<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722f839c7e80680e0c251djpeg.jpg" alt="" width="1200" height="800"/><figcaption>Photo: PRASANSA BUDHA LAMA</figcaption></figure>From 1991 to 2016, the maternal mortality rate in Nepal declined by a staggering 72% -- from 850 deaths per 100,000 live births to 239 in 25 years.This was a dramatic advance, but since then progress has slowed and almost plateaued off, mainly due to high rates of neonatal deaths.And at the current rate, Nepal will have to further bring down this figure by 71% by 2030 to meet its Sustainable Development Goals (SDGs) on maternal health. This is a considerable challenge given that Nepal has the highest maternal and neonatal mortality rates in South Asia, behind only Afghanistan.A shortage of skilled birth attendants, weak referral systems and difficulty in accessing treatment for complex pregnancies all point to the government’s chronic neglect of women’s health and the subsequent high mother-baby death rate.It is well established that the six pillars of safe motherhood are family planning, HIV/STD control, antenatal care, obstetric care, postnatal care and abortion care. And these can be strengthened through education, gender equality and access to primary health care. However, the Ministry of Health has overlooked these aspects, and this is undermining past gains.The 2015 Right to Safe Motherhood and Reproductive Health Act guarantees women the right to necessary counseling and maternity services from a midwife. But this does not apply to a majority of women in rural areas due to a lack of trained staff.Read also: <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Saving one mother at a time</a>, Bikash GauchanThe government needs to produce more than 10,000 midwives with a minimum of a three-year certificate if it is to reduce the maternal mortality rate to 75 for every 100,000 births by 2030, as per the SDGs.Under the previous Millennium Development Goal (MDG), Nepal had committed to reducing maternal mortality by three-quarters by 2015, which included midwifery education and services in the five-year plan. A policy was then formulated in 2006 to produce skilled birth assistants (SBA) with other staff to be given two months of training to develop 27 basic maternity services.The strategy includes basic nursing skills in nursing and medical education such as ANMI certification, BSc Nursing, MBBS and MDGP and aims to produce professional midwives in the long run.At present, Sudeni Maternal and Child Health Workers and Assistant Nurse-Midwife (ANMI) who underwent midwifery training for two months are deployed to communities as maternal health service providers.Since 2006, the program has produced more than 10,000 SBAs and reduced maternal mortality by 15% in the past decade at the cost of Rs1 billion, but we are yet to see the kind of progress we aspired to. The program has significantly increased awareness about maternal healthcare, but has not produced as many professional midwives.Read also: <a href="https://www.nepalitimes.com/editorial/nepali-ama/">Nepali Ama</a>, EditorialIn India, ANMI must have passed high school and undergone two years of training. In Nepal, those who have passed grade 8 and trained for 29 months can become ANMI. Therefore, people at the forefront of providing maternal and child healthcare are already lagging in resources, skills and education levels.In urban centres, mothers have the choice of obstetricians and gynecologists, but in villages, their best bet are ANMIs, many of whom have not even completed remote obstetric training. This negligence has cost the lives of many young mothers.Further, women accessing health facilities face humiliation, and even violence, and are stigmatised. The main reason for this is the lack of midwives, and the shortage of such an important position within the National Health Care System.Read also: <a href="https://www.nepalitimes.com/here-now/another-babys-life-is-saved-in-rural-nepal/">Another baby’s life is saved in rural Nepal</a>, Naresh NewarThere is also a tendency to announce popular programs only to source large budgets from state coffers. The President’s Program for Women’s Upliftment is an initiative to save the lives of mothers at childbirth.Launched in 2018, the program has only spent Rs36.6 million in three years when its budget was Rs50 million a year. In the same period, while it saved 360 women, 789 died without treatment.Expecting women in remote areas are constantly at risk due to the delays: at home while making a decision, on-road in lack of proper transport and at health facilities.Even then we can mitigate the illiteracy, ignorance and financial constraints that cause decision delays at home and on roads with public awareness programs. But the bigger challenge is that of local health facilities take time to transfer women to better-equipped hospitals.According to 2020 Maternal Infant Mortality Monitoring and Response (MPDSR), most maternal deaths were due to preventable causes such as bleeding, high blood pressure, infections and prolonged labour pains. The analysis also showed that 37% of women died on the way from one health facility to another, 30% at home, 23% in private and non-government hospitals and 10% on the way home from health facilities. Most of these deaths were of women under 34.Read also: <a href="https://www.nepalitimes.com/banner/balancing-life-and-death-in-nepal/">Balancing life and death in Nepal</a>, Ashmita Hamal and Naresh NewarBy mobilising skilled midwives at local-level health facilities, we can manage many complications and counsel families if a mother needs to be relocated. And one way to achieve that is by providing the ANMIs with a 3-year certificate level midwifery education.Midwives in essence stand for women's rights. They advocate for all women of reproductive age to receive the quality and dignified services they deserve, especially during pregnancy and childbirth.Midwives have proven their effectiveness in countries like Norway, Finland, Sweden, Denmark and the Netherlands for the past 250 years and have reduced maternal mortality rates to as low as 2 per 100,000 live births.With the maternity knowledge, skill and behaviour they have, only a midwife can determine the true condition of a woman in labour pain when there is no obstetrician and gynecologist present which is often the case across Nepal’s rural villages.If we want to save our mothers, it is of utmost importance that the Nepali state act immediately to produce midwifery practitioners.Laxmi Tamang is the president of the Nepal Midwifery Society.Adapted from the <a href="https://www.himalkhabar.com/news/130974">Nepali original</a> in Himalkhabar monthly magazine by Aria Parasai.Read more: <a href="http://archive.nepalitimes.com/news.php?id=16327#.Ys5GPOxBzAM">Homeward bound</a>, Sabhyata Timsina

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Midwives to the rescue in Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722eef9c7e80680e0c24ebjpeg.jpg" alt="" width="768" height="1024"/><figcaption>Bhavana with her young son. Photo: RITA ALE MAGAR</figcaption></figure>It was a night that Rita Ale Magar says she will never forget. Bhavana, 17, from remote Dumre Dara village walked 2.5 hours to reach a birthing centre of Udaypur.The underage mother was already 16 days overdue, her blood pressure was alarmingly high and she was going through prolonged labour. She was having difficulty pushing out the baby and was in severe pain.This was the most complicated case the centre had received, and the nurses were understandably nervous. But Nurse Rita had to lead the team and take the decision to try to save both the mother and her baby who were at high risk.“This was the moment when I had to use all the knowledge that I was taught by my mentors,” recalls Rita, who is a beneficiary of the Simulation-Based Mentorship Program (SBMP) of the group, One Heart Worldwide.After nearly two hours, the baby was born but that was only the beginning of the ordeal. The baby was not breathing and had no heart rate or muscle tone.“All of us thought the baby was dead, but we had to try our hardest to save him. I had less than a minute to give my best,” adds Rita, still shaken as she narrates her experience.It was at that point she remembered the ‘Golden Minute’ session she had learned about at the mentorship program -- the time needed for newborn resuscitation of babies born with asphyxia and deprived of oxygen.Nurse Rita quickly cut off the umbilical cord, put the baby on the resuscitation table and gave him electric suction which allowed it to start breathing. But the baby still looked pale, and was having difficulty crying.At the same time, the mother’s condition was worsening, she was bleeding profusely. The nurse sought help from a paramedic team to ventilate the baby with an Ambu bag while she tended to the mother.The baby's condition started to improve, but since there was no neonatal intensive care unit at the birthing centre, Rita referred the baby to a hospital in Biratnagar. The baby boy has since recovered and is now healthy.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722ef19c7e80680e0c24ecjpeg.jpg" alt="" width="389" height="515"><figcaption>Nurse Rita Ale Magar used the ‘Golden Minute’ to save a newborn who was suffering from severe complications. Photo: ONE HEART WORLDWIDE</figcaption></figure>“I was panicking but I benefited from my mentorship, and I will always be grateful to the clinical team from One Heart Worldwide who had trained me,” she adds.One would think that health professionals would not want to work in villages with minimal resources, but the opposite is true for Rita for whom being stationed in the far-off government birthing centre has been a challenge, but fulfilling when she can save lives like this recent case.Nurse Rita has delivered over 200 babies in the last three years. The birthing centre was initially under-equipped and she was the only Skilled Birth Attendants. This is where the One Heart came in to provide hands-on simulation exercises to nurses to get them ready for real-life birthing complications.Two nurses who received that simulated training were instrumental in saving the underage mother and her baby. They also counseled family members.Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">Who will save Nepal’s poor new mothers?</a> Rojita AdhikariThe patient, Bhavana did not know about the risks associated with pregnancies and was adamant about giving birth at home because she herself was born at home. Additionally, she had not seen anyone going to the birthing centre for delivery.Even after she was long past her due date Baavana was still not convinced about institutional delivery. It was only when she realised she was putting herself and her baby at risk did she relent.“Ultimately, she made the right decision but it was almost too late. Luckily, she survived. Saving her was so rewarding also because this could set an example to other villagers,” adds the nurse.But it is not easy for the villagers to get to the birthing centre due to the rugged terrain which further discourages them from accessing institutional delivery. There is no proper transport or ambulance service either. Most people have to walk over four hours to get to the centre which is especially inconvenient for pregnant women and girls.Says Rita Ale Magar: “But no matter how hard the journey, it is worth the effort because us nurses are here at the birthing centre to help mothers like Bhavana and their newborns.”Read more: <a href="https://www.nepalitimes.com/banner/no-conceivable-reason-for-unwanted-pregnancies/">No conceivable reason for unwanted pregnancies</a>, Rojita Adhikari

Balancing life and death in Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222f59c7e80680e0c0327jpeg.jpg" alt="" width="760" height="486"/><figcaption>Govinda KC, Nepal’s crusading surgeon and health activist, plastering a patient’s ankle at the Mugu District Hospital on Sunday. He saw 177 patients for free in five days before travelling on to Jumla on foot. Photos: ACHYUTRAJ BHANDARI</figcaption></figure>Nepal’s  crusading surgeon and health activist Govinda KC has been on hunger strike 19 times since 2012, demanding medical education  reform and equitable healthcare. After retiring from his government job, KC has served patients in all 77 districts and other disaster-stricken countries. He is currently at Khandbari District Hospital in Sankhuwasabha where Nepali Times caught up with him.Excerpt from the conversation:Nepali Times: What is the state of healthcare in Nepal?Govinda KC: Most citizens from both urban and rural areas do not have access to healthcare. Many patients are too poor to afford quality treatment, and those who can not get quality care.The law specifies that 70 types of medicines should be available free of cost in district hospitals, 50 in primary health centres, and 35 in health posts. That is not the case in practice.Some government hospitals even charge money for medicines that are supposed to be free. And hospital fees are just too expensive, so they end up dying, being disabled for life, or sinking deeper into poverty.Health facilities in many rural districts are under-equipped, under-staffed and many patients have to return home without treatment. There are no big hospitals there to begin with, and even the urban poor cannot afford priate city hospitals.Doctors, nurses and office assistants have stuck around in government hospitals only because they are bound by contract. Some hospitals are led by junior non-physicians, making a chaotic and inefficient system.So, where is the problem? The problem in providing basic healthcare arises when the local representatives and  politicians do not work to provide it. When the 2015 constitution was announced, I was in satyagraha. My only demand was that our representatives be treated in health facilities in the same place as their voters. That demand was not fulfilled.The Constitution guarantees the citizen's right to health, but elected politicians do not care about health reforms. They are too busy getting rich overnight by commodifying education and health.I have been fighting to have hospitals and schools in every village, but people prefer to open hospitals in the city. Locals can have access to specialist services at a hospital in their village. This can also help to produce doctors, nurses and public health workers in the provinces. But no one is willing to do that. Politicians are on the payroll of the medical mafia.Do you regret going through all those hunger strikes? Many of my demands were not met. Some promises have been made, but not been implemented in practice. But some have been addressed, like the Medical Education Act was formed after multiple satyagraha. Then the Medical  Education Commission was formed.Before the Act, MBBS entrance exams were conducted by colleges and institutes in their own way, but now it is regulated by the Medical Education Commission.Only those who pass the entrance exams are now eligible for government scholarships and can pick their own college. Action is taken against private institutions if they do not follow the regulationsNow, medical colleges are selected based on their infrastructure, equipment and human resource.  Fees have also  dropped from Rs7-9 million to Rs4.2 million. Medical school is a lot cheaper now, especially for students who are unable to get scholarships.Government medical schools charged up to Rs10 million for  specialised education. Now, students do not have to pay, but get paid instead. After getting an MD they also need to serve for two years in a place assigned by the government. These contract doctors run the country’s healthcare todaySo, the hunger strikes have not been in vain. One of my demands was to have one government medical college in every province. At present, the Karnali Institute of Health Sciences is in operation in Jumla, and the physical infrastructure of Geta Medical College in Dhangadi has been completed. One medical college is soon opening in Dadeldhura after my hunger strike.Despite this, some goals have been lost to the challenges posed by the alliance of political  parties with the mafia. The construction of the Rapti Institute of Health Sciences in Dang was halted due to obstruction from local leaders, and a medical college in  Bardibas due to land acquisition issues.What policies should the government focus on now?First of all, access to basic services, human resources, equipment and medicine should be extended to people in rural areas and the urban poor. If primary health centres and district and provincial hospitals are improved, then 80-90% of patients do not have to  come to Kathmandu for treatment. The government needs to add more human resources to meet the current demand for healthcare.There should be a 15-bed operational hospital in each municipality. Hospitals should also be made free for people to have quality healthcare. The government should take actions against hospitals that operate without meeting proper standards.Additionally, the Medical Education Commission, Nepal Medical Council and other organisations should appoint qualified applicants, not political activists. In fact, the practice of hiring contract-based employees should be eliminated. Contract doctors have a higher chance of fleeing if they are not given temporary incentives to stay.Despite the huge demand for rural doctors, the Public Service Commission opens only 20 seats for doctors each year. This has to change.Any more hunger strikes?I am committed to campaigning for medical education reforms. Along with health and education, we are also fighting for good governance and social justice, without which reform is impossible.I also want to serve in remote areas, which is why I am here in Okhaldhunga. I will fight for people in all parts of the country to have quality, free, affordable and equal access to healthcare as guaranteed by the Constitution for as long as I can.Read more: <a href="https://www.nepalitimes.com/latest/govinda-kc-treats-patients-in-remote-nepal/">Govinda KC treats patients in remote Nepal</a>, Achyutraj Bhandari

"Nepalis are dying because they are poor”

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e29c7e80680e0c031ejpeg.jpg" alt="" width="1086" height="724"/><figcaption>Charikot Hospital. Photo: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s medical industrial complex has modernised healthcare in the country, but it has also pushed treatment out of reach of most citizens.Collusion between politicians and medical magnates has made it so expensive to become a doctor that it has set off a chain reaction to make hospital treatment unaffordable.Meanwhile, government hospitals are <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/">under-funded, under-staffed and under-motivated</a>. Most medical personnel in district hospitals and health posts moonlight in private clinics, and patient treatment is substandard.Desperate families have to sell property, jewelry and other assets <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">to afford private treatment</a>, pushing even some middle-class families below the poverty line.Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, Nepali TimesBut there are notable examples of government hospitals that are running well because of various models of partnership with non-profits, foundations and charities. They prove that affordable high quality healthcare is possible, and those hospitals need not be so expensive to run.There is <a href="https://archive.nepalitimes.com/news.php?id=18362#.YrQjS-xByrc">Dhulikhel Hospital</a> which has a tiny registration fee, treatment is low cost, an insurance scheme pays for most treatment, and patients are charged according to their capacity to pay. Despite being a government hospital, Dhulikhel has upheld a consistently high standard of care and treatment.United Mission to Nepal has run a hospital in Tansen for over 60 years, a community hospital in Okhaldhunga, and was till recently managing Patan Hospital, providing high quality care at low cost to patients.Other public-private partnership institutions that could be models to be replicated across Nepal include:<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e59c7e80680e0c031fjpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><h3>Bayalpata Hospital</h3>After <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Bayalpata Hospital</a> was established in Achham 20 years ago, for many years it did not have a single doctor. Treatment was so poor that even emergency cases had to be taken on a grueling 12 hour drive down to Dhangadi.In those days HIV tagged along with the migrant workers returning from India, and there was a full-blown AIDS and TB epidemic in Achham and other district in Far Western Nepal. The mortality rate, already very high among women and children, soared.In 2009, Nepali and American medical students inspired by the community health model of <a href="https://www.nepalitimes.com/latest/paul-farmer-on-my-mind/">Paul Farmer</a> set up Nyaya Health Nepal (formerly Possible) taking over  Bayalpata under a public-private partnership with the government.Since then, Bayalpata Hospital has upgraded its facilities (left) and <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">treated nearly 1.5 million patients for free</a>, some of them for complicated caesarian and orthopedic surgeries.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeUp to 100,000 patients from Achham and surrounding districts come to Bayalpata because they get free treatment there, and many families have saved themselves from sinking into poverty.Bayalpata also runs a network of community health centres with an Electronic Health Record (EHR) system that digitally keeps track of all patients in the catchment area. The presence of just this one hospital has improved the health parameters of surrounding districts, bringing down the maternal and child mortality rates. Achham once had the highest maternal mortality rate in Nepal, today institutional deliveries make up 90% of total deliveries, and very few women die at childbirth.“We have a simple objective: to show that providing free and high quality treatment to the most underserved area of the country is possible at a very low cost,” explains Srijana Devkota of Nyaya Health Nepal.Once <a href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">fully funded by international foundations</a> to run hospitals in Bayalpata and Charikot, NHN now provides free medical treatment in Achham for just Rs200 million a year, of which half now comes from the Sudurpaschim Province and local municipality.+977 - 4100517<a href="https://www.nyayahealthnepal.org/">https://www.nyayahealthnepal.org/</a><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e89c7e80680e0c0320jpeg.jpg" alt="" width="750" height="401"><figcaption> </figcaption></figure><h3>Spinal Injury Rehabilitation Centre</h3>The <a href="https://www.facebook.com/SpinalNepal/">Spinal Injury Rehabilitation Centre</a> (SIRC) in Banepa is a public-private partnership  providing treatment and rehabilitation to people with spinal injuries. It was started by journalist and civil rights activist Kanak Mani Dixit after his miraculous survival and recovery in a trekking accident in 2000 along the Annapurna Circuit that damaged his spinal cord.SIRC now <a href="https://www.nepalitimes.com/here-now/injured-use-internet-to-reach-physiotherapists/">helps rehabilitate up to 100 spinally injured patients</a> a year, and the numbers are going up every year due to injuries sustained in highway accidents and falls from trees and cliffs. The facility was located in Banepa because of its proximity to highways and nearby trauma centres. The hospital has also been providing community treatment and tele-rehabilitation services for follow-ups.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">POOR HEALTH MAKES NEPALIS POORER</a>, EditorialThe hospital has medical officers, urologists, physiotherapists, occupational therapists, nursing care, prosthetics, orthotics, psychologists and consultants. Those who cannot afford to pay are still treated for free, others are charged the same rate as Bir Hospital.“Because patients often have to stay for more than five months, it may be difficult for them to afford the cost, so we charge them according to their capacity to pay,” says SIRC’s Raju Dhakal.SIRC’s annual running cost is Rs50 million, of which most comes from grants by non-profits and other fund-raising activities. The government also chips in with a budget for the physical construction and equipment as well as occasional allocations to cover budget shortfalls.infosirc@wlink.com.np, spinalnepal@gmail.com<a href="https://www.sirc.org.np/">https://www.sirc.org.np/</a><h3>Charikot Primary Health Centre</h3>The 2015 earthquake damaged <a href="https://www.nepalitimes.com/latest/unique-hospital-handover-in-dolakha/">Charikot Primary Health Centre</a> along with 98% of the medical facilities in Dolakha district. But the disaster was a blessing in disguise for the Charikot centre. It was rebuilt and upgraded to a full-scale 50-bed hospital and managed first by Médecins Sans Frontières and then by the non-profit Nyaya Health Nepal (NHN). Residents of Dolakha did not have to make expensive journeys to Kathmandu because medical treatment was available for free at Charikot.Read also: <a href="https://www.nepalitimes.com/opinion/dangers-of-privatising-health-insurance-in-nepal/">Dangers of privatising health insurance in Nepal</a>, Gaj B Gurung and Sushil KoiralaIn 2020, NHN handed over management of the hospital to Bagmati Province and Bhimeshwor Municipality which now run the facility with low cost treatment for up to 300 patients a day. The Charikot experiment has been hailed as a model for successful transfer by a private non-profit to the local government, and it has been running well despite the presence of two private hospitals in Charikot.“It has been a seamless handover from Nyaya Health to the government, and the level of care and treatment is the same,” says chief physician Binod Dangal. “We perform caesarean sections, orthopedics, telemedicine, free check-ups for the elderly, children and pregnant women, mental health counselling, and chronic illness monitoring.”+977 49 421125<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ea9c7e80680e0c0321jpeg.jpg" alt="" width="1080" height="608"><figcaption> </figcaption></figure><h3>Sagarmatha Chaudhary Eye Hospital</h3>For the past 30 years, the <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">Sagarmatha Chaudhary Eye Hospital</a> in Lahan of Siraha district has been providing the cheapest cataract surgery in the world for just Rs1,200 per operation.Thirty years ago when the hospital started, it had only 12 beds. It now treats 470,000 people every year with patients coming in from as far away as southern India and Bangladesh, and they pay the same amount as Nepalis. Just in the last three years, the eye hospital has treated 321,000 foreign nationals.“It is possible to provide the services at an affordable cost because we are a non-profit, and have an economy of scale,” explains Abhishek Roshan of Sagarmatha Chaudhary Eye Hospital.Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe hospital has <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">also set up 15 eye care centres throughout the district, and takes treatment directly to the people</a> so they do not have to make the journey to Lahan. It has a separate department for paediatric services, care for newborn babies with vision problems. In 2021 alone, it performed 1,170 eye surgeries on children.Apart from providing treatment of retina, cornea, glaucoma, oculoplasty, the hospital also serves as an international research centre, collaborating with institutions like The London School of Hygiene and Tropical Medicine.The hospital subsidises its eye treatment for patients with revenue from its agribusiness ventures. A part of the hospital’s land is dedicated to fish farming, and an orchard for litchi and mangoes, as well as a bamboo grove.“Income from those ventures help us keep the cost of treatment down,” says Roshan. The hospital is also supported by Christian Blind Mission (CBM), the European Commission and Arvis.+977-33- 560080https://www.erec-p.org/sagarmathaRead more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

Taking wealth out of health

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110151120/636d08aa9c7e80680e0a602ejpeg.jpg" alt="" width="1500" height="1000"/><figcaption></figcaption></figure>The Covid-19 pandemic has now killed more people than the devastating 2015 earthquake. Officially, over 9,700 Nepalis have died due to the coronavirus in the past year and a half, but the<a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer"> real figure</a> is said to be at least three times more.At a glance, it seems that densely populated urban centres with the most infections have <a href="https://www.nepalitimes.com/editorial/the-covid-tsunami/" target="_blank" rel="noopener noreferrer">recorded the highest fatalities</a>. But analysing the available government data shows that the fatality rate among infected patients is higher in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" target="_blank" rel="noopener noreferrer">remote areas of the country</a>.In Bagmati province, of every 1,000 Covid patients, 11.9 individuals have lost their lives, but it is 21.1 in Karnali Province. District-wise, Kathmandu saw 9.1 deaths per 1,000 cases while Mustang recorded a whopping 111.9 fatalities per 1,000.Public health experts blame limited health care facilities in rural Nepal including ICUs, ventilators, drugs and oxygen for Covid-19 treatment for this huge discrepancy. They also have notably fewer doctors, nurses and other paramedics.“A majority of coronavirus patients recover but most of those who died did not survive because of the <a href="https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/" target="_blank" rel="noopener noreferrer">lack of medical oxygen</a> and this is also largely due to uneven distribution of health infrastructure,” says Bijay Acharya of the Massachusetts General Hospital, also associated with the US Nepal Health Foundation.He adds: “In many places, patients have died on their way to hospitals or while being moved from one to another. Many more people in the villages have likely passed away unable to access the treatment.”Binita Adhikari, a public health specialist affiliated with the Health Nepal Foundation and the Johns Hopkins Bloomberg School of Public Health agrees. “The fatality rate is high in remote Nepal also because many people who need treatment never reached the hospital. The Covid-19 outcome depends on how soon a person is diagnosed, hospitalised and receives treatment,” she says.The fact that the entire<a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer"> Karnali Province</a> has only two functional laboratories for Covid-19 testing (Karnali Academy of Health Sciences in Jumla and Surkhet’s Provincial Hospital) means that official figures for total cases in the region are largely under-counted. And this could also have made the fatality rate among confirmed cases higher.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/nepals-local-governments-lead-from-the-front/" target="_blank" rel="noopener noreferrer">Poor road infrastructure</a> and having to travel distance, sometimes several days, for diagnosis or to access hospital care also adds to the casualties. This also means additional expenses for the poor.The annual per capita income of people in Karnali is $606, which is nearly half of the national average, and a third of the population there is living below the poverty line. The region’s Human Development Index (HDI) at 0.538 is also much lower than the rest of the country.Even within Karnali Province, the poorest and the most disadvantaged have been disproportionately affected. The coronavirus mortality in Karnali stands at 2.1%, but in remote Dolpo, the figure rises to 7.01%. There is just one ventilator here at the district hospital, but even that is non-functional in a lack of skilled human resources to operate it. There are only two beds with oxygen.Similarly, the fatality rates in Mugu, Humla, Rukum East and Salyan were 6.1%, 5.15%, 4.86% and 4.07%, all much higher than the national average of 1.5%. These are also some of Nepal’s most economically and socially disadvantaged districts. Dolpo’s HDI is 0.4 and Mugu’s 0.39.“It is very likely the total number of people infected and dying of the pandemic in the region is much higher than reported. Much of this is due to continued lack of testing and contact tracing,” says epidemiologist Lhamu Yangchen Sherpa.Director of Teku Hospital at Kathmandu Anup Bastola agrees: “The high fatality rates in <a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/" target="_blank" rel="noopener noreferrer">remote districts</a> don’t necessarily mean they have more deaths, but that many of them have not had sufficient testing, which means most of the infected people barring those in critical condition didn’t reach us.”It is however clear that regions with good health infrastructure, economically sound environment, and with higher human development index are better placed to save those infected.While Solu, Bhojpur and Ilam saw districts 5.06%, 4.8% and 4.09% of their Covid patients succumb to the disease, Morang, Chitwan and Kaski reported only 1.02%, 1.25% and 1.52% fatality rates respectively. The figure is even lower for Kathmandu at 0.91%.Province-wise, after Karnali, Lumbini has the highest Covid death rate at 1.77%. This is followed by Gandaki at 1.73%, with the lowest being Bagmati (1.19%).There is also a huge <a href="https://www.nepalitimes.com/banner/once-nepal-gets-vaccines-they-need-to-be-fairly-distributed/" target="_blank" rel="noopener noreferrer">disparity in Nepal’s Covid vaccination drive</a>. Of the 1.42 million Nepalis (4.9% of the total population) who have been fully vaccinated, 55.45% of them are from Bagmati Province alone. Karnali accounts for a mere 3.5% of people who have received either both doses of AstraZeneca Covishield or VeroCell or a single shot J&amp;J vaccine.In other words, 14% of Bagmati residents have been fully inoculated versus 3% of Karnali people. The figure is even lower for Province 1, 2 and Far West where 2.4%, 1.71% and 2.78% of their population have been fully vaccinated.However, some public health experts have argued that the vaccination drive when doses are scarce should not necessarily aim right now for equity, but focus on high-risk, crowded cities with mobile populations, and regions along the Indian border.Says Bijay Acharya: “Age alone shouldn’t factor into who gets the vaccine first, economic status and social background should also be taken into account to ensure those other than the affluent also benefit. Areas with a high risk of infection and marginalised communities with poor health infrastructure should be equally prioritised.”Nepal government is in a process procure six million dose of Pfizer vaccines for teenages from 12-18 years of age in the next six to nine months' time. Health Ministry is in the final stages of preparing -80 degree Celsius storage facilities in all seven provinces.Translated by Sonia Awale from the <a href="https://www.himalkhabar.com/news/125201" target="_blank" rel="noopener noreferrer">original in Himal Khabar</a>.

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Nepal’s uneven Covid-19 deaths

<figure><img width="1400" height="663" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a52fe9c7e80680e052328jpeg.jpg" alt=""/><figcaption>Photo: PRAKASH SINGH</figcaption></figure>Last month Kalpana BK delivered a healthy newborn baby on the way to <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a>, but her placenta did not come out spontaneously. As a female community health volunteer, she was usually the one providing support for women before, during and after they give birth. But when the road to the hospital was blocked for nearly 10 hours by a landslide (above) she became <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">the emergency</a>, bleeding massively and was increasingly short of breath.Luckily, once she finally made it to the hospital near Sanfebagar, Kalpana BK’s retained placenta was removed and she was transfused with blood. Today she is recovering from her life-threatening post-partum haemorrhage. More recently at Bayalpata, a surgical team was preparing to perform an emergency caesarean section to save both the mother and foetus. But the surgery was delayed for 20 minutes because of lack of water needed for the surgical team to scrub in, protecting the patient and her baby against infections. The delay significantly heightened the risk that the two lives would be lost, not saved.Across Nepal, <a href="https://www.nepalitimes.com/opinion/nepals-silent-emergency-springs-going-dry/" target="_blank" rel="noopener">traditional springs are going dry</a>, and hospitals are also affected. Without adequate water, staff at health facilities are finding it increasingly difficult to maintain cleanliness and best practices for preventing infections. When this happens, hospital-acquired infections are likely to rise. <figure><img width="1500" height="712" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a53019c7e80680e052329jpeg.jpg" alt=""><figcaption> </figcaption></figure>Due to a combination of factors, such as <a href="https://www.nepalitimes.com/opinion/where-is-the-monsoon-this-year/" target="_blank" rel="noopener">lower rainfall</a> and <a href="https://www.nepalitimes.com/opinion/turning-on-the-heat/" target="_blank" rel="noopener">rising temperatures</a> caused by <a href="https://www.nepalitimes.com/banner/weather-warning-for-climate-meeting/" target="_blank" rel="noopener">climate change</a>, rampant construction of poor-designed roads, <a href="https://www.nepalitimes.com/banner/who-now-owns-nepals-forests/" target="_blank" rel="noopener">deforestation</a>, overpopulation, overconsumption and inadequate maintenance of pipes and wells, Nepal’s mountains are suffering <a href="https://archive.nepalitimes.com/article/editorial/h20-shortage,3456" target="_blank" rel="noopener">water shortages</a>.Roads are supposed to improve access of patients to hospitals, but have themselves become killers in two ways. <a href="http://archive.nepalitimes.com/article/nation/accident-prone-Mugling-Narayangadi-highway,3828" target="_blank" rel="noopener">Haphazard construction triggers landslides</a> that endanger lives, and roads are blocked, delaying patients like Kalpana BK from reaching hospitals in time. These two recent examples of a landslide and water shortage in Achham reflect the adverse impacts of worsening environmental conditions on our health system and their possibly devastating impact on people who are already ill and often vulnerable. So-called ‘natural disasters’ actually have a strong connection to human decision-making and are frequently caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">reckless road construction</a> that does not pay sufficient attention to environmental factors.Navin Bhatt, staff physician at Bayalpata Hospital, says environmental degradation can undermine health care delivery: “Deforestation is one of the causes of landslides, which lead to roads being blocked, hampering the transportation of people who are ill to the hospital. Rising temperatures are resulting in more <a href="https://www.nepalitimes.com/banner/hisss/" target="_blank" rel="noopener">snake bite</a> cases. The quality of healthcare services is affected by environmental pollution.” The urgency to recognise that health and the environment are strongly connected is growing worldwide. To raise awareness about the issue and motivate grassroots solutions to these problems, the World Health Organisation announced in its ‘Ten threats to Global Health in 2019’ that <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">air pollution</a> and <a href="https://www.nepalitimes.com/editorial/climate-climax/" target="_blank" rel="noopener">climate change</a> are the number one public health threats. Nepal Government officials at all levels, health workers, environmental experts and development partners need to collaborate with advocates for <a href="https://www.nepalitimes.com/banner/between-existence-and-extinction-in-nepal/" target="_blank" rel="noopener">ecological balance</a>. Only when we work hand-in-hand rather than in isolation, can we take tangible steps to prevent environmental damage and restore healthy and resilient ecosystems.   Bikash Gauchan is a doctor in Achham. Nathaniel Uchtmann is a medical doctor and lawyer.

Environmental destruction is a medical emergency

Nepal’s only international aviation gateway, at Kathmandu airport, will cut night-time operation hours to allow construction of taxiways, and airlines have been told to curtail flights. This is expected to lead to more than normal chaos during the height of peak autumn and spring tourist seasons at an airport that is congested even at the best of times. The airport will close from 10PM to 8AM from 8 November-31 March 2025. The taxiways will now connect to the thresholds at both ends of the runway, making the airport more efficient in handling higher frequencies of landings and takeoffs. The parallel taxiway extension will allow international flights to land every 4 minutes instead of the current every 7 minutes. At present planes have to wait to land until a plane taking off backtracks along the runway.&nbsp; Kathmandu is Nepal’s only airport with international operations, and it has only one runway that is only one way in from the south over the mountains. With the taxiway improvement, the airport will be able to handle 42 aircraft landings and takeoffs per hour — double the current capacity.&nbsp; The Civil Aviation Authority of Nepal (CAAN) has been trying to entice international airlines to also start flying to and from the other two international airports at Pokhara and Bhairawa (Lumbini) by slashing landing and handling charges. But so far only Nepal Airlines operates a weekly flight to Bhairawa from Kuala Lumpur.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32.jpg" data-media-id="editor_0" data-image-id="20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32" data-rendition-name="original" width="2356" height="1134" loading="lazy" alt="Kathmandu airport expansion"> <figcaption>Kathmandu Airport Expansion plan with extension of taxiways to the thresholds of runways 02 and 20 that will limit airport operations from 8 November 2024 - 31 March 2025. Areas in blue are existing structures, including the international terminal which in future will be the domestic airport, and the new international terminal near the north end of the runway,</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a.jpg" data-media-id="editor_1" data-image-id="20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a" data-rendition-name="original" width="1353" height="1328" loading="lazy" alt="Kathmandu airport NT"> </figure>  CAAN has reportedly told international airlines to cut their flight frequency to Kathmandu citing the shorter operation hours and has told budget airlines to shift some of their flights to Pokhara or Bhairawa, or face cuts. Many airlines currently operate regular flights to and from Kathmandu between 10PM and 8AM: Air Arabia to Sharjah, Fly Dubai to Dubai, Jazeera Airways to Kuwait, Cathay Pacific to Hong Kong, Singapore Airlines, several Nepal Airlines flights, and one of four daily flights by Qatar Airways to Doha. Jazeera Airways, FlyDubai, and Thai AirAsia have applied and got permission from CAAN to begin regular flights to Bhairawa’s Gautam Buddha International Airport. Starting 9 November, FlyDubai will start making a stopover in Bhairawa before flying on to Kathmandu. Immigration, customs and security are all fully functional in Bhairawa. In Kathmandu, the next phase of the airport upgrade includes converting the current international terminal for domestic operations, the construction of a new international terminal where the domestic departure area is now, as well as moving the hangars and the Nepal Army Air Wing to the eastern side of the runway. The apron area will also double its parking space for widebody jets. This is part of a Airport Capacity Enhancement Project that was initially funded through a $80 million loan from the Asian Development Bank (ADB), and the entire masterplan is expected to cost $800 million. This project is the latest upgrade to Nepal’s only international airport since it saw its first flight in 1949. The current international and domestic terminals are too small to handle the current annual traffic volume of 8.5 million passengers a year that is growing at 20% a year.

Kathmandu airport to cut flight hours

As Kathmandu becomes more congested and polluted, and with remote online work becoming the norm, many professional Nepalis are planning to retire in Pokhara, or move there.&nbsp; With its stunning mountain panorama, balmy winters and proximity to a profusion of wilderness areas, builders are responding to this demand with new townhouses, housing development and apartments. One such block of flats is the 10-storey <a href="https://sungavaapartment.com/">Sungava Apartment</a> located at Phulbari above the Seti River, near the point where it flows into and under Pokhara. The imposing structure near Manipal Hospital is almost complete, and on a recent visit the site was strewn with huge boulders unearthed while digging the foundation.&nbsp; The Seti brought down these boulders during a gigantic flood that geologists estimate happened 800 years ago when a chunk of Annapurna IV broke off and ploughed into the glacier below. Today, Sungava (means ‘orchid’) sits safely on a high terrace, 100m above the blue-green Seti and commands a view of Dhaulagiri, Annapurna South, Machapuchre, Annapurna III and IV.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9.jpg" data-media-id="editor_1" data-image-id="2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9" data-rendition-name="original" width="2016" height="1512" loading="lazy" alt="High living below the Himalaya NT"> </figure>  The soil here is conglomerate that has solidified like concrete, and the boulders were extracted by heavy earthmovers. It is intriguing to think that these metamorphic rocks as big as cars, rounded by glacial grinding, were once a part of a much higher Annapurna IV. Even for those with little interest in geology, Sungava is an ideal place to contemplate the tectonic forces that pushed these peaks into the sky to be sculpted into delicate shapes by wind, snow, earthquake and avalanche over millions of years. The view of the Himalayan panorama from Sungava’s many balconies are breathtaking when not obscured by clouds, or the haze that drifts in from across the southern border. On most days, just watching the towering pyramid of Machapuchre (Tamu name: कतासुँ क्लिको) play hide and seek with the clouds is mesmerising. There are rocks aplenty at Phulbari, and it is probably the flowers that grew along the flat terraces e that gave the place its flowery name. The boulders will hopefully be turned into a rock garden while landscaping. An nearby restaurant complex is making the best use of the stones in its design, using flat rocks as outdoor benches and tables. Sungava was designed by the husband-wife architect team of Deepak Sherchan and Jyoti Joshi of <a href="https://thedarkmermaidamarbshrestha.blogspot.com/2013/12/creative-builders-collaborative-cbc.html">Creative Builders Collaborative (CBC)</a>, which also built Heritage Plaza, Indreni Apartment and numerous other projects in Nepal. Sadbhavana retains CBC’s trademark Newari-style masonry and here it borrows from the orange brickwork of the old town of Pokhara, integrating it with modern design elements. A few of those heritage houses are still standing in Ganesh Tole and Ram Krishna Tole in Pokhara’s old quarter.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab.jpg" data-media-id="editor_3" data-image-id="2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab" data-rendition-name="original" width="1362" height="595" loading="lazy" alt="High living below the Himalaya NT"> </figure>  About 400m from the apartment past a bend on the river, and down below three tiers of terraces in the canyon is a suspension bridge. Below it, the Seti is still swollen with post-monsoon flow as it tumbles away in a hurry to head down south.&nbsp; Back at the apartment, it is quiet, far away from the hubbub of Lakeside a 15 minute drive away, and in the lap of greenery. There are 52 units at Sungava and it already has a close-knit prospective community of professionals, including doctors, publishers, engineers, and businesspeople from the renewable energy and IT sectors.&nbsp; Some residents say they opted for a second home in Pokhara to make it a ‘base camp’ to explore the Annapurnas with its many hiking trails made newly accessible with new roads. With the NRN citizenship law, overseas Nepalis can now also buy the flats. &nbsp; The floor plans include options for north and south-facing 3-bedroom apartments with verandas, and the facility has underground parking has EV charging, heated pool, sauna and gym. There are still some unsold apartments with panoramic views of the mountains and one can imagine oneself at the kitchen with its huge window, humming a ditty while preparing breakfast: “खाना पकाउँ हिमाल हेरेर...”

High living below the Himalaya

When the United Nations held its Summit of the Future at its headquarters in New York in September, many world leaders, including Nepal’s Prime Minister K P Oli, highlighted the effect of climate breakdown in increasing the frequency and intensity of natural disasters. What did not get as much attention was the long term impact of the climate crisis on food production. In fact, heat stress, weather extremes and the consequences on rain-fed agriculture is already being felt worldwide, undermining the chances of the <a href="https://unstats.un.org/sdgs/">UN’s Sustainable Development Goals (SDGs)</a> being met by 2030.&nbsp; The SDG’s 17 targets commit countries like Nepal to reduce poverty and inequality, end malnutrition, protect the natural environment, and ensure that citizens all enjoy health, justice and prosperity without leaving anyone behind.&nbsp; However, besides the impact of climate breakdown on agricultural production, in Nepal the area under cultivation is impacted by urban expansion, falling productivity and the need for expensive inputs like fertiliser and pesticides.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62.jpg" data-media-id="editor_1" data-image-id="20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62" data-rendition-name="original" width="999" height="1500" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Kathmandu's urban sprawl is eating into its fertile cultivable lands. Photo: TAYLOR MASON</figcaption> </figure>  Now, a new study led by Nepali researcher Prajal Pradhan at the University of Groningen in The Netherlands looks at how urban agriculture may offer a solution to falling food production and meeting SDG targets. The researchers evaluated 1,450 publications exploring the contributions of urban agriculture with both positive and negative effects, and published their findings in the journal Cells Report Sustainability. Urban agriculture can help achieve 17 SDGs, positively influencing 81 targets. However, it could also undermine 51 goals.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/the-vanishing-land">The vanishing land</a>, Taylor Mason “Urban agriculture offers immense potential for sustainable development, but realising this potential depends crucially on adopting practices that minimise its adverse effects while maximising its benefits,” Pradhan explains. Urban agriculture can substantially enhance urban food security, provide employment to the urban poor, serve as ground water recharge in built-up areas, and preserve open spaces that can serve as safe havens during disasters like earthquakes. However, it also presents problems like the potential health risks from contamination and the need for expensive inputs. &nbsp; “Urban agriculture plays a definitive role in advancing the SDGs, but achieving this requires tailored, context-specific solutions that address the unique challenges of different regions,” says Yuanchao Hu of Wuhan University in China and who is a researcher at the Potsdam Institute for Climate Impact Research. “But it needs equitable access and rigorous management of environmental risks.”&nbsp; Rapid urbanisation is eating into Nepal’s most fertile agricultural land, which means farming in remaining open spaces inside cities can be a viable alternative, especially as food prices rise.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8.jpg" data-media-id="editor_3" data-image-id="20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>A vegetable patch in between new houses in Thimi. Photo: TAYLOR MASON</figcaption> </figure>  “The conversion of Nepal’s most fertile land into cities is a severe problem,” Pradhan told Nepali Times. “Crop cultivation, horticulture, agroforestry, beekeeping, livestock rearing, or aquaculture can all be farming activities within and around cities.”&nbsp; The study makes recommendations for sustainable practices that build on the positive aspects of urban agriculture while mitigating the downsides, thereby promoting more resilient cities in future. Research shows that urban agriculture has been helping many countries attain SDG targets by enhancing food security and biodiversity while helping education and preservation of open spaces.&nbsp; Indeed, many farmers from the hinterland who have settled in Kathmandu Valley or other urban areas of the country have been practicing urban agriculture, leasing neighbourhood patches or cultivating roof gardens both out of necessity because of inflation and falling income to grow their own food, and also as a fulfilling hobby. Saurav Dhakal, a sustainability advocate with Story Cycle and now research fellow at the Asian Institute of Technology in Thailand, says there are socio-economic and environmental benefits of urban agriculture. “It provides benefits to all urban dwellers, regardless of their income status,” says Dhakal, “families get fresh food, and there are many other benefits like water retention, heat regulation and biodiversity. These are all public goods, so special government incentives may be needed.” It is not unusual to see vegetable patches and even paddy fields within inner city Kathmandu where an older generation of farmers are using available fertile land and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/rooftop-gardens-kathmandu,1415">roof gardens to produce fresh, nutritious food </a>to reduce their dependence on food items that have to be bought after being trucked in from large distances.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77.jpg" data-media-id="editor_5" data-image-id="2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>An older generation of farmers are using any available fertile land to continue farming but it is getting more and more difficult. Photo: TAYLOR MASON </figcaption> </figure>  Nepal’s urban population grew rapidly from only 3.6% in 1991 to 25% today. There is large outmigration from the mountains to peri-urban areas of the Tarai, to Kathmandu Valley and Pokhara, with many young men then moving abroad for work. Kathmandu Valley’s population has swelled to nearly 3 million, and is growing at 6.5% a year. Dilip Shrestha, 71, used to work for Nepal Food Corporation, so he knew firsthand about inflation, shortages and vegetables with pesticide residue. So, when he designed his new house in Kathmandu, he built a spacious roof where he grows cucumber, ginger, garlic, coriander, onions, tomatoes, chili, beans, okra, pumpkin and lettuce. His family eats healthier, and he has reduced dependence on the market.&nbsp; The co-author of the Cell Reports Sustainability journal article, Daya Raj Subedi who is a PhD candidate at Beijing Forestry University, says urban agriculture also promotes inclusion and psycho-social wellbeing.&nbsp; He says, “A crucial finding of the study is the identification of opportunities and challenges associated with urban agriculture, it can promote sustainable transformation of society.” In Banepa, 55-year-old Bijaya Manandhar in her lifetime has watched the fertile farms of her neighbourhood that used to supply vegetables to Kathmandu, now completely built up with no open space left. The pandemic lockdown prompted her to turn to the family’s <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world">ancestral livelihood by growing food</a> not on terrace farms, but on the roof terrace. Manandhar is now a part of <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world%5C%5C">कौसी खेती र करेसाबारी क्रान्ती</a> (Rooftop Farming and Garden Revolution) which has an online membership of 52,000, and awards annual prizes to women who excel in urban agriculture.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d.jpg" data-media-id="editor_8" data-image-id="20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d" data-rendition-name="original" width="1600" height="736" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Rooftop farming is gaining popularity as a form of urban agriculture. </figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed.jpg" data-media-id="editor_9" data-image-id="20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed" data-rendition-name="original" width="4000" height="3000" loading="lazy" alt="urban agriculture in Kathmandu"> </figure>  Pradhan says the challenge now is to upscale such examples of successful urban agricultural practices so they support Neal’s efforts to meet SDG targets. He adds, “Crop cultivation around cities can be protected by land use plans and regulations. Promoting community-based agriculture, including rooftop gardens, requires community engagement and public-private partnerships across the food value chain.”&nbsp; Such support would accelerate the popularity of existing rooftop farming and community gardens in Kathmandu Valley, or kitchen garden initiatives in Pokhara, and building on traditional farming practices that are preserved and integrated into urban settings like in Bhaktapur and Banepa. In Lalitpur, the Women Entrepreneurship Facilitation Center promotes urban farming enhancing both sustainability and empowerment.&nbsp; Another co-author of the report, Yuanchao Hu from China says followup research of the team will aim to identify good practices in local urban agriculture practices. He adds, “There are examples of urban agriculture that optimise sustainability, ensuring that it remains a viable solution for cities globally while countries try to meet SDG targets.” Prajal Pradhan, Daya Raj Subedi, Kshitij Dahal, Yuanchao Hu, Prakriti Gurung, Sijal Pokharel, Sagar Kafle, Biplav Khatri, Sudeeksha Basyal, Monika Gurung, and Aruna Joshi. Urban Agriculture matters for sustainable development. Cell Reports Sustainability, 1:100217, 2024. [DOI: 10.1016/j.crsus.2024.100217] Prajal Pradhan (<a href="mailto:p.pradhan@rug.nl">p.pradhan@rug.nl</a>) This article is brought to you by <a href="https://nepalitimes.com/" target="_blank">Nepali Times</a>, in collaboration with <a href="https://inpsjapan.com/en/" target="_blank">INPS Japan</a> and <a href="https://sgi-peace.org/" target="_blank">Soka Gakkai International</a>, in consultative status with UN ECOSOC.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758.jpg" data-media-id="editor_14" data-image-id="20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758" data-rendition-name="original" width="680" height="103" loading="lazy" alt="SDG logo"> </figure>

Back to the land in the cities

The 700-year-old Lakshmi Narasingha temple in Bhaktapur houses a rare half-lion and half-human incarnation of Lord Vishnu carrying the Goddess Lakshmi. The temple was destroyed in the 1934 mega earthquake that killed 10,000 people and destroyed many monuments in Kathmandu Valley. It was rebuilt by a German project in the 1980s, but as a single-storey structure instead of its original two-tier pagoda design.&nbsp; With new findings from in-depth research, Bhaktapur municipality began re-restoring the temple in 2021, preserving its original architecture.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18.jpg" data-media-id="editor_0" data-image-id="20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “Our temples and heritage sites hold deep meaning. It is disheartening to witness how often they lose their original elements, whether by design or accident,” explains Kumar Chawal of the Consumer Committee of Bhaktapur. “There is a need to preserve our architecture and protect its historical value for future generations. Otherwise, we risk losing a vital part of our identity.” The Laksmi Narsingha restoration is similar to the Bhai Dega temple in Patan Darbar Square which also collapsed in 1934, but was rebuilt with a Moghul-style dome by the Rana government at the time. Only two months before the 2015 earthquake, heritage conservationists had started to rebuild Bhai Dega as the original three-tier based on early photographs. But priorities shifted when four other temples in the square were brought down by the 7.8M earthquake on 25 April 2015.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130.jpg" data-media-id="editor_1" data-image-id="20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  This showed how damage to monuments in Kathmandu Valley spanned from one earthquake to the next. Bhai Dega restoration remains half-complete to this day because money for its restoration ran out.&nbsp; Whereas Bhai Dega restoration was done by the Kathmandu Valley Preservation Trust with grants from western embassies and international foundations, in Bhaktapur it is the municipality itself that allocated the Rs30.7 million needed to restore the Lakshmi Narasingha temple. The expected date of completion is early 2025. The municipality and local communities are focusing on two main aspects: preserving the past and promoting localisation. The restoration team has designed a blueprint for the temple by using historical photographs and insights from older generations.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30.jpg" data-media-id="editor_2" data-image-id="20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30" data-rendition-name="original" width="1200" height="560" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “At first, the Lakshmi Narasingha temple had only one entrance, but during the demolition process, we uncovered the foundations of four doors. Now, we are restoring all of them. This is an example of how our ancient structures have changed over time, often without our knowledge,” says Chawal. “Constructing temples is not like building houses. They carry historical and spiritual values, which is why they hold a special place in our hearts,” he adds. By replicating ancient design elements and rebuilding the temple as accurately as possible to its original form, the team has stayed true to Bhaktapur’s soul. But the restoration also revived ancient techniques that were in danger of being forgotten, generating employment for woodcarvers, masons, and contractors. The community of Bhaktapur’s Gahiti neighbourhood near the famous Nyatapola Temple has also set aside specific days for locals to volunteer in the reconstruction work. This has encouraged young people to take pride in ownership of their heritage. Families have also supported the effort by donating funds for bells, the temple pinnacle, and other structural features to the temple.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6.jpg" data-media-id="editor_3" data-image-id="20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “I feel at peace knowing I have contributed my sweat to restoring this temple,” said one volunteer. “It is our duty to preserve our temples and heritage. The Nyatapola area will look magical once this temple is completed.” Community mobilisation is a long-standing tradition in Bhaktapur. In the past, locals have actively participated in the restoration of other temples in the city, such as Bhairav and Nyatapola fostering a strong sense of ownership. This collective engagement has not only been crucial in preserving the city's historical monuments but also in strengthening the bond between local communities and their heritage, says officials at the municipality. While securing funding is essential, and the municipality showed it values heritage conservation, the Lakshmi Narasingha restoration is proof that active involvement and sense of responsibility of the local community is as important, if not more. Local involvement also means that the monuments will be cared for into the future, When locals take ownership of these efforts, the restored monuments are not only protected in the present but are also cared for in the future.

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