Ashna Pathak & Surangana Rajya Laxmi Rana

About the Authors
Researchers at the Centre for South Asian Studies, Kathmandu, Nepal 

Introduction
Nepal has faced persistent healthcare challenges owing to its inadequate infrastructure, shortage of medical professionals, and limited access to advanced technologies. It has traditionally relied on international aid and partnerships to sustain. Health Diplomacy between Nepal and China is increasingly gaining momentum. This partnership has been crucial in deepening bilateral ties and fostering mutual trust. While Nepal relies on this support to build its healthcare sector, China's involvement in Nepal’s healthcare sector is often seen as a strategic extension of the Belt and Road Initiative (BRI). Which uses healthcare aid/support as a soft power tool to strengthen its influence in the region and Nepal.

Background: China’s role in infrastructure development
China has played a key role in improving Nepal’s health infrastructure since the 1990s, contributing to the construction, upgradation, and modernization of numerous healthcare facilities across the country. B P Koirala Memorial Cancer Hospital in Bharatpur was established in 1998 with a generous grant from the Chinese government. Over the years, China has continued to support the hospital's advancement through ongoing upgrades and expansions. In February 2024, China financed the establishment of a four-bed bone marrow transplant unit at the hospital, investing NPR 110 million.
 
The hospital’s Executive Director, Shivaji Paudel, stated that 10-12 Nepalis travel to India each month for bone marrow transplants, but once the new unit is operational, this necessity will be eliminated.  This development is poised to substantially reduce the need for Nepalese patients to seek such treatments abroad, thereby making critical care more accessible and affordable domestically. In August 2023, the hospital inaugurated Nepal’s first international Traditional Chinese Medicine (TCM) Rehabilitation and Treatment Centre. They plan to expand the hospital's services across all seven provinces of Nepal, indicating a strategic effort to decentralize specialized healthcare services and enhance nationwide health outcomes.
 
The Civil Service Hospital, constructed in 2008 as a gift from the Chinese government, serves as another prominent example of China's contribution to Nepal's healthcare infrastructure. Renowned for its robust engineering and comprehensive facilities, the hospital played a critical role as a rescue center following the devastating 2015 earthquake.
 
Recognizing the need for continual improvement, an extensive upgrade and expansion project commenced in 2018 with Chinese assistance amounting to approximately NPR 130 billion. The project encompassed the addition of a new surgical building equipped with 115 beds and advanced medical facilities, including specialized units for neurosurgery and plastic surgery, as well as the renovation of existing structures. The upgraded hospital was officially handed over to Nepal in April 2023, with Prime Minister Dahal saying: “I believe that this hospital stands as a symbol of deep and close Nepal-China economic cooperation that our two countries have been enjoying for decades.”
 
Following the devastating 2015 earthquake, China also aided the Chautara Hospital in Sindhupalchowk. With assistance exceeding NPR 1.1 billion, the hospital was rebuilt, and also equipped with modern amenities such as a vaccination center, a fire control center, a children's section, and a medical wastewater processing unit.
 
In addition to hospitals, China has also constructed the National Ayurveda Research and Training Center. The project was initiated in 2009 when the Government of Nepal proposed its establishment in 2003 to the Government of China. The center, estimated to be NPR 680 million worth, includes a 25-bed hospital, outpatient wards, research and training facilities, and dormitories, marking a significant milestone in promoting Ayurveda in Nepal.
 
China’s role in Nepal’s human resource development
Health diplomacy between China and Nepal has been significantly strengthened through a range of initiatives, including scholarships, training programs, and capacity-building efforts. Each year, the Chinese government offers scholarships to Nepali students. Many Nepali students pursue medical degrees at prestigious Chinese institutions such as Peking University Health Science Center, Fudan University School of Medicine, Sichuan University West China Medical School, Kunming Medical University, and Tsinghua University of Medicine.
 
Beyond educational exchanges, China has played a pivotal role in the capacity-building of Nepal's medical personnel. Since 1999, 14 Chinese medical teams have been dispatched to the B.P. Koirala Memorial Cancer Hospital, with over 265 Chinese doctors working alongside their Nepali counterparts. The medical teams have treated more than 6 million patients, conducted 150,000 surgeries, and helped train over 6,000 Nepali medical professionals. Chinese medical teams have also been proactive in conducting free medical check-ups in Kathmandu and traveling to rural areas to reach communities that often lack access to healthcare services.
 
Typically, after the completion of construction projects, Chinese medical teams remain on-site to provide ongoing training and support to their Nepali counterparts. The National Ayurveda Research and Training Center, China has provided medical and training equipment, with a Chinese technical team supporting the installation of equipment. This sustained engagement by China has drastically reformed Healthcare infrastructure and capacity in Nepal, further solidifying the partnership between the two countries.
 
 The increasing presence of Traditional Chinese Medicine (TCM) in Nepal
Traditional Chinese Medicine (TCM) is a complete medical system that has been used to diagnose, treat, and prevent illnesses for more than 2,000 years. Its foundational premise revolves around the concept of Qi, a vital life force that permeates the body. According to this framework, any disruption in the equilibrium of Qi can precipitate disease and illness.
 
As of March 2023, China has entered into over 200 cooperation agreements with 149 countries and 32 international organizations in pursuit of constructing the Belt and Road Initiative (BRI). Through the proactive promotion of the BRI, China is actively facilitating its integration into the global community initial transmission of Chinese medicine to Nepal was predominantly characterized by the adoption of acupuncture practices. Apart from acupuncture, the use of aromatic and mineral medicines is customary in both Nepal and China. Due to their geographic location, Chinese medicine, Tibetan medicine, and Nepalese Ayurvedic medicine have interacted and shared some commonalities in their treatment methods. They both prioritize the use of herbs and employ diagnostic techniques such as observation, questioning, and pulse diagnosis.
 
An international TCM rehabilitation and treatment center, the first of its kind in Nepal, was inaugurated at the B P Koirala Memorial Cancer Hospital in Bharatpur central-southern Nepal. The rehabilitation and treatment center provides comprehensive neurological and orthopedic rehabilitation services, as well as pain management therapies. The integrative approach incorporates both TCM modalities and modern technological interventions. In the past 25 years, over 250 Chinese medical team doctors have been sent to the Memorial Cancer Hospital to help improve the Nepali people's health along with Nepali doctors.
 
The TCM physicians practicing at the Memorial Cancer Hospital have garnered a strong reputation and following among the local patient population. Their expertise in integrating TCM principles and therapies into comprehensive cancer care has been highly regarded.
 
China-Nepal during COVID-19
When the COVID-19 pandemic began its rapid global spread in early 2020, Nepal, similar to numerous other nations, found itself underprepared to effectively respond to the unprecedented scale and complexity of the unfolding health crisis. As the first cases of COVID-19 inevitably emerged within Nepal's borders, the government recognized the necessity for immediate and robust action to mitigate the virus's spread. Given the country's geographic proximity and longstanding diplomatic ties with China, Nepal proactively sought technical assistance, medical resources, and expertise from its northern neighbour to bolster its response to the escalating outbreak.
 
China was one of the first countries to provide medical supplies and support to Nepal. In March 2020, China sent medical experts, testing kits, personal protective equipment (PPE), and other essential supplies to help Nepal combat the virus. Nepal got a fresh donation of medical supplies including Polymerase Chain Reaction (PCR) test kits, N95 masks, surgical masks, and personal protective equipment (PPE) sets from China to fight the COVID-19 pandemic, Nepal's Ministry of Health and Population noted. This swift response not only demonstrated China's commitment to assisting its neighbors but also reinforced its influence in the region.
 
China provided Nepal with 800,000 doses of COVID-19 vaccine under grant assistance. Despite high demands for the vaccines, both in China and around the world, President Xi Jinping personally announced an additional one million doses under grant assistance. Despite the pandemic, China continued its investment in infrastructure projects under the BRI, including the construction of roads, hydropower plants, and airports.
 
China is the largest donator of vaccines in Nepal
Nepal also purchased four million doses of Vero Cell vaccines from China under a non-disclosure agreement. China donated 1.8 million COVID vaccines developed by Sinopharm to Nepal in two different grants of 800,000 doses and 1 million doses in March and May respectively.
 
On 22 September 2021, a formal handover ceremony was held at the Rapti Provincial Hospital in Tulsipur, Dang. This event marked the official transfer of vital medical and waste management supplies from the Government of the People's Republic of China and the United Nations Development Programme (UNDP) to the hospital. The donation, underscoring the ongoing collaboration between the Chinese government and the UNDP to support Nepal's healthcare infrastructure, aimed to enhance the hospital's capacity to manage the continuing COVID-19 pandemic and deliver essential medical services to the local population.
 
The Rapti Provincial Hospital received various hospital equipment, including autoclaves; segregation trolleys; incubator; as well as automatic hospital laundry washing machine to ensure proper waste management from the hospital. Following the handover, healthcare workers will be trained on the proper use of the various equipment, as well as the means to manage medical waste. Alongside this, 100 officials from the local government will also be trained on better handling of health emergencies.
 
Challenges of China-Nepal Health Diplomacy
First, geopolitical considerations as Nepal are sandwiched between China and India. The geopolitical landscape of the region, particularly the delicate balance of power with India, renders the bilateral relationship between Nepal and China potentially volatile. Fluctuations in alliances or diplomatic postures could inadvertently strain health cooperation initiatives.
 
Second, infrastructure disparities and capacity gaps. Nepal's healthcare infrastructure, especially in rural regions, may lack the necessary capacity to fully leverage advanced Chinese medical technology and resources. This disparity could lead to inefficiencies in the implementation and utilization of Chinese Healthcare investments.
 
Third, cultural and linguistic gaps. Differences in language, cultural norms, and health beliefs between the two nations could engender misunderstanding and hinder the effective collaboration necessary for successful health initiatives.

Fourth, sustainability of health diplomacy. As Nepal faces a resource crunch, the long-term viability of health diplomacy projects is contingent upon sustained commitment and resource allocation. In a resource-constrained country like Nepal, ensuring the durability of such initiatives poses a significant challenge.

Fifth, dependency/over-reliance on Chinese aid and technology. Provokes concerns regarding Nepal's sovereignty and its capacity for autonomous health sector management. This can also have a spillover effect in another sector of governance and the economy.

Benefits of China-Nepal Health Diplomacy
First, access to advanced medical technology. China's cutting-edge medical technology, pharmaceuticals, and expertise could greatly enhance Nepal's healthcare capabilities, improving health outcomes for its population.

Second, capacity building. Through education and training, collaborative health diplomacy initiatives could provide avenues for Nepali healthcare professionals to acquire valuable training and education in China, thereby augmenting their skills and knowledge base.
 
Third, pandemic preparedness and response. Joint efforts in combating pandemics, such as COVID-19, could bolster Nepal's public health infrastructure and preparedness through the sharing of resources and expertise.
 
Fourth, revolutionize Nepal’s healthcare sector. Chinese investment in Nepal's health infrastructure, including the construction of hospitals, clinics, and research centers, could revolutionize the country's healthcare delivery systems.

Fifth, the promotion of traditional medicine. Both nations boast rich traditions in herbal medicine. Collaboration in the research and development of traditional medicine could unearth new avenues for health diplomacy and foster greater cultural exchange.
 
Conclusion
In conclusion, health diplomacy between Nepal and China offers both great opportunities and notable challenges. China's investments in Nepal's healthcare infrastructure and initiatives for developing human resources have significantly improved health outcomes in Nepal. Nevertheless, issues related to geopolitical tensions, cultural differences, and the sustainability of these projects need careful handling to ensure long-term success. As Nepal continues to navigate these complexities, the partnership holds promise for modernizing its healthcare sector, enhancing pandemic preparedness, and promoting traditional medicine, all while maintaining a delicate balance in regional geopolitics.
 
References:
“'Bone Marrow Transplant Unit' being set up at BP Koirala Memorial Cancer Hospital,” Republica, 24 February 2024
“1st traditional Chinese medicine rehabilitation, treatment center inaugurated in Nepal,” Xinhua, 05 August 2024
“Civil Service Hospital upgrading underway with China’s assistance,” Setopati, 26 September 2018
“PM Dahal to inaugurate China-assisted 50-bed hospital in Sindupalchowk,” Radio Nepal, 29 May 2024
“Chinese Government provides grant worth 680 million Nepali rupees for National Ayurveda Research and Training Centre Construction Project,” Aid data
“Medical team heads to Nepal for year of service,” China Daily, 28 June 2023
“Tibetan medicine: a unique heritage of person-centered medicine,” Springer Nature Link

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