Nanda Devi Bohara faced an exhausting five-hour walk and then a rough five-hour bus ride to get to the hospital in Dadeldhura with her sick daughter.

In this remote corner of far western Nepal, where doctors are few and far between and medical facilities are almost non-existent, the only reason her child is still alive is the presence in her village of 50-year-old Sarita Chettri, the local female health care volunteer (FHCV).

Chettri, and hundreds like her across the country, are on the frontline in the battle to reduce the 65,000 needless deaths of young children each year who succumb to malnutrition, measles, diarrhoea and acute respiratory infections.

She gave the little girl the medicine needed to keep her pneumonia at bay, and then travelled with her all the way to Dadeldhura's charity-run Team Hospital.

"Thank you for saving my daughter," Bohara told her as the doctor's nebuliser calmed her daughter's rasping breath. Without Chettri, Bohara's daughter would have been at the mercy of well-meaning but largely ineffectual traditional healers.
Volunteers like Chettri receive a very small allowance and 18 days of basic health training. This is often enough for them to counsel and guide parents of sick village children, who can then avoid the tedious and expensive trip to a hospital hours away.

More than half of Nepal's children younger than five can now be treated for diarrhoea and pneumonia close to home thanks to the volunteers, says a 2007 report by Save the Children (US). But health workers say there is still room for improvement.

"Death among children under five years is common and it's a tragedy that even today we still can't control the mortality," says Kalpana Swar, a volunteer in Dadeldhura.

The number of young deaths rises during the monsoon, when water-borne diseases are widespread. For the volunteers, the job means sometimes having to fight their way through torrential rain and landslides, and being permanently on call, which can put pressure on their family relationships.

"It's a 24-hour job and we can't say no to anyone or we will make enemies," says Rita Sharma from Achham district.

Saraswati Shah has been a volunteer for the last 10 years and has treated hundreds of cases in her village. She feels the government and aid agencies could provide more support, considering the key role FHCVs like her play.

Indra Devi Kunwar, a volunteer for 12 years who often treats 600 villagers in a month, would like to see the government committed to building more local heath centres and replacing the volunteers with professional medical staff.

"We do our best to serve the nation and save lives but we cannot continue like this forever," she says. "We need real doctors and qualified medical workers in the local health centres."

Abhinesh Dhital, medical officer at Dadeldhura District Hospital, admits the huge shortage of doctors, qualified nurses, hospitals and medical centres does put pressure on the volunteers, and says their role should be praised.

"Despite all the odds against saving lives, there has been progress and there is optimism of saving more if such community-based efforts are sustained," he says.

More than 95 percent of Nepali children are covered by Vitamin A and immunisation programs, and this is largely due to the contribution of the nationwide network of female health workers.

Where there are no doctors

Achham, one of Nepal's poorest districts, has only one hospital for its population of 250,000. There are only 15 health assistants, 40 assistant health workers and eight auxiliary nurses in the whole district.

"The health situation is very worrisome," assistant health worker Pushpa Buda says. "How many lives can a handful of medical workers like me save?"

The meagre medical supplies last barely a month or two, and in the monsoon when infections are endemic they run out of vital medicines. It is not surprising that Achham's child survival rate is the lowest in the country. The district's health centres rarely have medicines for many of the most common ailments, including worms, urinary tract infections, gastrointestinal and eye infections.

"The shortage of doctors in rural areas has always been a problem and despite the government's efforts to recruit them in the villages, the plan has not worked so far," said Prakash Thapa, a medical officer at the Doti District Hospital.

Out of 500 Nepali doctors joining the workforce annually, less than one-third choose to work in villages. Says Thapa: "There are so many vacancies for doctors in village hospitals but graduate doctors prefer to stay unemployed than work in villages."