (especially given the current demands on doctors and their staff’s time), and for system integrators and device manufacturers to develop the technology (Hoffman, 2020).

National Insurance Program of the United States

Medicare is the federal health insurance program for people in the U.S. who are 65 or older, while Medicaid provides the same services for low-income families. Telehealth services of Medicare as a substitute for in-person visits include consultations, office visits, psychiatry services, and some physician fee schedule services. Since telehealth coverage can differ from one state to the other, many restrictions apply to this type of coverage. The implementation varies in terms of what service providers will be reimbursed for delivering, as well as how the parity between in-person and telehealth consultations is expected.

However, opponents of telehealth argue that telehealth services are not equivalent to in-person services and therefore should not receive parity to in-person services in reimbursements. According to them, telehealth should not be reimbursed the same amount as in-person care because of the costs and the savings associated with the two. Telehealth services are cost-effective and efficient, but opponents have argued that reimbursement for services should “mirror” those savings. Because of higher risks, possible lack of quality in care, and cost savings, many physicians believe that telemedicine should not be reimbursed on the same level as in-person care (Yang, 2016 ). Just as many innovative or beneficial ancillary services delivered in person are not reimbursed, those and more may not meet requirements for claims submission when delivered over distance (Waller and Stotler, 2018 ).

In the case of licensing requirements, the full professional medical license usually covers the ability to perform telemedicine visits with patients residing in a particular state (Shah, Amann, and Karlitz, 2020).

Telemedicine infrastructure costs are still largely either borne by the provider or paid for through grant funding. This threatens the long-term viability of telemedicine projects. Reimbursement of telemedicine transactions by private insurance is still somewhat rare and government reimbursement through Medicare and Medicaid is generally limited to services provided to under-served populations in real-time (Silverman 2003).

In early 2020, the COVID-19 pandemic threw a wrench into healthcare delivery models across the USA. Recognizing that without widespread availability of safe and accessible healthcare, the COVID-19 pandemic might also bring with it the second wave of morbidity and mortality from untreated acute and chronic conditions, CMS, commercial carriers, and state governments acted with unprecedented speed to dramatically expand telemedicine access and reimbursement (Bajowala, Milosch and Bansal, 2020). The Centers for Medicare and Medicaid Services and several state governors and medical boards reduced the burden on multistate licensing requirements for out-of-state providers and increased reimbursement and recognition for telemedicine services across insurance carriers (Shah, Amann, and Karlitz, 2020). Before COVID-19, insurance coverage for telemedicine was far from complete and included several restrictions even for the older population under Medicare (Dorsey and Topol, 2020). When the COVID-induced emergency expansion of telehealth expires, coverage and reimbursement rules will likely revert at least partially to these policies. Reimbursing for telemedicine visits at the same rate as in-person visits has been instrumental in encouraging increased telemedicine adoption among providers (Bajowala, Milosch, and Bansal, 2020). Regulations involve specifics on what types of providers, types of care, location of patient and provider (type of facility and geographical area), and nuances regarding facility billing. Some current procedural terminology (CPT) codes allow for telemedicine, but many do not (Waller and Stotler, 2018 ).

Telemedicine reimbursement policies have been slow to adapt to rapid advances in technology and increased demand for the service. Stringent geographic coverage and payment restrictions from both public and private health insurers have been barriers to telehealth adoption among healthcare providers (Bajowala, Milosch, and Bansal, 2020).

The Case for China

The characteristics of effective healthcare systems for developing nations like China are:

(1) equitable access to quality care;

(2) affordable health insurance; and

(3) financial sustainability.

Access to healthcare in China is very inequitable. For example, although 60% of China’s population lives in rural regions, only 20% of China’s health services resources are located in rural regions. Telemedicine, which improves access to care, would help to rectify this maldistribution of resources. Given that a telemedical business can be established with existing technology and minimal capital expenditures, China could likely improve its healthcare system by providing insurance coverage for telemedical services. Such insurance coverage would stimulate providers to enter the telemedical market, thereby improving access to care in rural China.

Telemedicine is likely to mean that far fewer healthcare institutions will be needed, and conceptually a handful of cities might be able to provide specialized healthcare services to the world. Moreover, because of the worldwide expansion of both health insurance and capital markets, the increased ability of patients to pay for medical services indicates that today’s telemedicine market should continue to expand in parallel with the global expansion of the insurance market (McLean, 2006).

The Case for Developing Countries

In developing countries, if a patient is taken care of using a telemedicine system, the delivered healthcare may not follow traditional techniques and as a result, the telemedicine consultation cannot be covered by insurance. European Health Telematics Association’s (EHTEL ) research shows that in most countries where healthcare is not state-funded there is no reimbursement process for telemedicine (Mahoney, 2003).

There is a paucity of dedicated, focused, and visionary telemedicine leaders in developing countries. Whatever telemedicine work we see in these developing countries is due to the individual efforts of these leaders and brand ambassadors of telemedicine. Lack of formal organizational structure to deliver telemedicine services is the biggest barrier for the development of telemedicine services in any country. Being a hybrid discipline, it needs collaboration with all possible stakeholders at each level of the healthcare delivery system.

Most telemedicine applications require a high speed and reliable Internet bandwidth to run smoothly. Tele-surgery, real-time teleophthalmology, real-time teleradiology, and emergency consultation are some examples of such applications. Unreliable and low wideband internet pose barriers to smooth delivery of telemedicine service (Bali, 2018).

It is a common fact that many provider physicians and clients cannot fix the technical problems arising from computer systems and ICT networks. So, for the proper and smooth functioning of the telemedicine system, we need to train manpower to establish stable and continuous communication during teleconsultation. Unfortunately, there is a serious lack of such trained persons in the system in most of the developing countries. The time gap between acquiring hardware and the development of customized software is so large that by the time software is ready, the hardware becomes obsolete. This mismatch between software and hardware also creates a bottleneck in the development of effective telemedicine solutions. Most telemedicine applications require a high speed and reliable Internet bandwidth to run smoothly.

Standardization of both hardware and software, as well as guidelines for practice, would help program managers to overcome interoperability, portability, and security issues. Several developing countries do not have a systemic telemedicine industry which means that their services are equivalent to that of an in-person consultation. Telehealth should be considered part of our tool kit for delivering healthcare and not a replacement for existing care, by transcending the conventional boundaries of traditional health services. Appropriate clinician reimbursement is key to telehealth uptake (Bursell, Zang, Keech, et al 2016).

On Technology

Availability of appropriate internet services and technological competence plays a key role on the patient side. Privacy concerns matter, even if we are temporarily allowed to use less secure lines (Shah, Amann, and Karlitz, 2020). Most doctors are not aware of the latest information technology and find difficulty using modern IT gadgets. There is a lack of telemedicine experts in the healthcare sector. There is a need to include a few chapters related to telemedicine in the medical education curriculum to sensitize and orient budding doctors to learn the technical part of this discipline. When a patient avails healthcare services through a telemedicine system, the insurance claim may not cover the cost of care as it is not delivered through the traditional healthcare system. Such discrimination seldom occurs in developing countries, where health insurance is still a rare commodity (Bali, 2018).

Several types of research on telemedicine support health policies that increase access, improve population health, and remove constraints to reach patients who live in developing countries and rural areas, and align both incentives and reimbursement to support the technology necessary to deliver these services. Telemedicine has the potential for growth and adoption (​​Kruse, Willians, Bohls, 2021).

INTRODUCTION TO TELEMEDICINE

What is Telemedicine?

Telemedicine is simply the use of technology to connect patients, doctors, types of research, or any other participant of a medical consultation at different locations. Telehealth, on the other hand, is used to encompass a broader application of technologies to distance education, health promotion, preventive services, consumer outreach, and other applications wherein electronic communications and information technologies are used to support healthcare services (Bali, 2018).

Traditional healthcare is far more expensive in terms of indirect costs. These costs outweigh the overall affordability of healthcare services whether they are public or private. Household health care expenditure constitutes a larger share (55.4%) of total health expenditure in Nepal. This high level of health expenditure implies that health care can place a significant financial burden on households and financial protection is one of the core components of universal health coverage. Individuals can drop below the poverty level when they pay for health care at the expense of meeting their basic needs (Poudel, 2019).

Due to the convenient, efficient, and progressive nature of the telemedicine solutions existing today, the idea of incorporating telemedicine as a possible replacement for physical consultation is becoming a viable policy option for many developing countries.

According to the Facts and Factors market research report, the Global Telemedicine Market size & share revenue is expected to grow from USD 40 Billion in 2019 to reach USD 150 Billion by 2026, at a 20% Compound Annual Growth Rate or CAGR growth during the forecast period of 2021-2026. Additionally, according to the Market Data Forecast, the telemedicine market of the Asia Pacific is estimated to grow from USD 10.33 billion in 2021 to USD 27.24 billion by 2026, with a CAGR of 21.40% over the next five years.

Benefits of Telemedicine

People living the furthest from a proper healthcare facility tend to compromise with their health if the total cost of seeking treatment is significant and catastrophic. As a result, medical problems which are visible or which have led the patient to a critical life-or-death situation get priority, while others are usually ignored until things get worse. One of the most common reasons for lack of motivation to visit the nearest (free) medical facility is the out-of-pocket expenditure on health, second only to geographical limits and distance. Educated communities or communities that have received awareness via local health workers are likely to give more attention to their health, but the gap between urban and rural communities in seeking healthcare stretches in a much more convoluted manner.

That being said, telemedicine solves the obvious problem of distance and limited time. In the case of public hospitals, Catastrophic Health Expenditure or CHE is usually caused by expenses other than low-priced medical fees such as expenses of travel, lodging, food, opportunity cost, etc. which telemedicine services do not require. For a patient to conveniently use telemedicine, there is a certain investment in technology during the very beginning – the burden of which can be taken over by the local municipality. In this case, the municipality arranges the telemedicine service on its premises. Otherwise, mobile-application-based telemedicine requires already-existing technology and some digital literacy.

Health workers and nurses too can communicate with their patients once both the parties are sufficiently trained to make use of the technology. They can also serve as mediators for patients who want to consult with doctors but may not do it independently. In the case of doctors, they can communicate with patients all over the country, while being ensured that their payment channels are secure and they will be automatically reimbursed per consultation.

Since the Coronavirus Pandemic has begun, telemedicine, for many patients, has become the only way to stay in touch with their doctors and actively seek consultations.

When Telemedicine Does Not Work

Urban concerns revolve more around privacy and quality.  There is no public policy related to telemedicine for the end-users, which can ensure privacy, confidentiality, and security of patient’s health information during teleconsultation.

In the case of rural communities, patients or health workers need to be welcoming of the technology without being biased. Internet speed and lack of digital literacy are some of the reasons why telemedicine won’t be accepted, let alone work.

Even if the country’s health initiatives do not rule out the importance of telemedicine, policies on the doctor’s end also need to be clear. Many practitioners fear malpractice-related legal issues, which prevents them from actively participating and developing telemedicine programs. Malpractice liability is an important barrier in the practice of telemedicine services.

Telemedicine set up can deploy varieties of information and communication technologies (ICTs) for transmitting information through texts, pictures, audio, and videos to a variety of healthcare providers. Cost depends on the type of ICT being used for the start-up. Setting an audio-visual ICT platform for teleconsultation needs huge investment. Budgetary constraints become a major barrier in the development of telemedicine networks in developing countries.

Reimbursement of telemedicine services has been reported as one of the important barriers in developed countries. When a patient avails healthcare services through a telemedicine system, an insurance claim may not cover the cost of care as it is not delivered through the traditional healthcare system. Such discrimination seldom occurs in developing countries, where health insurance is still rare (Bali, 2018).

PRACTICES IN TELEMEDICINE

International Practices of Telemedicine

Among the various countries currently drawing out their framework of how their telemedicine system should be, the telemedicine services are widely covered by the public health systems and if not, they are backed by private insurers. These countries are on their way to formulating specific laws that govern telemedicine following its unique nature in comparison to traditional consultation (DLA PIPER, 2020).

For this analysis, five countries with leading healthcare systems in the world that have identified telemedicine as an official means of healthcare consultation have been selected: Denmark, Austria, Australia, France, and Japan.

PROTOCOLS

While technically telemedicine is encouraged in Austria, medical guidelines stating that the doctor is personally and directly interacting with the patient could imply otherwise. In Denmark, innovators have adopted web and mobile applications that can assist patients to contact their local doctor, renew prescriptions and get reminders for medicines.

In Australia, telehealth medical practitioners are required to have an existing and continuous relationship with their patients. Therefore, ​​they can only provide telehealth services to patients who have seen the practitioner for a physical consultation in the last year or have seen another medical practitioner at the same practice for similar consultation during the same period.

Telehealth service in France is divided into telecare and telemedicine. In telecare, patients interact with pharmacists and medical auxiliaries while in telemedicine the patient has a typical consultation with the doctor.

LAWS AND REGULATIONS

There are no specific laws relating to telehealth but the practices are regulated by the Danish Healthcare Act. The Danish government has additionally issued guidelines that set a benchmark for telehealth projects. It also released “Strategy for Digital Health 2018-2022” focusing on digitization in the context of prevention, care, and treatment as well as development and research in the field of healthcare.

Telehealth in Japan are subjected to the Medical Practitioner’s Act which has been recently modified as was the need during the Covid-19 pandemic. The Act on the Protection of Personal Information (“APPI”) applies to the provision of telehealth in Japan, which assures that doctors and medical practitioners are seeking consent and explaining to patients why they need specific medical information.

In Austria in 2013, the Ministry of Health established a TeleHealth Commission, Tel Gesundheitsdienste-Commission, which continues to work on improving the scope of telehealth. But there is no official list as to which type of healthcare services are provided under telehealth. At this time there is no legal framework developed specifically for telehealth in Austria.

COVERAGE BY PUBLIC HEALTHCARE SYSTEM

Countries leading in healthcare systems such as Denmark and Australia provide telemedicine services under their public healthcare system. In Japan, only telehealth services of specific areas like pediatrics and life-style related diseases are covered by public health insurance. Additionally, medical institutions are allowed to decide if they want to adopt telehealth services. The rest are mostly covered by insurance companies. Telehealth services like videoconferencing with the doctor are included under France’s public healthcare system. Since January 1, 2018, the use of telemedicine is reimbursed in the same way as a face-to-face consultationinitiative% of the conventional social security rate, with the remaining 30% generally covered by the insured person’s private complementary health insurance. In Austria, medical advice via phone or video conference is reimbursed by the public health system.

RECONSIDERATIONS DUE TO COVID-19

The Covid-19 pandemic has accelerated the use of digital systems in both public and private healthcare facilities. Given Covid-19, the French social security system covered 100% of the cost of teleconsultations from March 18, 2020, until the end of 2020. In Australia, a health insurance package known as Telehealth Determination came into force under which the treatments and consultations delivered through telehealth but were not subsidized now become eligible for subsidy. In the case of Austria, remote health advice is reimbursed through the public system but in the light of the ongoing Covid-19 pandemic, several private insurers have begun including telemedicine services in their package.

Recent Telemedicine Practices in Nepal 

Recent government health strategies have been focused on strengthening Nepal’s telemedicine ecosystem.

In 2004, HealthNet Nepal conducted a pilot project for telemedicine in Nepal. It aimed to pilot the potentials of the store and forward methods in pathology, dermatology, and radiology. Om Hospital and Research Centre collaborated with Apollo Hospital in India in 2004 and started a telemedicine program. In 2010, the Ministry of Health started a rural telemedicine program in 25 district hospitals which was eventually expanded into further five districts. It provided services through the store and forward method,

video-conferencing, and hotline service “Hello Health”. In 2009, Nepal Wireless Networking Project was established by connecting a hospital in Pokhara with a health post in Nangi Village. Initiated by Dr. Mahabir Pun, he later went to facilitate municipalities like Kavre for telemedicine, along with experimenting with drones to carry medical items.

Recently an agreement was made to support Dhulikhel Hospital for Telemedicine and Health Informatics Program to serve remote and underserved communities through quality health care services, using technology and data-driven health care methods. Medic Mobile designs, builds, delivers, and supports open-source software for health workers and health systems including NGOs and INGOs in Nepal. WHO and UNICEF are supporting the piloting of the VaxTrac system that uses hand-held devices to record and track vaccinations.

Released in 2017, Nepal’s National E-Health Strategy aims to develop protocols and guidelines for implementing telemedicine services, develop user-friendly telemedicine consultation mechanisms and strengthen its services to link specialized medical experts at the central level with community health workers and volunteers.

Additionally, the 2019 Digital Nepal Framework policy includes digital health initiatives such as the National Digital Healthcare Program, Next-Generation Digital Healthcare Facilities, Electronic Health Records 2.0, Mobile Health Units, e-Maternal Care, Drones for delivery of emergency medical supplies, and Centralized Telemedicine Center.

Code of Conduct for Telemedicine Practitioners

Understanding these remote care developments, Nepal Medical Council released a Telemedicine Guideline for the registered medical practitioners in Nepal. According to this Code of Conduct, a Medical practitioner with a valid license of the Nepal Medical Council is entitled to provide telemedicine consultation to patients from any part of Nepal. Registered Medical Practitioners are expected to have been well trained in telemedicine before practicing telemedicine; Nepal Medical Council shall develop, or delegate a

A professional organization to develop, a defined short course on the practice of telemedicine, with the help of the experts working in the field of telemedicine in Nepal.

The guidelines have also set strict standards on bridging the gap felt in virtual consultations. However, it has specifically pointed out that Telemedicine should not be practiced as a substitute for conventional in-person care but should be practiced as a complimentary service where traditional in-person care is not

feasible is not accessible and is not affordable.

If the patient and/or accompanying relative is not able to understand the language, is not able to follow the guidance provided by the medical practitioner, he/she must be accompanied by the healthcare professional of the local area to interpret and guide the instructions provided by the medical practitioner.

While NMC has set its standards and the government has shown interest in strengthening this virtual healthcare package, there are relatively more efforts rolling out from the private institutions’ end. Even though their projects are following a short timeline, their impacts have become foundational and have guided us to brainstorm for Nepal’s next big telemedicine initiative.

Since the mentioned Code of Conduct advises patients to consider telemedicine as a complementary service and a necessity only when physical consultation is not possible, we cannot consider it as a true replacement for the health services that we currently have in hand.

HEALTHCARE SYSTEM IN NEPAL

Insurance Program in Nepal: Public and Private

The Social Health Security Program or SHSP acts as a Universal Health Coverage Program initiative affordable and accessible quality healthcare to all. It aims to promote pre-payment and risk pooling mechanisms to mobilize financial resources and subsidize health expenses for families identified as living in poverty, to eliminate their Catastrophic Health Expenditure or CHE. The government had announced this year that it had officially included all the provinces under this insurance program. The cost for this insurance is as cheap as USD 35 for a year for a family of up to 5 members, which individuals above 70 and those with severe and specified diseases will be provided with 100% subsidy.

Among the private insurers in Nepal, those providing medical insurance do not provide telemedicine products as of now. The number of checkups tied with the medical insurance in the policy does not specify if the checkups are supposed to be physical or virtual, but since telemedicine is still a new concept, it is understood that these checkups are physical.

The Burden of Healthcare during the Covid-19 Pandemic

Forecast of the first wave of Covid-19 in Nepal led to a nationwide lockdown in late March 2020. Ever since Nepal has been lifting and declaring lockdowns by reviewing the number of cases. 2020 left a lot of Nepalese confused and fearful, with fake news taking over the streets and people becoming more and more triggered by the day. As a result, while the first wave did not exactly challenge our healthcare channels, people suffering from non-Covid conditions did not visit hospitals out of fear, even when their health was worsening. Those who did go to the hospitals to receive treatments were sometimes ignored by hospital staff for the fear of catching Covid. Patients with long-term chronic conditions and even pregnant mothers faced untimely deaths due to this unsettling confusion and fear.

The second wave of Covid-19 which occurred around early May in 2021 did severely challenge our health system and left space for non-Covid patients to seek consultations or treatments. In both these Covid waves, we can see Nepal’s healthcare system being aggressively challenged. Patients with different degrees of health issues were scared of visiting hospitals. On the service end, while Covid doctors were working at full capacity, doctors of other healthcare problems had to take a break from their duties to make space for Covid patients. Even minor healthcare issues were not being addressed.

However, doctors and patients who had learned about recent healthtech innovations gave it a try. This year also saw an increase in the consumer base of leading digital wallet companies. We have yet to see if the habit of considering telemedicine as a substitute will be retained post-Covid. Considering the practices and responses in other countries, retention is likely to be low, since insured patients will favor hospital visits if telemedicine services are not being reimbursed and are not considered equivalent to a physical hospital. Therefore, while the crisis did favor innovations, post-crisis consumer behavioral patterns can bounce back to their original state.

CONSIDERING TELEMEDICINE UNDER PRIVATE INSURANCE

Inclusion of Telemedicine in Private Insurance

In the context of Nepal, telemedicine is technically not up to the benchmark to be able to replace a normal, regular visit to the doctor. If telemedicine is treated as a complementary service, that would have two extremely different impacts on the urban and rural communities. Urban communities who have covered by the health insurance would not bother investing in additional services while the uninsured would fear the risk of catastrophic health expenditure that may befall upon them and thus they would not be interested in accumulating any more fees. Rural communities will not consider complimentary services when even basic healthcare isn’t very easy to receive.

If the government considers establishing a proper telemedicine facility, that would require additional investments in technology, infrastructure, and training. Over the years, while the national health strategies have continuously highlighted the need for telemedicine, a specific model for it hasn’t come into action. As a result, rural healthcare is running on whatever means possible, but telemedicine approaches have never truly been a national, long-term priority. However, running a public telemedicine facility would remove the burden of cost from the rural communities’ shoulders.

Narrowing down the exact problems in the evolution of telemedicine, we are severely lacking investments in the overall industry. Over the past years, we have seen many telemedicine projects initiated by private bodies for a certain period. Hospitals, health facilities, and ICT experts have shown more enthusiasm in building telemedicine platforms and providing healthcare consultations through convenient platforms than the government. Therefore, it is likely that private institutions will eventually show interest in adopting long-term telemedicine technologies. When non-covid patients are avoiding hospitals, doctors and medical experts of all other kinds of health issues will have no choice but to remotely provide consultation in whatever way possible. This is where recent telemedicine technologies, whether mobile and website-based, have come in handy to bridge the gap.

This shows that no matter how much thought we give to the telemedicine industry, our demands for it do not shrink. Through whatever means possible, we rely on telemedicine. Be it in a rural community or a pandemic scenario, we need to reach our doctors anyhow. In specific times or places, it stops becoming a choice and starts to become a necessity.

Desired Outcome and Expansion of Healthcare

Reimbursable telemedicine services are cheaper and convenient to deliver. If insurers do include telemedicine in their overall medical insurance package, then depending upon the platform of the telemedicine, middlemen can be cut and teleconsultations can be provided directly by doctors on verified consultation platforms. For example, seeking teleconsultation through a mobile application allows the doctor to be paid as per their demand, without having to register as a patient, much like when we normally visit a hospital. Teleconsultation, therefore, becomes accessible and affordable, making it easier to be included in the already existing healthcare insurance plans.

Even though it is a complimentary service, when consumers are reimbursed for each teleconsultation by their private insurers, they will have more incentives to seek medical checkups if they weren’t seeking it before. This applies to lower-middle and middle-income families, who are digitally literate but cannot always afford to go to the doctor when they face any health problems. It allows them to ask several questions about health issues that they were previously ignoring. Doctors in teleconsultation can also assess patient’s reports and provide prescriptions while helping the patient to maintain digital records of the session. On the insurer’s end, the validity of the consultation and service can thus be regulated through these maintained digital records.

The surest way to make any mode of teleconsultation much cheaper is through ICT investment. The right investment in technology can make telemedicine services more compact, comprehensible, and convenient. This will also lead the insurers to educate their consumers about the digital possibilities of the telemedicine packages.

As for the low-income families, since they are covered by the national health insurance program already, the best way to include them in reimbursable telemedicine packages would be when the government decides to invest in “tried and tested” telemedicine technologies that have been verified or backed up by the private insurers. This way the government can pool the ICT resources at a national level, thus reducing the scale of investment in intangible resources and strengthening healthcare channels.

POLICY RECOMMENDATION

In light of the recent pandemic, we are more than aware of the fact that our healthcare system needs to be expanded and upgraded. Observing the current technical capabilities of healthcare innovations, we require solid medical insurance policies that allow the insured to access virtual healthcare consultations. Being insurance policies, Rastriya Beema Sansthan, the official regulator for the insurance companies of Nepal needs to direct their attention towards adding some telemedicine features to existing health policies.

Keeping in mind the identification of telemedicine in Nepal as a complementary service by the Nepal Medical Council, its service needs to be specified and therefore added to the existing policies and recognized as “ineligible as a replacement for a physical consultation”.  The nature of telemedicine also needs to be specified: is it operated via telephone, videoconferencing, or simply over the internet? How much would the insured have to pay to receive the consultation? Would they need simply a phone? Or would they need a smartphone, certified applications, and a good internet connection? Would the insurance also cover these costs? How will the insured be assisted in learning about the particular telemedicine operation?

To begin the demand for telemedicine services, insurance companies can provide a limited number of free telemedicine services in their existing policies with an additional fee for each additional teleconsultation.

Institutions that are running these telemedicine services, whether public or private need to be officially certified by the insurance companies as “eligible to provide reimbursable telemedicine services”. To ensure the smooth flow of certification, starting a telemedicine board is recommended.

Under the current telemedicine services, the clusters telemedicine providers have not been systematized properly. Therefore, even doctors or other consultants need to be included in a formal loop that can recognize them as official telemedicine providers and then provided them the required insurance policies accordingly eg. telemedicine malpractice insurance.

Finally, once the demand for privately insured telemedicine services rises, Rastriya Beema Sansthan can recommend similar policies to be added to the national insurance program which currently has nationwide coverage.

Upon making these policy changes, existing telemedicine services will have incentives to work upon their current services and improve them for insured users. The new policy will be financially reliable and they will be able to participate in a market that is far more competitive and excelling in terms of quality.