Bureaucracy in Nepal Leads to HIV Deaths

by Kyle Knight

Bureaucratic deadlock is starting to kill people in Nepal. The country’s NGO sector working with populations deemed high-risk for contracting HIV-AIDS are in desperate need of $10 million of donor funds currently held by the cash-strapped government. While stories of stagnant bureaucracy in Nepal’s fledgling democratic government are not new, the consequences this time will put those increasingly dependent on NGO support at great risk. The failures of Nepal’s ineffective—even Kafkaesque—bureaucracy have obstructed even the most basic services, leaving NGOs to care for the country’s population.

Working with the most at-risk groups in the country such as intravenous drug users (IDUs), men who have sex with men (MSMs), and Nepal’s sizable transgender (TG) population, these organizations are unable to help treat or prevent HIV from spreading, because of the government’s embarrassing financial disorganization. NGOs working with IDUs have already reported preventable deaths linked to the funding gap, and organizations working with MSMs and TGs have not been able to hand out condoms for nearly three months. “It’s not that we don’t know how to treat people, or that we don’t have the capacity—it’s that we don’t have the money, ” explains an activist working for an IDU NGO. “Basic infections are going un-treated. Staff are looking for jobs elsewhere. These are unnecessary deaths.”

This is nothing new for donor-dependent Nepal. Sadly, the country is used to funding crises, especially in its HIV-AIDS programs. A recent impending shortage of pediatric ARV (anti-retro viral) was averted, thanks to the intervention of the United Nations.

The UN action has been a lifeline for the medical community and Nepali children living with HIV-AIDS. But it is far from enough. The HIV prevalence rate in Nepal is believed to be below 1 percent of the adult population, but infection rates vary considerably, and are substantially higher in most at-risk populations. In 2009, the government announced that the prevalence rates were decreasing across the country. The blocked $10 million will surely and unnecessarily boost the number of people infected by the virus and erase any gains made in recent years. While the impassive government receives warnings from international organizations, the risk of a new wave of infection is reaching a critical point.

On September 21, the World Bank wrote urgently to Health Secretary Dr. Sudha Sharma, warning of the clear and present danger that the funding gap poses to the lives of at-risk populations, “We have now reached a point where… efforts are all but exhausted and service interruption is likely unless the contracts are signed immediately.”

The World Bank has good reasons to call for public attention. As early as February, it had warned the Nepalese government of the necessity to be quick and efficient in administering the needed funds. The Bank transferred the money to the government for distribution. That disbursement was supposed to occur nine months ago, in January 2011. It still hasn’t happened.

Still, the World Bank has suggested an easy way to avoid this debacle. NGOs providing services to these at-risk populations were, by and large, the same ones applying for the new round of funding. The Bank recommends “the Ministry contract NGOs that are currently providing these services for an additional two to three months.” What’s more, these NGOs had a documented track record of success. Even this advice was ignored, and because of a technicality, an additional two-month delay was inflicted.

Demand from the Blue Diamond Society, a group of peer education outreach workers delivering HIV services to local communities, was also rejected. It was, as in previous funding cycles, the only NGO applying for MSM/TG funding. But this time the Ministry said the Bank rules dictated a minimum of three bidders. 

Local NGOs and HIV-AIDS rights activists aren’t taking the government’s unwillingness to release the funds lying down. With reports of preventable deaths, the organizations have brought the disruption in services to the government’s doorstep. The message they want to share? That the government’s failure to deliver the needed funding is undercutting programs that reduce the transmission of HIV-AIDS.

On Sunday, September 25th, more than 300 sexual and gender minorities traveled from all over the country to Kathmandu to spread the word. Many of them are employees of Blue Diamond Society, which directly services 5,700 people in Rupendahi District alone. About a 1,000 of them are sex workers, 200 of whom have tested HIV positive.

None of them have been paid since July. Some not since March.

They borrowed money from friends to pay for transportation, and slept on floors of flats owned by other BDS staffers in Kathmandu.

“It works,” Bishnu Pandey, the BDS regional coordinator in Bhairahawa said of the organization’s programs. “We use local networks to reach out. We teach sex workers about safe sex, empower them to teach others, and they come in for testing, for condoms and lubricant and counseling. It works.”

The delegation followed the paper trail to Dr. Sharma’s office. Sunil Babu Pant, MP, the director of BDS, led the conversation. He explained the situation on the ground, gesturing around the room to his employees, who had trekked into the city to demand funds to be released.

“They have come to show you that it is their lives being affected, their communities. These are essential, basic services for health and survival,” he explained.

But Sharma hardly listened.

The Health Secretary argued that contracts were initially delayed because of various complaints issued by the applicants. In a memo released last week, the World Bank itself wrote that delays had occurred due to “turnover of government officials, a court case” and the “investigations of complaints.” One fraud complaint from one NGO unsatisfied with the bidding and granting process stalled the entire process for all the NGOs for an extra two months.

Blue Diamond Society representatives requested Dr. Sharma to complete the contract process for the sake of respect for MSM/TG’s basic human rights. Again, she remained vague, revealing how chaotic the administration’s action can be when it comes to HIV-AID policies’ funding.

Contracts would remain unsigned because no one really knew who at the ministry should sign them, Sharma said. On the deadly impact of the lack of funding? She replied evasively, “This sort of thing is and isn’t a human rights issue.”

Sharma says she’s in favor of expediting the NGO process, but that, “It’s important not to dramatize it by saying that all of these things are human rights violations.”

To observers familiar with Nepal’s bureaucracy, this current funding crisis has unfolded like a slow-motion traffic accident. Five years after the end of a bloody internal armed conflict, the new republic’s government remains at a bureaucratic impasse. Transitory coalition governments and the constant shifting of ministers set the background for a country in which marginalized populations rely more and more on stable NGO services for basic needs. When the money gets bottlenecked at an administrative level, support often disappears for effective programs.

Dr. Krishna Kumar Rai, MD, a public health specialist and former NCASC director, believes the negligence leading to the funding gap ignores reality. “During a discontinuation of services, people continue to behave like normal without the services—have sex, use drugs if they are drug users,” he says.

Indeed, the lack of funding has already increased risk behaviors. A BDS employee from Itihari reports that since July, “even some of our staff members have turned to sex work because it’s been so long since we could pay them.” Sex work, that is, without the basic tools for protection that they have been trained to promote.

As Dr. Rai explains, “Neglecting the rights of people to these basic health services takes them from high-risk to higher risk.” Bureaucratic deadlock also.

But Sharma refuses to take further action. The Health Secretary repeatedly told NGO leaders that her ministry wants this money for strengthening health systems. “The government can say they need the money elsewhere,” remarks Pant, but if they neglect “the most at-risk populations because they can’t decide who signs a piece of paper, what’s the point?”


Kyle Knight is a Fulbright Scholar in Kathmandu. You can follow him on Twitter @knightktm

[Photo by Kyle Knight] 

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