Nepal’s healthcare sector stands at a moral crossroads—and what we are witnessing is not merely a crisis in medical practice, but the full exposure of a deeply rotted system, run by a regime that can only be described as a mafiocracy. This is not just a theoretical term; it is a lived reality for every poor patient, every overworked doctor, and every underpaid nurse caught in a system where greed is institutionalized, accountability is performative, and ethics are optional.

The recent strike by doctors across the country—triggered by a Consumer Court ruling demanding millions in compensation for alleged malpractice—has brought this brokenness into sharp focus. But to frame this merely as a conflict between professionals and patients is to misunderstand the deeper pathology. The real disease is systemic, and the true diagnosis lies in the unholy alliance between political patronage and corporate healthcare profiteering.

When Healthcare is a Market, Patients Become Products

The commercialization of medicine in Nepal has reached grotesque proportions. What was once a profession rooted in service and care has now become a marketplace of misery, where everything—education, diagnosis, treatment, and even death—is monetized.
From the moment a student enters a private medical college, they are saddled with crippling debt, often upwards of ten million rupees. These colleges, run by politically connected business houses, are less about learning and more about lucrative investment portfolios.

Once graduated, doctors are thrown into the trenches of hospitals—many of which are equally commercialized—where they are expected to deliver perfection on salaries barely enough to sustain urban living. Nurses fare even worse, often earning less than security guards despite carrying the emotional and physical labor of care. The frontline workers, the actual backbone of any healthcare system, are treated as disposable cogs in a revenue machine.

Yet, when something goes wrong—when a patient dies, when a treatment fails—it is not the hospital board or the medical education mafia who face scrutiny. It is the doctor on duty, the intern on a 36-hour shift, the nurse working double overtime. In this mafiocracy, they are the scapegoats, offered to the public as symbols of “justice,” while the real culprits hide in plain sight.

Consumer Justice or Punitive Populism?

The rise of the Consumer Court in Nepal was, in theory, a step toward accountability. Patients deserve justice, and when medical negligence occurs, it should be addressed swiftly and fairly.

But the recent trend of slapping multi-million rupee fines on individual doctors or frontline staff, without comprehensive scientific and peer-reviewed investigation, smacks more of populist theatre than principled reform.
Medicine is not mathematics. It is a high-stakes field, often operating in environments of uncertainty, resource scarcity, and time pressure. No doctor can guarantee life.

But under current laws and media pressure, the expectation of perfection has become so pervasive that many physicians are now resorting to defensive medicine—ordering unnecessary tests, avoiding high-risk patients, or even leaving the country altogether.
And can we blame them? The system not only bleeds them dry during education and overworks them professionally—it also refuses to
protect them legally. What other profession demands both sainthood and servitude, but offers neither protection nor respect?

The Poor: Consumers Without a Choice

But let us not be mistaken—while doctors are being scapegoated, the poor remain the ultimate victims. In Nepal’s commercialized health system, the poor are seen not as citizens with a right to care, but as opportunities for profit extraction.
When someone in rural Nepal falls ill, their choices are limited to:

• Travel to an underfunded, overcrowded public hospital
• Borrow money to access private care
• Or simply stay home and pray

Out-of-pocket healthcare spending in Nepal remains one of the highest in the region, with over 55% of total expenditure paid directly by households. Each year, hundreds of thousands of Nepalis are pushed below the poverty line due to medical expenses. And even then, there’s no guarantee of adequate care.

The irony is cruel: The same system that underpays its doctors and nurses charges exorbitantly to the patient. Where does all the money go? To building private hospital empires, medical school chains, and luxury clinics, all owned by a tight-knit club of businessmen, many of whom also hold political influence.

Mafiocracy: A System of Predation, Not Protection

Let us call this system by its true name: mafiocracy. A regime where the political class and the business elite have formed a symbiotic cartel, hijacking public institutions and services for private enrichment. In this arrangement:

• Politicians grant licenses and regulatory cover to private institutions
• Business houses fund political campaigns and control media narratives
• Medical professionals are squeezed in the middle
• The poor are exploited on both ends

It is a food chain where nobody is protected, except the leopard at the top—a leopard that has tasted human blood, grown comfortable in its kill, and now prowls the system with impunity.

The doctor is devoured when politically useful, the poor when economically profitable, and the leopard is never hunted—only feared.
In this ecosystem, both the frontline workers and the public are not stakeholders. They are prey.

Education and Exploitation: A Shared Crisis

This crisis is not confined to healthcare. The general education sector reflects the same pattern of predation. Private schools and colleges, often run by the same business cartels, charge astronomical fees while delivering mediocre quality.
Students graduate with qualifications but no opportunities, and when they protest, they are told to either leave the country or accept the system.

Thus, a vicious cycle emerges:

• The poor remain uneducated or undereducated
• The educated remain unemployed or underpaid
• The professionals remain scapegoated and disillusioned
• And the elite remain comfortably in control

This is not a society in progress. It is a society in hostage.

Reclaiming the System: Four Imperatives

How do we dismantle this mafiocracy? Not with slogans or sympathy, but with structural reforms. Here are four urgent imperatives:

1. Reinstate Healthcare as a Public Good
Healthcare must be a social contract, not a consumer commodity. The government must invest in public hospitals, rural outreach, and universal health insurance. Thailand’s model of public health financing offers valuable lessons.

2. Regulate and Reform Medical Education
Licensing of medical colleges must be taken out of political hands and placed under an independent, transparent accreditation body. Cap fees, audit curriculum quality, and ensure that medical training is public-spirited, not profit-driven.

3. Protect Frontline Workers with Law and Ethics
Create a neutral medical tribunal composed of professionals, legal experts, and scientists to handle malpractice claims. No more ad hoc media trials. Make malpractice insurance mandatory for institutions—not individuals—and balance patient rights with professional dignity.

4. Empower the Public with Health Literacy and Rights
The citizen must not be reduced to a helpless “consumer.” Launch national health literacy campaigns. Institutionalize community health monitoring boards. Let public voices shape health policy—not just investor interests.

Conclusion: Healing the Soul of a Nation

At its core, this is not merely a policy failure—it is a moral and civic collapse. Nepal has handed its most sacred institutions—education and healthcare—to the market, and now recoils at the consequences.

A nation that cannot train its healers without bankrupting them, cannot treat its sick without exploiting them, and cannot protect its poor without blaming its professionals, has lost its ethical compass.

To restore it, we must rebuild trust, restructure institutions, and reassert values. The choice is not between doctors and patients. It is between a mafiocracy that profits from our pain, and a democracy that protects our dignity.
But this brings us to the most uncomfortable truth of all: Can these reforms truly happen under the existing system? Can a regime that is architected around profit, patronage, and predation genuinely dismantle itself for the public good?
Of course not.

Expecting systemic reform from within this mafiocracy is like asking the leopard to go vegetarian. It won’t happen—not voluntarily, not sincerely, not effectively.

Hence, the time has come not just for protest, but for a foundational change—a new social contract rooted not in corporate calculation or party decree, but in the real verdict of the people.

A verdict that says enough to syndicates. Enough to cartels. Enough to being prey.

Only when the people reclaim sovereignty—not just in constitution, but in everyday governance—can we begin to imagine a society where doctors heal without fear, the poor receive care with dignity, and public service is not for sale.
Until then, the leopard prowls. And we all remain, in one way or another, its prey.

(Dr. Janardan Subedi is Professor of Sociology at Miami University, Ohio. He writes on political ethics, democratic transitions, and institutional accountability in South Asia.)

• with HT