Doctor’s appointment

In the tail end of January 2016, the prospect of an orthopaedic surgeon sitting for a fast-unto-death emerged as a prominent media story in the febrile political atmosphere that pervades Kathmandu..This might have appeared unusual in a country where politics in recent times had revolved around issues like constitution writing and the deadly 2015 earthquake. Yet, a series of protests by Dr Govinda KC – a professor of orthopedics at Nepal's largest public hospital, Tribhuvan University Teaching Hospital (TUTH), popularly called the Teaching Hospital – over the last four years has managed to amass significant popular attention and support..Since 2012, Dr KC has launched seven separate rounds of hunger strikes to demand a wide range of reforms in medical education within Nepal. The demands began as an objection to political interference in the autonomy of the government-run Institute of Medicine (IoM) but have since expanded their scope. IoM was established in 1972 under the country's first and largest public university, Tribhuvan University (TU), with the aim of training different categories of health professionals in Nepal. With several medicine and nursing teaching colleges and hospitals under its umbrella, including the Teaching Hospital, IoM constitutes the largest such body in the country..At the core of Dr KC's demands is an effort to curb what is seen as the unfettered privatisation of the medical industry, particularly institutions providing medical education. Fellow activists and critics argue that such a trend compromises the quality of not only health education, but by extension, the public health system, while merely serving to line the pockets of investors and their political allies. In the process, an administrative dispute over the appointment of an official at the IoM has grown and transformed into a movement for the wholesale overhaul of medical education in the country..In the emerging political space of republican Nepal, these protests appear to serve another function. Beyond the concerns of the medical sector, a fundamental question regarding political economy has been raised in public: should healthcare, and its attendant aspects, be left to unregulated manoeuverings of the free market, or should the state step in and assert itself? This movement is as much about the specifics of medical education as it is about the reaction to the neoliberal economics in Nepal's healthcare..When I met Dr Govinda KC on 12 February 2016, he had deferred by three weeks what would have become his eighth round of fast-unto-death, halted each time when the authorities provided assurances and committed to deadlines. In what has become a recurring theme, the plan for the protest had been triggered by the government's inaction in attending to its past agreements with him. For now, he had been persuaded by a group of his supporters, which included fellow health professionals, senior journalists, activists and other members of civil society, to give the newest government in Kathmandu some more time. In Nepal's popular imagination, Dr KC's activism has made an impression similar to the one made by the anti-corruption movement of Anna Hazare in India. Even as Dr KC's demands were directed at reforms in medical education, like Hazare, his protests have found a way to channel public outrage against corruption of the political class..A medical professional for the past 40 years, Dr KC has been serving at the Teaching Hospital since 1994, where he is currently a professor in the Department of Orthopaedics. Over the years, he has earned a reputation among his fraternity and students for being something of an outlier: a senior physician with no private practice, who makes frequent trips in and outside the country to volunteer during medical emergencies and natural disasters, often at his own expense. Although the profession is known for being financially very rewarding, his frugal and austere lifestyle stands in contrast to most others: the surgeon lives in the government-provided hostel in the hospital campus. Added to that is the form of his dissent: the hunger strike. His critics have accused him of being naive and stubborn, even mad. But both his supporters and detractors appear to be responding to the same moralist tenor of his politics..These facts no doubt contributed to his ability to attract significant public attention when he began his first hunger strike in 2012. But his foray into direct political action had begun two years before that..On 15 March 2010, the students and teaching staff at the Teaching Hospital, including Dr KC, went on an indefinite strike, halting most of their professional services. The strike was in response to what they saw as an irregularity in the entrance examination conducted by the Tribhuvan University for post-graduate medical studies. The questions of the examination were found to have been leaked and the protesters accused IoM's dean, Dr Arun Sayami, of being involved. They demanded the cancellation of the exam, the resignation of the dean, as well as the formation of a body to probe the incident. The strike came to a resolution 17 days later, after the government agreed to form a committee to investigate the matter. The committee submitted its findings to the government, noting that there were sufficient grounds to implicate IoM officials, including those in the Dean's Office..After Tribhuvan University reassigned Dr Arun Sayami as an acting dean of IoM after the end of his tenure more than a year after this incident, the Teaching Hospital saw another wave of protests, demanding that he step down, and that the vacant positions be filled on the basis of seniority and not arbitrary decisions made by political parties in the government, which was the custom. By 14 May 2012, when Dr KC announced his decision to stage a hunger strike, he had started becoming the face of this movement. Several months of sit-ins and boycotting of the acting dean had produced little tangible result. And the doctor's warning to go on hunger strike seemed to have worked, since on the same day the then-Prime Minister Baburam Bhattarai acceded to the protesters' demands..However, one-and-a-half months later, on 5 July 2012, as the government failed to meet the demands and make necessary appointments, Dr KC began what is now considered the first among his septet of hunger-strikes. Sayami had been relieved once more of his services as the dean, and a committee responsible for naming his successor had run aground due to delays and disagreements. Further, the national attention at the time was dominated by another failure to meet deadline: the country's first elected Constituent Assembly had not been able to deliver a constitution and the prospect of a crisis prevailed in the background..Four days later, the doctor called off the strike after Tribhuvan University's vice chancellor appointed a senior professor from IoM as the dean. The new dean, Dr Kumud Kumar Kafle, however, had a little over a month left for retirement. A month later in August, Dr KC went on a second hunger strike, this time because he was worried that the government would foist the candidate of its choice on the university. On 18 August 2012, Dr KC broke his seven-day-long fast when another senior professor, Dr Prakash Sayami (the brother of Arun Sayami) – who Dr KC believed was sufficiently politically independent – was appointed as the new dean of the Teaching Hospital. For the time being, at least, it seemed the doctor was finally at peace..While it might appear that these were agitations directed at specific office bearers or instances of corruption, they were in fact reactions against the political parties' stronghold in the functioning of public academic institutions. Recalling his first protest of almost four years earlier, Dr KC told me that he wanted to bring to an end "appointments at the Institute based on political affiliation of candidates." To understand the rationale behind these appointments, one has to first look at how senior positions in these places are filled. In IoM's case, these offices, including those of the Dean's Office as well as the campus chief, are decided by the vice-chancellor of its parent institution, Tribhuvan University. Meanwhile, the vice-chancellor in TU, as well as in eight other universities, are political appointees, with the education minister recommending the nominee's name to the prime minister. More often than not, this has meant that these vice-chancellors are academics close to the political party in charge of the Ministry of Education..According to Dr KC, the offices of dean, campus chief and director at IoM should be selected autonomously "based on their seniority, expertise and experience", as those selected under the present method may not be the ideal candidate for the position. "Nepali politics has institutionalised impunity, corruption and lack of accountability," said Dr KC, where the "allegiance of the political appointees would be towards the party and their politics," and not their institution.."Nepali politics has institutionalised impunity, corruption and lack of accountability".A particularly blatant example of this was apparent in 2015 when the Nepali Congress-led government appointed an academic charged with plagiarism as TU's vice-chancellor. In a paper for a journal published by the Nepal English Language Teachers' Association, Tirtha Raj Khaniya, a professor of English education who was known to have close ties with Nepali Congress, had lifted whole paragraphs, including the conclusion, from a well-cited 2004 paper by a Turkey-based academic. Despite much criticism and demonstrable evidence against Khaniya, the government didn't reconsider his appointment. One member of the committee that recommended him simply stated that they were "unaware of any charges of copyright violation against Khaniya"..This chain of command, linking the political establishment with the executives who run these apex public academic institutes has considerable financial implications, especially at IoM. In addition to running the Teaching Hospital, the IoM also has powers to grant affiliations to new, privately-owned medical colleges. There are currently eight such colleges affiliated with IoM that give undergraduate medical education and train physicians and dentists. Over the last two decades, these medical schools have been one of the more lucrative avenues for investors: returns are quick and the market has a ready supply of students who are willing to pay up to NPR 6 million (USD 54,000) for a degree..Crucially, all new medical colleges require an affiliation from either IoM, under Tribhuvan University, or the non-government, privately-owned Kathmandu University (KU) to run their programmes. The investments run into billions of rupees, some of which is invested in land and infrastructures even before the affiliation is sought. For this to be worthwhile, the cooperation of university officials, such as the dean, and their political masters becomes essential. Thus the establishment of every new medical college can potentially become a mutually beneficial event for all parties involved: the investors get to enter an unregulated market; the regulators, high-office bearers of IoM and TU in this case, can seek illegal or unethical pecuniary benefits by looking the other way; and the political parties, who get contributions from both the promoters and office-bearers..This structure of medical education establishment and the preponderance of private colleges has been at the centre of the conflict between those who are pushing for change and those who hope to preserve the status quo. Of the 23 medical colleges in operation in the country, including the dental schools, 17 are privately-owned. These private colleges took 2300 of the nearly 3000 students admitted to medical colleges in undergraduate and graduate levels during the 2014-2015 academic year. For critics of the current landscape, like Dr KC, the problems exist at multiple layers. It begins with an ideological objection – that something as sensitive to public interest as medical training should not be dominated by profit-seeking actors in a country where government regulation is very weak. Whether market incentives abet or interfere with a medical school's objective of imparting quality education and training is a question that cannot be adequately addressed without tangible data. But in today's Nepal, this question becomes more urgent when one considers the virtually unregulated nature of this industry, and the kind of connections that investors enjoy with regulatory institutions like IoM. For Dr KC, this nexus of medical-school owners, investors, university officials and political parties – a coalition he calls the "medical mafia" – is the biggest threat to the future of medical education and of public health in Nepal..***.The political clout that private medical colleges enjoy affords them several impunities. One common complaint is that they are able to admit more students per year than their infrastructure and faculty can possibly handle. This was also one of the accusations levelled at Dr Arun Sayami. Dr KC told me, "Two years ago at TUTH, we used to admit 60 students per year for MBBS and now we take 76 students. It is already difficult for us to maintain our standards." If this is the case in the largest medical institute in the country, he asked, "how could those with lesser infrastructure manage 150 students?" The complaint is valid – all the private medical schools have either as many, or in most cases, twice as many students as the Teaching Hospital. More problematically, the private colleges, all of whom are mandated to have a functioning hospital, get fewer patients in their hospital which limits the students' clinical exposure hours and the quality of their exposure. According to a student at the private KIST Medical College in Kathmandu, the low number of patients and large student body means that sometimes the same patient is inspected and interviewed by several students, serially. Sometimes, she said, "the patients just start making up new answers.".The incentive for admitting more students is easy to understand. With the standard cost for undergraduate medical education hovering between NPR 40 and 55 lakh (USD 37000 and 47000), they are the primary source of revenue for colleges. Foreign students are encouraged to take admission as they have to pay even higher. The other source of income, patient fees, cannot be hiked too much as the colleges already risk low patient intake. In fact, hospitals run occasional health camps providing free check-ups to attract patients. Those opposing the privatisation of medical education make the case that university officials permit higher student intake at these colleges either expecting financial kickback from the college owners or under pressure from political parties who also have these financial interests in mind – the same interests that are in play when some new colleges are given affiliations. This aspect of medical education came under attack after early 2014, when Dr KC started his next phase of protests..On 4 December 2013, IoM dean Dr Prakash Sayami, who had been appointed after Dr KC's intervention in 2012, resigned from his position after disagreements with the parent body TU over granting affiliation to certain new medical colleges in the pipeline. In a press statement at the Teaching Hospital a month later, he said he had "received high pressure to grant affiliation to proposed medical colleges that lacked the basic infrastructural facilities for colleges." On 26 September 2013, TU had put out a notice requesting applications from prospective medical colleges that were seeking accreditation. The university had also written to Dr Sayami asking him to grant affiliations to Birat Medical College and National Medical College, two new private institutions. But the faculty at IoM, led by Dr Sayami, resisted, arguing that the IoM didn't have the capacity to regulate more medical colleges when they were already having difficulties monitoring the existing ones. When these facts emerged on 16 January 2014, Dr KC was already six days into his fourth fast-unto-death..The roster of the doctor's demands this time was more far-reaching. His strike was a response to the appointment of the new dean of IoM, Dr Shashi Sharma. Dr Sharma was being investigated by the country's anti-corruption body the Commission for the Investigation of Abuse of Authority (CIAA) for his past tenure as the vice-chairman of the Nepal Medical Council, which conducts licensing examinations and gives formal recognition to medical practitioners. But Dr KC was also asking the university to stop granting affiliations till a 'national policy for medical education' was in place..Once again, after two weeks of hunger strike which severely debilitated Dr KC's health, the government agreed in principle to three of KC's seven demands, and sacked Dr Sharma. Exactly two weeks after the agreed deadline for appointing a new dean passed without any development, the doctor resumed his strike. After eight days of protest, representatives from the Prime Minister's Office signed a six-point pact with him ending his protest. The government would ask the CIAA to investigate the former office bearers of TU and IoM for allegations of corruption during the granting of affiliations. By then, the senior-most professor at IoM, Rakesh Srivastav, was made the new dean and the process of clearing new affiliations was halted..After two weeks of hunger strike, the government agreed in principle to three of KC's seven demands.Unlike the Doctor's protests in the past, the latter were different both in terms of the support they garnered and the opposition it created. In a show of solidarity, the Nepal Medical Association, the largest professional group of doctors in Nepal, had 400 hospitals around the country close all professional services, except emergency. This caused the Supreme Court to step in and order the hospitals to resume services. In response, on 21 January 2014, 200 doctors at the Teaching Hospital put in their papers en masse..But the opposition did not back down easily. At its forefront was TU, and the deposed dean Dr Shashi Sharma, who filed a writ petition in the Supreme Court asking for the nullification of Dr Rakesh Srivastav's appointment and his own reinstatement as dean. The court dismissed the plea. Meanwhile, there were also new medical colleges that were seeking to get their affiliations and set up shop. In recent years, the lobbying done by five prospective medical schools, including Birat Medical College and National Medical College, to procure affiliation has been well documented in the public domain. Some of these were not only promoted by those close to political parties, but had party members and even members of the legislature as their promoters and shareholders. According to the Kathmandu Post, "more than 50 lawmakers [as of January 2016] have direct or indirect ownership in medical colleges or institutes"..The most prominent and controversial among these was Manmohan Memorial Institute of Health Sciences (MMIHS), for it best illustrated the nexus between business and politics. Founded in 2007, MMIHS offers undergraduate and graduate courses in public health, nursing, pharmacy and other medical disciplines. The organisation is owned and run by a profit-making cooperative called Nepal Health Care Co-operative Limited (NEHCO), many of whose nearly 2600 shareholders are members of the ruling Communist Party of Nepal-United Marxist Leninist (UML). Rajendra Pandey, chair of the cooperative is a prominent leader of the party and among the 25 members of Parliament who have shares in the organisation. Having run a community hospital as well as a health-science institute, NEHCO also had plans to start a medical college..In December 2007, the cooperative acquired a letter of intent (LoI) for starting a medical college from the Ministry of Education. The first in the series of steps required for starting such college, it also enables the college owners to take out loans for the venture. According to Swasthya Khabarpatrika, a magazine on health, NEHCO had taken out a total of NPR 1.75 billion (USD 16 million) in loans from eight different banks and was having difficulties with interest payments. When Dr KC's anti-affiliation fast was gathering momentum in January 2014, the cooperative wrote to the Nepal Rashtra Bank, the country's central bank, saying they were unable to make interest payments. In the letter, NEHCO requested the central bank to direct all loan-providing banks to defer the payments until MMIHS was granted affiliation. The cooperative claimed that the affiliation has been delayed by a year "due to the difficult circumstances created by the doctors' strike at Institute of Medicine," and hoped the Rashtra Bank would "protect this project"..It was therefore not unusual when some investors of MMIHS, who were in the legislature, used their position in the Parliament to press their side of the story. In December 2014, when the Parliament was deliberating on the draft for a new education policy, several lawmakers came out strongly in favour of granting affiliations to new private medical colleges. Former Health Minister and UML MP Bansidhar Mishra, who also happens to be the vice-chairperson of NEHCO, complained that "an infrastructure built with billions of rupees has become useless due to lack of affiliation". He said, "But instead of shedding light on this side of the story, the media has been making the mad doctor a hero.".An appeal was made by 146 out of UML's 173 lawmakers in the 601-member body, led by Rajendra Pandey to the then Prime Minister Sushil Koirala to allow the affiliations. They threatened to disrupt Parliament if no such action was taken. A few days later, the Parliamentary Committee on Women, Children, Elderly Citizens and Social Welfare – led by another UML parliamentarian and which included Pandey and Mishra – directed the Ministry of Education to permit all medical colleges that had LoI to operate, overriding the sequence of agreements the Prime Minister's Office had made with Dr KC and his supporters..A turning point for medical-education activism, and possibly for the future of medical institutions in Nepal, came in late 2014, a month before the parliamentary committee's direction to the Ministry of Education. In November, the Prime Minister's Office had formed a high-level committee, later to be known as the Mathema commission, "to recommend to the government a new national policy on Health Profession Education (HPE) and in doing so also define the directives principles of the HPE in Nepal". This had come after Dr KC had warned the government of another strike on 16 November 2014, only a week before the 18th SAARC Summit was to be held in Kathmandu. Dr KC was demanding the formation of a body to formulate national medical education policy. "Government cannot cheat us every time," he told the media, also indicating the backlog of past agreements which had not been addressed in full. The doctor didn't go ahead with the protests, and the government was spared the embarrassment of having a fast-unto-death in the capital's freshly revamped streets on the eve of the Summit..This committee, composed of healthcare and education experts, was led by Kedar Bhakta Mathema, an educationalist and a vice-chancellor of TU in the early 1990s. Also a former ambassador to Japan, Mathema has the air of the polite patrician. When I met him on 9 February 2016 at his residence, Mathema told me that he had agreed to take on the assignment on one precondition: that he be allowed to choose the members of the committee. This autonomy given to Mathema, and subsequently to the committee's work, was a curious decision for the government to take, given the inflexibility and unenthusiasm shown in the past in this regard. "It was six months of hard work," Mathema said, "often we would work till the midnight," describing the deliberations of the committee, which submitted its 110-page report to the then-Prime Minister Koirala in June 2015..The government was at first reluctant to make the Mathema Committee Report public. The reason for this delay was clear enough. The Report made the same recommendations that Dr KC and his supporters had been advocating for so long. Only now, they carried the stamp of a government-instituted body of experts. The cabinet had sent the report to a parliamentary committee for review, and according to Mathema, it was this committee which was sitting on the report and delaying its release. This was the same committee that consisted of UML lawmakers who were also chairperson and vice-chairperson of MMIHS. Mathema said that they did not want the report to be publicised as it would jeopardise MMIHS's chances for affiliation. But contents of the report were already out in the press in some detail. After a push from several quarters, including Dr KC, the report was finally put on the website of the Prime Minister's Office, more than a month after its submission..The general drift of the report could be surmised quite early on, from its foreword which argued that:.From there on, the recommendations and observations made by the Mathema Committee appeared quite antithetical to those hoping to start private medical colleges on the fly. First there was the report's recommendation to put a moratorium on establishment of new medical colleges inside Kathmandu Valley for the next ten years. According to Mathema, with seven medical schools – almost the same number as those in India's National Capital Region – Kathmandu was already saturated with them. "Medical education is more than just education. It also is an avenue for public service," he said, explaining his committee's recommendation that new medical college be established away from urban centres. This was problematic for some colleges in the pipeline, and especially MMIHS, which had already erected its building infrastructure in Kathmandu. Not surprisingly, people like Rajendra Pandey and Banshidhar Mishra were critical of the report, saying it was biased to the extreme..The report also found detractors among those running existing private medical schools. Their objection, in fact, began even before the Mathema Committee had begun its work, when they protested that as stakeholders, they had not been represented in the committee. But the big issue for them was the report's recommendation that student intake be reduced to 100 per year, even for those presently admitting more than that. According to Dr Bhola Rijal, senior gynaecologist and president of Nepal Private Medical Colleges Association, "Our infrastructure has been planned for 150 seats. If we are not allowed 150 seats, it will not be possible to manage costs, students' dignity, staff salaries and other things, along with the services we offer." The report counters such claims, arguing that a majority of institutes cannot justify the present intake numbers based on their faculty size, hospital capacity, patient numbers and teaching infrastructure. It also proposes that these colleges gradually reduce their student intake numbers to 100. Other proposals that Dr Rijal found unacceptable were the ceiling on student fees (NPR 3.5 million, or USD 32,000, for an MBBS degree); mandatory entrance examinations for foreign students; and a 60 percent cutoff for those appearing for the entrance examination, an increase of 10 percent..For all its recommendations, however, Mathema's 'Health Professional Education Policy' report, has no binding powers; its only safeguards are the past agreements made by the governments with Dr KC, and Prime Minister Koirala's assurance to implement the report's recommendations. Events thus far had shown these to be rather weak collaterals. Even as the Mathema-led committee was doing its work, Koirala, as the chancellor of TU, had directed the Ministry of Education in February 2015 to start the procedures for granting affiliations to all the medical colleges awaiting it. In doing so, he had directly contradicted his own November 2014 instructions. This directive had come after about a month after the parliamentary committee's directive to the Ministry to do the same..The commands given by the prime minister reached IoM on 2 March 2015. After nearly two weeks of deliberations, the 32-member faculty board at IoM decided to deny affiliations to new medical colleges. Meanwhile, Dr KC was once again ready to agitate, accusing the prime minister of reneging on his promise. He acknowledged IoM's resistance, but thought they wouldn't be able to hold out for too long. Among several things, he wanted the government to stop any action granting affiliation until the Mathema-led committee produced their report. After 12 days of Dr KC's hunger strike, which crippled health services around the country as thousands of doctors around the country showed solidarity by stopping all non-emergency work, the government once again relented..Dr KC's hunger strike crippled health services around the country, as thousands of doctors around the country showed solidarity by stopping all non-emergency work.For the foreseeable future, the Mathema Report is set to remain the platform from which activists like Dr KC will derive legitimacy for their claims. This was precisely what he did in two other protests in August and September 2015. In addition to his earlier demands, he was also asking the government to implement the recommendations of the Report, in particular, the formation of the Health Profession Education Commission (HPEC), which was to draft a comprehensive bill on medical education, as well as function as an autonomous body to regulate matters of accreditation, examination, and curriculum, among others..Dr KC suspended his seventh fast-unto-death on 29 September – which had spilled into the day Nepal's new constitution was promulgated – after the HPEC was formed and filled. The entirety of his other demands were addressed in a lengthy 11-point pact with the government..***.In these last four years, it can seem as if the future of medical education in the country has merely been oscillating between Dr KC's bursts of activism and long phases of government inaction. I asked the doctor what had been the value of his protests. He responded with specifics: the threshold fee for undergraduate medical studies had been set; the Health Profession Education Commission had been formed, and in three months, was set to prepare a draft bill for regulating medical education; postgraduate medical education was going to be free of cost or supported by government grant. Beyond these, he thought the increased participation of students – not just from the medical community – and support from the civil society had been significant and would be useful in the long run..To be sure, the three specific changes were all results of the Mathema Committee's report, not all of which had been implemented in full. The NPR 3.5 million limit for an MBBS, for instance, had technically been in effect after a government directive. But there were anecdotal reports of a few colleges still charging around NPR 4 million (through unofficial channels) for admission. Still, these were lower than the NPR 5 or 5.5 million that had not been unusual before. As for his more recent demand regarding HPEC, he seemed satisfied with its formation but said future activism all depended on what the imminent bill looked like. "We will have to fight when it goes to the Parliament," Dr KC said, indicating that the next front in his activism could be the legislature..The tussle with Parliament came earlier than anticipated. In December 2015, UML-led government's Health Minister Ram Janam Chaudhary introduced a bill titled 'Manmohan Adhikari Academy of Health Sciences Act-2015', which sought to convert the existing privately-owned MMIHS into an academy with similar powers and the autonomy enjoyed by a national university, including that of running a medical school. Since Parliament was the one place least hostile to granting new affiliations, especially to MMIHS, this was an ingenious way to bypass the existing regulatory framework, as well as all the agreements that the government had made in the past. It was also an unusual bill, drafted with the concerns of one private institution – and essentially 2600 of its shareholders – in mind. MMIHS would no longer need to seek an affiliation from Tribhuvan University; it would to be able to gift one to itself..Dr KC was once again ready to strike. "This was a way to give affiliation by deceit," he said, asking the government to withdraw and scrap the bill. But the doctor postponed his fast by two weeks after Prime Minister K P Oli asked for time to study his demands, citing the national crisis the country had found itself in following the Constitution's promulgation. Regardless, the Parliament had forwarded the bill to its Women, Children, Elderly Citizen and Social Welfare Committee. In a clear case of conflict of interest, two MPs who would have to deliberate on a legislation regarding a profit-making organisation were also the organisation's chairperson and vice-chairperson..The bill was also under attack from several quarters around the country, including the medical fraternity, legal experts, journalists, retired bureaucrats and members of the Mathema Committee. Dr KC had issued two more warnings that he would go on fast, and had decided to delay it both times; his supporters had asked him to give the government more time, since they were believed to be coming up with a compromise. In February 2016, the government initiated a process to buy out the medical institute, with a plan to run it as a public institute. It will look into the financial profile of NEHCO, and decide if and how it would acquire it. Interestingly, this was also the recommendation made by the Mathema Committee report..The solution might work for both competing parties: the owners of MMIHS who have to pay an annual interest of NPR 18 million (USD 166,000) on their loans for the institute, and those like Dr KC, who want a greater public role in medical education. But the exact logistics of how the acquisition will be done, and what is to be done with the bill being floated in the legislature is not yet clear. Meanwhile, on 1 March 2016, Dr KC once again postponed his impending fast-unto-death, although it would be wrong to assume that he is slowing down. With the vacancy of the dean's position in IoM after the resignation of Rakesh Srivastav – who cited health reasons but reports indicate pressure on him to increase student seats at private medical colleges – Dr KC's activism appears to have come full circle..For a person often noted for austerity in his private life, Dr KC's political demands appear to carry exuberant limitlessness. I asked him what precise developments would stop him from going on further hunger strikes. Characteristically, he had a list in mind. For now it started with the appointment of IoM's new dean based on seniority, the withdrawal and cancellation of the Manmohan Academy bill, investigation on the former office bearers of IoM, and so on. "Old challenges," he said, "have started getting complicated. And new ones keep adding up." And so he intends to keep his protests alive? "The battle, the struggle, is unending," he replied.