KUNDA DIXIT BAREFOOT DOCTORS: Nanda Lal Sikarmi, chief doctor of the Sindhupalchok District Hospital (above right) counsels a patient in Chautara, where the wards were destroyed in a battle in April 2006.

More than a decade ago, Kul Bahadur Sapkota began to suffer from uncontrollable fits almost daily. When the seizures became more frequent four years ago, he retreated to his bed, too distrustful of the local district hospital to seek treatment there and too poor to travel to Kathmandu.

But when 36-year-old Sapkota took his daughter to Sindhupalchok District Hospital two months ago, he told the hospital's general practitioner, Nanda Lal Sikarmi, about his symptoms. Sikarmi did some tests and diagnosed epilepsy. He gave Sapkota some medicine to control the seizures, and he hasn't had a fit since.

"GPs need to know everything-we have to be able to diagnose all kinds of diseases," explains Sikarmi. "Our work is quite multidisciplinary."

Sikarmi's day at the hospital in Chautara starts with his routine early morning rounds of the 17-bed general ward, which is almost always full. The outpatients department typically handles about 80 cases each day. A team of 12 medical officers, paramedics and nurses deals with both emergencies and minor surgery at the hospital, and is
also responsible for dozens of health posts and clinics around the district.

"The day goes by so fast that usually we don't even have time to get lunch," says Sikarmi, who has been at the hospital for more than seven years, four of them alone with no other medical support. He was there two years ago when the hospital was virtually destroyed in fighting between the army and Maoists, but decided to stay on to help rebuild it.

Now, with the war over, Sikarmi still sees a future for himself at Chautara. "There's no point looking back when there is so much we still need to rebuild," he says. "I got my medical degree in Nepal and I don't feel like I need to recoup the money I spent getting the degree. I was in Chautara when no other doctor was around-I'm attached to this place."

He says there is an urgent need for more GPs, especially in rural areas, where many people cannot afford to go to the towns to seek specialised treatment. It is obvious, seeing Sikarmi's dedication and his all-rounder skills that Nepal's health situation would be much better if there were more doctors like him. And that is the challenge: how do we make more Sikarmis?

The good news is that a growing number of young doctors are showing an interest in becoming GPs, says Urmila Bharati, who is one herself and has worked in the Myagdi district hospital. She believes incentives from the government would encourage more GPs to work in remote rural hospitals where their services are most required.

She also says the government should send more than one GP to each district to lighten the work load. A doctor often ends up doing the administrative work of the District Health Officer, coordinating the health posts and dealing with emergencies, as well as doing their own medical work.

Adds Bharati: "GPs are used to multitasking, but reducing the admin load will help us devote more time to the overwhelming health needs of the people."

Great idea

Minister for Health and Population Girija Mani Pokhrel, an MP from Janamorcha Nepal, may not be health minister for much longer, but his work while in office for the past two years has been recognised by the Ministers' Initiative for Global Health.

Pokhrel was in Geneva this month to attend the annual meeting of WHO, and was cited for his ministry's proposal to bring health services within the reach of very poor Nepalis. The trust, which was established with support from Bill Gates, analyses the proposals made by health ministers of developing countries and awards the five best ideas.

The trust then funds the selected proposals. The other countries that received the award were Senegal, Ethiopia, Mali, and Syria. Pokhrel says, "I am really happy that our proposal to take health services to the 28 percent of the country's poor population who don't get it now was deemed worthy."

The prime ministers of Britain and Norway and the World Bank have also pledged to help Pokhrel's plan through the International Health Partnership. "It would be really good if others also learnt from this initiative of the health ministry," says DfID's Nepal representative, Bella Bird.

Under Pokhrel, the Health Ministry has made it free health services to the poor possible in various health centres around the country, although it may take time for it to go nationwide. And it will also depend on who becomes the next health minister.