"Health reform makes health care more affordable, expands coverage to all citizens and makes our health system sustainable."

That was US President Barack Obama defending his Health Care Bill earlier this year, but he may as well have been speaking about Nepal. Of all the responsibilities of the state, guaranteeing citizens affordable health care is primary. In a country cursed with inequality and neglect like Nepal, it means making sure that malnutrition doesn't stunt children, that they are vaccinated against childhood killers, and that anemic mothers do not give premature birth to underweight babies and they have access to skilled maternity care.

It is in an elected government's terms of reference to do all it can to prevent infectious diseases, and when people do fall ill, or have to give birth, hospital care will be accessible and affordable. Poor health care in Nepal is not a medical problem, it is a political one.

But despite being in a state of statelessness now for more than five years, despite a ruinous decade-long war that set health care back decades, despite corruption, mismanagement and an uncaring bureaucracy, Nepal has been internationally recognised for its remarkable progress in maternal-child health. More than 850 mothers in every 100,000 used to die at childbirth in 1990, today it is down to 280. Under-five infant mortality has dropped from 162 per 1,000 live births in 1990 to 50 today.

True, there are still parts of Nepal where these figures are high, but the country is set to meet most of the UN's Millennium Development Goal health targets by 2015. Just imagine how much more progress would have been made if there hadn't been a conflict, and the state machinery was more responsible and responsive.

Even with all the achievements in mother-child survival, vaccination programs and awareness, health care access in Nepal is seriously skewed. Thirteen medical schools produce 1,300 MBBS doctors a year. But most of them work in private hospitals in the city, or emigrate. Same story with staff nurses. The Health Ministry needs just 140 doctors for 75 district and zonal hospitals, but it finds it difficult to fill those posts. Most private hospitals are too expensive, government hospitals are mostly mismanaged, and in the absence of a national health insurance scheme, Nepalis are left to fend for themselves.

As the health focus in this issue shows, there are working examples of hospitals that are affordable and efficient. There are health assistants who are not attracted by the bright lights of the cities, and there are government programs for the care of mothers and newborns that are saving lives.

We need specialist doctors and surgeons, too, but for the bulk of the population, MDGP (general practitioners) are more appropriate. These are all-rounders who can perform caesarians, simple orthopedics, and are able to diagnose childhood ailments. MDGPs are foot soldiers on the frontlines of health care in rural Nepal. And our experience with MDGP courses in medical schools are a model for other South Asian countries.

MDGP doctors turned around a neglected district hospital in Dadeldhura which is now performing 70 operations a month. The Panchthar district hospital in Phidim has saved lives of hundreds of mothers and babies because of a dedicated MDGP. The Chautara district hospital has stayed relevant because of one doctor who refused to work in the city. Many mothers used to die due to complicated pregnancies until an MDGP arrived in Baglung, and he is now performing 800 deliveries a year, many of them C-sections.

Having a dedicated and compassionate general practitioner in a far-flung hospital makes the difference between life and death to many Nepalis every day. Their work gives the country a healthy majority. They are the true heroes of Nepal today.

Read also:
Healthy progress
Nepal's maternal mortalityrate has dropped from 850 per 100,000 live births twenty years ago to 280 today.
No home delivery, DAMBAR KRISHNA SHRESTHA in BARDIYA
Birkha Dai's clinic, ABHAYA SHRESTHA in MUGU
Do hospitals have to be so expensive?, ELIPHA PRADHANANGA in DHULIKHEL
Dhulikhel and Chhetrapati hospitals show the way in making health care affordable to all Nepalis