Nepali Times
In rural Nepal, health is about more than the body


It is the light that draws them to Bolde Pheriche, a village perched high on a hill here in Cenral Nepal, a two-hour
walk above the banks of the Saptakosi river.

The solar-powered lights, a beacon in the darkness that stretches for miles around, tells them that the doctors from Dhulikhel have arrived. "The lights are kept on all night long so people from the surrounding area can see them. Even in the villages across the river," says Kanchi Tamang.

Kanchi is one of hundreds of villagers who have turned up at the health centre here. She is waiting to be examined by a team of young doctors and nurses struggling to keep up with the lengthening line of patients. Common cases of gastroenteritis, fractures, inflammation and fever are treated on the spot, while more complicated cases are sent to the referral hospital in Dhulikhel. In a room adjoining the crowded consultation quarters, free operations take place in quick succession with the medical team breaking briefly for lunch.

"Operating here is much more convenient now," says Dr Ram Kantha Makaju, as he removes a tumour bigger than a tennis ball from a patient's back. Next he operates on a hydrocele, a collection of watery fluid in the scrotum, and a hernia. Next is a vasectomy. The facilities are much better now. Two years ago visiting surgeons operated inside the crumbling premises of the government sub-health post while staff held torches and towels to catch falling dust. Today, the post is empty, overshadowed by this spanking new health centre built with help from Friends of Bolde, a team of German well-wishers.

Dr Makaju was instrumental in setting up the Dhulikhel Hospital, the closest thing to a community hospital in Nepal, and its four satellite health stations in Kavre and Dhading. Now self-sustaining, run by efficient medical staff on land donated by the people of Dhulikhel and with infrastructure built with the help of European well-wishers, 16,000 operations have taken place at Dhulikhel and 135,000 patients have been treated in the past five years.

Today, its health outreach centre in Bolde is a compact stone and cement building complete with a pharmacy, a lab, a consultation room, and an operation room. The centre serves 30,000 people from as far away as the neighbouring districts of Ramechhap and Sindhuli, nearly two-day's walk away.

"The medicines at the health post in my village are not effective, so I come here," says 72-year-old Bhim Lal Pant. A weak and sickly Pant walked two hours uphill to see the doctors. Villagers, mostly women, walked up the same route while the health station was being constructed. They each regularly carried 50 kg bags of cement for six hours while others broke rocks to make the natural stone wall.

"It's good to see people getting health care," says Horst Schmel who with his wife Ursula and their friends raised about $100,000 for the centre. The couple are from near Munich, Germany, where there is one doctor for every 300 patients.

On average Nepal has only one doctor for 20,000 people (in remote areas it can be as much as 1:100,000) and a poor rural road network, health stations like this one in Bolde play an important role in taking care to the Nepali countryside, and compliment the government's own network of rural health facilities.
Nepal's New Health Policy 1991 visualises a wide and efficient rural network that takes health care to the ward level in villages by carrying out Gaun Ghar, or community clinics. While district and city hospitals stress curative services, the network of 137 primary health care centres headed by doctors, the 745 health posts and 3,185 sub health posts, each staffed by an auxiliary health worker and a female maternal and child health worker, provide preventive and essential clinical care, as well as counselling and awareness-raising services.

"The structure is extremely well-developed," says Dr Laxmi Raj Pathak, director of the Family Health Division, the focal point for the reproductive health programmes of government and non-government organisations. "But not all of the components are functional." Nepal's health care sector is constrained by several factors. According to a 2000 World Bank Study (Nepal:Operational Issues and Prioritisation of Resources in the Health Sector), public sector spending, including donor expenditure, on health care is a mere $3.10 per person per year-far less than the $12 (1993 prices) needed to provide a basic package of health care services in a developing country. The result, the report says, are gross inadequacies in terms of infrastructure, human resources, and service delivery.

The situation has worsened because of a one-pill-fits-all approach. "Dolpa and Pathaliya, two vastly different areas-one in the mountains, the other in the tarai-get the same supply of drugs," says Dr Aruna Uprety, a health and reproductive rights activist.

In addition, most health facilities lack personnel and are perpetually short of essential drugs and supplies. "Extreme poverty and lack of health education both discourage people from seeking health care, but the country's rugged terrain also limits access to health facilities," adds Uprety.

In the recent budget the government committed itself to adding three more beds for maternity care in each electoral area. But so far, there are no signs of that happening. "Everyone from the planning commission to the government has been going on about the high maternal mortality rate and safe motherhood. They should actually do something if, as they say, it is a priority after family planning," says Pathak.

Nepal's demographics reveal the poor state of health in the country: the fertility rate is 4.6, the infant mortality rate is 79 per 1,000 live births, and maternal mortality is about 5.4 per thousand live births, one of the worst statistics in the world. Half the children under five suffer from malnutrition, life expectancy at birth is a mere 57 years , and just 29 percent of the population of child bearing age uses contraceptives.

Even under relatively optimistic scenarios, says the Bank's report, Nepal's population is likely to grow at about 2 percent annually in the forseeable future. This would double the population in 35 years, putting enormous pressure on the country's already meagre health services. Infectious diseases, maternal and prenatal ailments, and nutritional deficiencies are the major causes of sickness and death in Nepal, accounting for 50 percent of all deaths and 69 percent of disease.

The Bank report suggests what many health care professionals have been saying all along-that programs are simply not well managed or coordinated with each other, that their roles are ill defined, and that there is not enough decentralisation at any level, whether budgeting or monitoring the operation of health posts.

But the more basic reason that health care, especially for women and children, is not improving fast enough, is a lack of political and bureaucratic will which, in its turn, has more socially-rooted causes.

Argues Uprety, "This is not only about hospitals, doctors, and medicines. It is more about recognising women as humans, about gender equality, good nutrition, sanitation, and awareness." On a ten-day visit to far-western Nepal, Uprety came across 1,600 women, close to one-quarter of whom suffered from prolapse of the uterus mostly caused by too many babies, and heavy workloads.

Most health analysts acknowledge the role of an estimated 48,000 Female Community Health Volunteers at the forefront of the battle to slash the high child and maternal mortality levels in the countryside.

(11 JAN 2013 - 17 JAN 2013)