Nepal’s rural lifelineOne far-flung hospital shows that it is possible to provide free quality medical care to isolated communities in Nepal
It is nearing 6PM and Mandeep Pathak is on the daily evening round of the in-patient ward at Bayalpata Hospital in Achham District. The section is crowded with patients young and old.
Most have respiratory problems, women with limbs broken in falls from cliffs, some have diabetes, and there is a psychosis patient in an isolation ward. There is wailing from the delivery room of the maternity ward.
Pathak’s mobile phone buzzes. He listens, and rushes off to the emergency room. A crowded tractor has fallen off the road and there are mass casualties. The wounded soon arrive, and Bayalpata’s staff go into practised triage mode.
The team declares a 12-year-old boy dead on arrival. Others are rushed into x-ray and readied for splints and plaster casts. Some are discharged after treatment to join crowds of waiting relatives outside.
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Patients in this isolated hospital in a corner of one of Nepal’s most remote districts are from all over Sudur Paschim and Karnali Provinces. One 8-year-old girl with a broken arm has been brought here by her father from Humla, after walking four days to get to a road.
In the 14 years since it was established, word has spread that Bayalpata provides high quality service free of cost, and the hospital is treating 100,000 patients a year with a team of dedicated staff, surgery, lab, pharmacy and a high dependency unit.
In the maternity ward is a 35-year-old new mother who is quietly taking her supper. She has a shining smile as her husband fusses over her. They are now happy parents of twin boys, their fourth and fifth children.
A few beds away is another young mother recuperating from a caesarean delivery. The husband is not happy — the baby is a girl and they already have two daughters. Hospital staff try to persuade him to get a vasectomy, but he still wants to try for a son.
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Unlike private hospitals in Nepal, some of which have up to 80% caesarean deliveries, at Bayalpata most births are natural. Doctors do caesareans only on complicated deliveries, or on referral patients.
In one recent case a 17-year-old mother died on the way to Bayalpata from Bajura district. She had twins, only one of whom survived. Another woman who was 30 weeks pregnant suffered a stillbirth, but because it was a girl, the mother-in-law and husband did not look too perturbed.
A mother who gave birth after a difficult delivery was nearly bleeding to death from postpartum haemorrhage. While doctors tried frantically to save her life, the family was celebrating the birth of a son.
Despite improved literacy, patriarchy is still entrenched in these remote mountains of far west Nepal. Boys are sent to school while girls help with house chores and raise their little brothers. When children fall sick, the boys are likely to be taken to an expensive private hospital in Dhangadi, while girls are brought to free institutions like Bayalpata.
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“The paradox here is that girls are getting world-class treatment while boys have to settle for less than optimal healthcare at private facilities,” says Mandeep Pathak, one of few orthopaedic oncologists in Nepal who has been working at Bayalpata for eight years.
Pathak examines a 14-year-old girl from Mugu on whom he operated to remove a benign but complicated tumour that had restricted her mobility for the past two years.
As he does his evening rounds, Pathak tells us: “Our patients are among the poorest and neediest and from the remotest part of the country. They would not have got a correct diagnosis, let alone get timely and affordable treatment otherwise.”
The only cost families have to bear is for transport to the hospital. The hospital even provides free food for one relative accompanying the patient.
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Bayalpata Hospital is managed by the non-profit Nyaya Health Nepal (NHN) in partnership with the provincial and municipal governments.
Although the hospital gets much of the attention, NHN’s emphasis is on the community that provides door-to-door care to families in Achham. There are up to two Community Health Workers (CHW) for every ward who regularly visit families to monitor the condition of pregnant women, provide ante-natal care, or check up on those with chronic conditions. This reduces the pressure on the hospital, and also saves families money.
CHW can even assist while community nurses perform lab tests including for HIV, hepatitis, urine, sugar, protein, pH level, haemoglobin so patients do not have to come to hospital. The nurses even provide psycho-social counselling, since mental health is still not discussed openly.
Aside from healthcare, the female CHWs also demonstrate the important role women can play in this socially conservative society. Jamuna Saud, a 24-year-old CHW, is visiting families in the village of Patalkot, and recording data of patients on her Electronic Health Record app that provides physicians at Bayalpata with instant information on the medical condition of patients in case they need to be taken to hospital.
“We are still a male-dominated society here, as you can see, but things are improving,” says Saud, as she climbs up the trail to another family’s homestead. “I have seen families sending daughters to school because they see us being respected for our job. They are starting to treat their own daughters better.”
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The work of NHN’s community health program is already seen in Achham district’s health parameters. After a dip during the pandemic, institutional deliveries have climbed again to 80%, and this has sharply reduced maternal and child mortality.
“Mother and child health is our main focus and ensuring that we follow the progress of pregnant women means most now go to Bayalpata to deliver,” says Program Associate Bhawana Bogati, 28.
The hospital which recently marked its 15th anniversary has so far treated 1.2 million people free of cost, and sustainability continues to be the biggest challenge for Bayalpata’s public-private partnership with the local government. Half the annual budget still comes from international donors.
But more than anything else, Bayalpata is a working example that free quality medical care is possible. Other government district hospitals have larger budgets, treat fewer patients and charge fees.
Given the remoteness of Achham, the other challenge is retention of doctors and paramedics. Flights to Sanfebagar are unreliable, and a jeep ride to Dhangadi takes 10 hours.
Says surgeon Bhaskar Pant of HAMS Hospital in Kathmandu and a board member of NHN: “Bayalpata is a rural lifeline, we need hospitals like these in the remotest corners of Nepal and to run them we need medical staff who are willing to be posted here.”
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Her baby son is only nine months old, but Community Health Worker (CHW) Jamuna Saud is already back to making door-to-door visits to advise other expecting mothers about safe delivery. Her visit today to Patalkot village, a 3 hour drive through rough roads from Bayalpata, is hindered by a sudden thunderstorm, but she is not bothered.
“You need to eat for two now, it will not be good if you skip meals,” says Saud as she counsels Pabitra Auji who is six months pregnant with her first baby and looks undernourished. “Fruits, leafy vegetables, meat and egg, and don’t forget to take your iron capsules.”
Saud has been a CHW for four years. She had originally wanted to be a doctor or a nurse, and was a class topper in school, but her family could not afford medical school fees. Moreover, young women in her community were expected to get married, not go to college.
“Mine was the only family in the neighbourhood that let girls go to school,” recalls Saud. “But my parents passed away when I was in the 9th grade and my brothers were not planning to educate me further. I cried until they admitted me to +2.”
Saud moved to Sanfebagar and paid her own way through college, supporting herself by doing odd jobs. She is happy to have been accepted by Bayalpata’s community health program, and feels a personal sense of achievement that childhood diarrhoea, malnutrition and respiratory infections among babies is decreasing, while more women accept family planning advice.
Over the years, Saud has seen changes among women like her in Achham. Girls are no longer restricted to just doing housework and producing babies. She says, “I am proud to have contributed to raising the living standard of people here even if by the tiniest bit.”
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The story of Florence Nightingale was the inspiration for Ramita Bogati, who always wanted to be a nurse herself. Back in her village, girls were actively discouraged from going to school, and were married young so as not to be a drain on the family.
“My parents did not actually want to send me to a school but my mother’s side of the family were educated, and many of them were in medicine,” says Bogati. “But I had to prove myself to change my father’s perceptions about what women should be allowed to do.”
Today, Bogati is one of 10 Community Health Nurses at Bayalpata overseeing 70 community health workers with her colleagues. Her passion for the job and the importance of the service she provides is all the encouragement she needs. She does not envy her staff nurse classmates who have flown to Australia and other countries.
On a typical day, Bogati is involved in early detection of chronic and infectious diseases, tuberculosis and hypertension so that the poorest in the community do not have to borrow money for treatment or, worse, have their lives shortened due to the lack of diagnosis and treatment.
Bogati has seen tangible impact of her work in birth spacing. In the past, women here used to give birth to as many as 15 children, and most died young. Now, they give birth to fewer but healthier children.
“As a nurse, the concept of community health was new to me but I have seen that we need to look beyond those who are able to come to Bayalpata. If they cannot come to hospital, the hospital needs to go to them.”
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