Shaking up the health sector

Nepal’s oldest maternity hospital is still recovering from the April 2015 earthquake: its main building had to be demolished after earning a red sticker because of its structural damage. Soon, it will move into a new seismic-resistant wing, designed to withstand future earthquakes.

For now, the hospital is working out of temporary cramped quarters offering only 375 beds out of the normal 415. But when the new building is inaugurated next month, the hospital will have more capacity, lecture rooms, an emergency ward, operating theatres and an ante-natal section.

Hospital director Jageshwor Gautam looks excited to show  visitors around the construction site. “We expect our work to be much easier when the new building is completed and we can use the new space,” he says.

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The project is supported by the Japan International Cooperation Agency (JICA), built by consultant Hazama Ando and is expected to be handed over on 15 May.

The 2015 earthquake damaged 1,197 health facilities across Nepal, offering them a chance to rebuild so they can withstand future quakes. A survey done before the 2015 disaster had shown that of the 14 hospitals tested in Kathmandu, only 2 (Teaching Hospital and Patan Hospital, built by the Japanese) were seismic resistant. The situation in other parts of the country was even worse.

JICA is working to rebuild modern and safe hospital wings at Paropakar Maternity Hospital (pictured, right) and Bir Hospital, both in Kathmandu. They will enjoy advanced technologies like motion-sensor taps in order to reduce infections in washrooms, flush systems that reuse water from handwashing, handicapped-friendly toilets and treatment plants for hospital waste.

Elsewhere in the quake-affected areas, however, reconstruction of health facilities is not going as well. Only 55% of the health posts and hospitals that were damaged or destroyed have been repaired, according to the National Reconstruction Authority (NRA).

“The construction of hospitals was delayed due to technical reasons, but now they are our top priority,” says Manohar Ghimire of the NRA. “Of the 643 structures built, most are pre-fab structures which have already been handed over to the communities. Now we are focusing on rebuilding the rest.”

The reconstruction of health facilities was delayed because the central government could not agree on who should rebuild them. The Ministry of Health and Population had planned to do it, before passing it on to the NRA almost a year after the earthquake, where the plans faced further delays. That cost a total delay of two years, resulting in a reconstruction rate of only 53%, when the target was 65%.

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Of the 524 medical facilities that need to be rebuilt, 145 are under construction, while the rest seem to be inordinately delayed due to technical reasons. "Many health centres do not have their own land, and there are no guidelines for buying land. We can only build on already available land," says Pranaya Upadhyaya, senior Public Health Administrator at the Ministry of Health. "Before the earthquake, many were operating from schools or other government buildings. But now we have strict standards for medical facilities including size of land, type of soil, etc. The institutes that are having a hard time fulfilling these criteria are the one that are delayed." Upadhyay informs that work has not begun on the 250 health centres that the Indian government committed to, which contributes to the reason more than 500 of them remain to be built.

Even if the earthquake had not occurred, Nepal’s health sector needed a structural revamp. A survey two decades ago of 14 hospitals in Kathmandu by the National Society for Earthquake Technology (NSET) showed that only two of the facilities would be fully functional if hit by a high-intensity earthquake, and four would be partially operational.

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Survey leader Ramesh Guragain explains that quake intensity is not just  measured in the Richter scale, but by many other factors like depth, type of soil and distance from the epicentre. Which means that the intensity of the 2015 earthquake caused greater damage nearer the epicentre than in districts around Kathmandu.

A subsequent NSET survey of five regional hospitals outside Kathmandu also showed that Nepal’s health care centres are structurally unprepared for future large-scale disasters. Although services and facilities in some of the hospitals have improved, the structures within which they are housed are weak and could collapse.

Kathmandu’s oldest medical centre, Bir Hospital, in the heart of the city, has no space for expansion. After the 2015 earthquake damaged its mortuary, the hospital is constructing a new building in its place, which will also house its nephrology, cardiology and gastrology departments, but it is still short of space.

“Even after we start using our new facilities, we will need more space for the nursing campus, pediatric and maternity departments, organ transplant centre and many other services,” says Bir’s director Kedar Prasad Century, adding that there is no option but to expand to Duwakot in Bhaktapur, outside of Kathmandu.

Hospitals with large capacity will be much in demand after the next earthquake, and if they are knocked out of service, the injured will have nowhere to go. In 2015, many hospitals worked in the open or out of tents for months after the earthquake.

“In order to avoid such a situation in future, it is imperative that the reconstruction and retrofitting of hospitals be carried out with the utmost priority,” says NSET’s Guragain.

If this is the situation in Nepal’s privileged capital, one can only imagine what it is like in district hospitals. Many of the buildings are in advanced stages of disrepair, lack hygiene and are overcrowded, even in normal times. During disasters, hospitals will have to cope with a large influx of patients but the medical centres themselves will have suffered damage.

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