I would like to start by extending my gratitude to you. Despite the political upheavals, in the last five years, we have successfully made our way to the second periodic election following the promulgation of the 2015 constitution. Your and my journey from the time the constitution was adopted to this point has been filled with confusion, chaos, crisis, contention, and catastrophe but without a doubt it has also filled us with hope and demonstrated opportunities. The biggest positive has been that we have stuck to our democratic ideals as we continue to believe in the power of ballot as the panacea for our economic and social development. The beauty of democracy is that once in five years the political leadership of this country becomes an advocate alluring voters to side with them on specific agendas while voters like me become the deciding forces. Therefore, before the November 20 elections, while I have the power, I thought it is a good time to write to you about issues that worry me and probably something that should be concerning you too. I am a public health professional. But I will not be talking about health here, instead things related to our economy touching on public health issues.
I am sure you are well informed about the rising life expectancy in Nepal. Since 1990, it has increased by 12.7 years resulting in a life expectancy of 71.1 years by 2019. However, the fact that more and more Nepalis are living longer means that there must be greater investments in creating healthy living spaces, driving disease prevention efforts, especially noncommunicable disease, including cost of management and treatment of such chronic conditions. While increasing fiscal space for the health sector could be achieved by improving the efficiency in our delivery mechanisms and budget absorptive capacity. Simultaneously, we need to work on expanding the size of the economy.
You and I alike often boast of our demographic dividend—the engine accelerating our country’s economic growth. But it seems like in the next couple of years this engine that we are banking on may be running out of steam. As per a report from the National Planning Commission published in 2017, “Nepal will become an aging society around 2028…, and an aged society around 2054…”. This report further states that Nepal’s demographic window of opportunity—the demographic dividend which started in 1992—is ending in 2047. Hence, 2028 could be the beginning of the end. But the bigger concern here is the rising prevalence of chronic diseases amongst the working age population. Chronic health conditions reduce the productive years of life, impacting our economic potential. Hence, if we want to continue to dream and live in a prosperous Nepal, we have no option but to think about addressing these health challenges. My realization has been that topics such as noncommunicable diseases are primarily an economic agenda associated with a health agenda. But I bet you have already thought about it that way, or have you not?
Chronic health conditions reduce the productive years of life, impacting our economic potential. Thus if we want to continue to dream and live in a prosperous Nepal, we have no option but to think about addressing these health challenges.
Unfortunately, the moment we press the economic accelerator the paradox of health versus development begins to challenge our ideals. The government seems excited about the reopening of Janakpur Cigarette Factory. As per media reports the government plans to restart operation of old factories by partnering with the private sector. I understand that we would like to see our economy grow but plans to boost production of tobacco products is without a doubt suicidal. So, the question here is how far should we go to press the economic accelerator? In the debate between idealism and realism, are you looking at the practicalities or the ethics?
Meanwhile, as Nepal moves up the economic ladder, Foreign Direct Investment (FDI) as a key pillar to drive Nepal’s growth will get more and more reinforced. But you and I know that that FDI has been, due in part, responsible for nutrition transition shift from traditional diets to “diets rich in fats, sugars, meat and highly processed foods and low in fiber, and accompanied by a rise in sedentary lifestyles” in the developing economies because of the increasing availability and affordability of ultra-processed food. A paper from Corinna Hawkes states: “In the 1980s, as liberalization accelerated, FDI began to shift away from raw materials for export to processed foods for the host market, as transnational food companies such a PepsiCo and Nestlé invested in foreign manufacturing facilities for foods such as soft drinks, confectionary, dairy products, baked goods and snacks.” She further states “FDI is thus playing a role in the nutrition transition by shaping the processed foods market and making more processed foods available to more people”. Meanwhile, it is surprising that, in 2015, globally based on revenue 69 of the top 100 economic entities were corporations. For instance, Walmart was found to be richer than Australia.
Dear leaders, more than the wealth, what worries me most is the political influence that global food and beverage companies have demonstrated. The Indonesian government, for instance, recognized food and beverage companies as one of the five priority sectors in its economic plan. The battle between economy and health never ends. But I think the question to you is how do you intend to pushback? Meanwhile attempts are made by transnational food and beverage companies to partner with health actors stepping on Goals 17 of the sustainable development goals which talks about partnerships. Are you for the partnership or against it?
I am sure you are aware about the review held by the United Nations Committee for Development Policy in February 2021 which recommended Nepal for graduation from the least developed country (LDC) category. It means that, until 2026 we will continue to qualify for LDC-specific support. So, what happens after 2026? Does Nepal face a graduation shock? Will Nepal continue to receive similar support from the international community? These were some of the questions I asked myself. The answer I wanted was well captured in the concluding section of the report which stated: “most development cooperation will not be affected by LDC graduation. Important development partners such as the World Bank, the IMF, GAVI – The Vaccine Alliance, the Global Fund, the European Union, most of the UN system, and most bilateral partners (including south-south cooperation partners) do not consider, in determining the scale and nature of their assistance programmes, whether or not a country is on the LDC list”. On this I have two questions for you. First, are you happy that the foreign assistance is not going to be significantly disrupted? Second, are you happier that Nepal is graduating from the LDC category?
Before you begin to think about it. I want to share a personal story in relation to Nepal’s economic graduation. In July 2020, the World Bank moved Nepal to Lower-middle income country status based on GNI per capita data for 2019. Almost from the following day, I found that the Journal that I was planning to submit my paper required me to pay 50% of the processing charges which was previously free of cost because of my country’s low-income status. The sad thing here is not the requirement to pay for the processing charges of a scientific paper but the comfort that I was enjoying being in the low-income status. The disruption to this status quo should have come as happy news but instinctively I was sad. Unfortunately, I was happy and comfortable being categorized as the poorest. Are you comfortable with the low-income status? Dear leaders, it’s time we gave it a thought.
We must start thinking about how we are going to fund our own development as the donor community moves from social development to mutual benefits arising from trade and commerce.
We both agree that the least developed or low-income status is just a phase in our economic development. As Nepalis you and I must start thinking about how we are going to fund our own development as the donor community moves from social development to mutual benefits arising trade and commerce. We will need to find new and sustainable sources of funding our investments and interventions.
In the last ten years, the urban population of Nepal has nearly quadrupled. In 2011, 17.7 percent of the population resided in urban areas; in 2021, the percentage rose to 66.08 percent. Urban-rural migration, natural growth, and expansion of urban areas by local government restructuring have been cited as the primary reasons. While the first two reasons, due in part, contribute to the rise, in Nepal’s context, the restructuring of local government areas at various points in the last decade has led to this massive rise. Meanwhile, irrespective of how urban space is defined, these urban municipalities are engaged in designing blueprints for their future cities. The impact of built environments on NCDs is well established. It has been observed that the linkages between NCDs and built environments are talked about in the context of physical activity, food, mental health, and urban planning. This offers a unique opportunity to influence the urban municipalities to think about how they plan their future cities from a public health lens. I would love to know if you are excited about this opportunity.
By this time, you must have started thinking that everything which I have mentioned above is way more than what we can chew and to even think about intervening we might have to constantly punch above our weight. This reminds me of a conversation in the movie Invictus. The movie is based on the famous Rugby World Cup Victory by the South African team in 1995. In a scene, Morgan Freeman (in the role of Nelson Mandela) invites Matt Damon (playing the role of Francois Pienaar, captain of the South Africa’s World cup winning Rugby team) to his office to inspire him to think about winning the 1995 Rugby World Cup. The global event was happening right after the end of apartheid in South Africa and Nelson Mandela wanted to inspire his team to win the cup to unite a broken nation. At a point in the conversation in that scene, the president says “…in order to build our nation we must all exceed our own expectations”. Rightly so, in our case too, you and I need to exceed our own expectations about what we can do. Please think about it.
Student of Public Health