<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664f9c7e80680e059974jpeg.jpg" alt="" width="1200" height="793"/>Around the world, in rich countries and poor, financing healthcare is one of the biggest challenges. In poor countries, it becomes a life-or-death issue.Over 40% of global healthcare expenses are still covered by patients and their families, and more than half the world’s population lacks access to essential health services. Medical bills push 100 million people into extreme poverty every year.Nepal has taken remarkable strides in healthcare in past decades despite internal conflict and instability, but <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical care is still unaffordable</a> or inaccessible to most. More than half the healthcare expenditure of Nepalis is still covered out of pocket. Nearly a third of families spend over 10% of their annual income on medical care.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">State of the art rural hospital</a>, Marty LoganThursday, 12 December, is Universal Health Coverage Day, an important date to remind ourselves of the next steps we need to take to achieve healthcare for all. The 2015 constitution of Nepal declares basic and emergency healthcare as fundamental rights of citizens, putting the responsibility of financing such care on the state. Following federalism, municipal governments have got the responsibility to manage basic and essential care. A national health insurance bill has been passed and is being implemented.The state guarantees quality healthcare without financial burden on citizens, for which the insurees pay Rs3,500 per year for a family of five, and receive care worth Rs100,000. This is expected to reduce the burden of out of pocket and catastrophic expenses, while the government covers the premium for citizens under the poverty line.Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialThere is also a provision for free essential drugs and free treatment for patients with cardiovascular disease, cancer, spinal injuries, renal ailments and sickle cell anaemia, through the Disadvantaged Citizens Medical Treatment Fund.None of these initiatives is being implemented fully yet, but with federalism Nepal has a chance to build an accountable and sustainable healthcare system. The country therefore needs to focus on the following areas to manage health financing to meet the targets of the Sustainable Development Goals:<ul><li>Increase public sector healthcare investment to at least 7% of annual national budget. This should also be targeted towards reducing external aid.</li> 	<li>Empower people for self-care and make treatment more strategic and efficient as the burden shifts from communicable to non-communicable diseases.</li> 	<li>Focus on primary health care and improve services at the first point of care with comprehensive, accessible and community based care.</li> 	<li>Coordinate multisectoral policy action involving education, agriculture and social behaviour.</li> 	<li>Launch a priority national campaign to spread insurance coverage. Enrollment can be top-down starting with all government officials and then the public at large.</li></ul>A mixed financing model using tax-based funds through the treasury, and premium-based funds through health insurance can work for public, private, community, and other hospitals that run under the state-non-state partnership. An example of state- non-partnership is Bayalpata Hospital in Achham district, managed through a public-private partnership between the ministry of health and population and the non-profit Nyaya Health Nepal, where insurance reimbursement covered over 60% of the hospital’s operating costs.The hospital provides healthcare with no user fees. The care is extended from hospital to communities using a network of community health workers. How can care delivery with no user fee sustain? Can Nepal afford to provide such care to its entire population?It is possible. The country should effectively implement the national health insurance program, and strategically invest tax based funding. In the mixed financing model, for a ‘district level hospital, insurance can cover 60% of healthcare operating costs, and tax-based funding can take care of the rest. But to ensure effectiveness, the tax-based investment will need to be unrestricted and tied to audited performance indicators. The cost of care should also incorporate the extension of hospital-based services into communities in the catchment area.Bayalpata Hospital serves both as a primary care facility and also as a referral hospital. In this case, the tax-based contribution can be split into the three government tiers, with the federal government providing support for infrastructure, and provincial and local governments covering the cost of basic healthcare, and referral care not covered by the insurance.Insurance reimbursement then covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage.<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490" target="_blank" rel="noopener">Bayalpata Hospital</a> provides basic and referral care, and its tax-based contribution can be split into the three government tiers, with the federal government providing support for basic infrastructure and provincial and local governments covering the cost of basic and referral care not covered by the insurance.Insurance reimbursement then covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage.The proposed model has a 60:25:15 ratio to pay for health care, with 60% from insurance and provincial and local governments paying 25% and 15% of the cost. When the benefit package increases to cover the cost of healthcare without capitation, the share of health insurance coverage percentage will increase significantly, thereby reducing the tax-based direct public sector investment.S P Kalaunee is Executive Director of Nyaya Health Nepal, which manages Bayalpata and other public hospitals in partnership with the ministry of health and population.

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Is free health care possible in Nepal?

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179b9c7e80680e02c286jpeg.jpg" alt="" width="1400" height="905"/><figcaption>IN GOOD HANDS: Community Health Worker Bhajan Kunwar checks patient Namsara Tamrakar at her home in Chandika village of Achham. Pics: Marty Logan and Srawan Shrestha</figcaption></figure>Rounding a steep curve on the road to the district capital of Mangalsen a startling set of modular structures comes into view. The modern buildings look out of place in this scenic, but underserved, region of western Nepal.The construction is part of a $4 million expansion of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">Bayalpata Hospital</a>, a unique medical facility that is a model for public-private partnership to improve medical care in Nepal’s remote interior.Inside the ward, orthopaedic surgeon Mandeep Pathak is examining an elderly man with a swollen knee. Clearly visible on an x-ray monitor is a short pin inserted by a general practitioner a few weeks ago, after the patient fell and broke his kneecap.https://www.youtube.com/watch?v=SuWvlDGasEAIn the same room with the surgeon today is Community Medical Assistant (CMA) Khagendra Pant, who is wrapping plaster around the arm of a small boy. Thanks to training at the hospital, Pant was able to diagnose the boy’s injury as a clean fracture that did not require an operation.Such training means Bayalpata now has to refer just 10-20% of orthopaedic cases to hospitals in Dhangadi and Nepalganj, compared to nearly 70% two years ago.“I am proud to say that all the basic trauma care can now be done by general practitioners. Plus they can diagnose cases and decide which need to be referred to outside centres,” says Pathak.Training is integral to Bayalpata’s mission, says Director of Medical Education <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Bikash Gauchan</a>: his hospital has continuing medical education for clinicians, and on the job training for future nurses and other staff. General practitioners from various centres learn rural surgery at Bayalpata while mid-level staff come to improve their clinical knowledge.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179e9c7e80680e02c287jpeg.jpg" alt="" width="1400" height="650"><figcaption> </figcaption></figure>For some <a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">patients who travel many days</a> to reach Bayalpata, access to basic surgery here means avoiding an expensive trip to the city. People whose limbs were fractured as long as three years ago delayed treatment until surgery was available at the hospital because they couldn’t afford the trip to a city hospital.Treatment at Bayalpata and at another hospital in Dolakha run by the non-profit Possible, is <a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">free</a>. The group believes healthcare is a fundamental human right protected by Nepal’s Constitution, and should have no cost at point of delivery.Possible is funded by donations and Nepal government grants, which will grow as its hospitals attain clinical targets, such as the percentage of women who give birth in a facility with a trained clinician. Operating expenses last year were $4.8 million, of which 9% came from the government.Arrivals are registered in the hospital’s Electronic Health Record (EHR), which puts patients’ information at the fingertips of clinicians throughout the hospital, and eliminates bulky paper records.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a19c7e80680e02c288jpeg.jpg" alt="" width="1400" height="823"><figcaption> </figcaption></figure>One patient already on the EHR is Namsara Tamrakar. Sitting cross-legged on a raised, wooden platform outside her home in Chandika village (left), the elderly woman shows visiting hospital staff that she knows how to use her inhaler, but it is empty.Three years ago, a doctor at Bayalpata diagnosed her with chronic obstructive pulmonary disease and prescribed medicine via inhaler. Now Community Health Worker Bhajan Kunwar (see box, left) visits regularly to follow up. Like others, Tamrakar’s house has a small blue metal tag on an outside wall with a unique household ID. The houses are also geo-tagged.Kunwar’s visit is guided by CommCare, a software developed by Dimagi and customised by Possible that includes counselling information and checklists for each patient. Plans are to integrate CommCare with the EHR so that field followups are immediately reflected in the hospital’s system. Eventually, Bayalpata’s EHR will be linked to a national data system.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a49c7e80680e02c289jpeg.jpg" alt="" width="1400" height="1024"><figcaption> </figcaption></figure>Kunwar takes Tamrakar’s blood pressure: 120 by 80. The woman is happy to hear the news and to see Kunwar again: “She comes, does a check-up, and tells me what sickness I have, and if it is getting better or worse. She insists I go to Bayalpata for a follow-up.”The hospital's <a href="http://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">community health program</a> focuses on maternal and child health as well as non-communicable diseases such as hypertension, diabetes and respiratory ailments. Possible employs 56 community health workers looking after more than 80,000 people in Achham and Dolakha. It is planning to more than quadruple that number next year.Bayalpata Hospital started in 2009, when the group <a href="http://archive.nepalitimes.com/article/nation/Crowding-it-out,1003">Nyaya Health</a> (now Possible) took over an abandoned government facility. Then it had five beds and treated up to 12,000 patients a year. Last year, Possible saw 86,000 patients at Bayalpata: the goal is to treat 150,000 people annually after the new wards, emergency room, administration building, a dormitory and remaining small houses for on-call staff are added.“Our integrated, hospital-to-home approach will be a model for Nepal, and beyond,” explains Gauchan, “and we will be proving that in a resource-limited setting, health care expansion, providing universal health coverage to people is possible.”But is the Bayalpata model really replicable? Skeptics say that two hospitals could have been built for the cost of the new buildings, which feature rammed earth technology, solar energy and rainwater collection, and that only substantial donor support made the expansion possible.Gauchan admits that the initial investment may seem high but says it will be more cost-effective in the long run.He adds: “The existing infrastructure for rural health care is way less than the minimum needed to address the emerging burden of non-communicable diseases and road accidents as well as infectious diseases. That is why we are investing in a very robust infrastructure.”<h2>Community spirit</h2>In 2011, Bhajan Kunwar (pictured above) was living an “Ok” life with her husband Purna and children in Bhageswor village of Achham when her sister-in-law Shavitra asked for a favour.Shavitra had been hearing rumours that her husband, who was working in India, was having an affair or had even remarried. Would Purna take her to India to find out? Purna agreed, and brother and sister set off with a friend. En route, Purna received a phone call from Shavitra’s husband warning them not to come, or there would be trouble.They continued anyway, and after crossing the border got on a train. That night, a group of men, perhaps including police, boarded the train and took Purna away. He later called Shavitra’s husband to say he had been kidnapped and would be killed unless help came quickly.Police found Purna’s body the next morning, on the roadside in Ahmednagar, east of Mumbai. It looked like he had been run over, but Bhajan believes he was murdered.Widowed at 25 and with two small children, Bhajan spent the mourning period worrying about how she would afford to send the children to school, and if her mother-in-law and community would accept her becoming the breadwinner for her husband’s four younger brothers and sisters and their families. (Her father-in-law had died earlier).That month, Bayalpata Hospital had a vacancy for a community health worker for the area. Bhajan was hired and six years later, still visits on foot the more than 700 households in her catchment area, checking that patients are taking their medicines, and much more (see main article).“This hospital made me strong,” she tells us. "Before I didn’t know anyone in my village and I didn’t know so many things.” Now with a college certificate, Bhajan advises young women to get educated before they get married. “I tell them ‘if I can do it, you can do it too’. I believe in myself and don’t care what others say about me. If you are true and honest, no harm will come to you.”Bhajan says she will never forget her husband. “But I have to live for my children, and control my mind and my heart. If I am strong, they can have a regular life. The hospital is now my husband, I cannot imagine leaving it.”Marty Logan in Achham<h2>Operating remotely</h2>When nine-year-old Samir Tamang was bitten by a dog on his way to school in Rayale village of Kavre last week, he had to take a two-and-a-half hour long bus ride to Kathmandu with his grandfather Suk Bahadur Tamang, for a rabies vaccination at Teku Hospital.Samir missed school and his grandfather, who works as a driver in Kathmandu, had to ask for leave from his employers.“We are relatively close to the capital, but imagine what it must be like for people living in remote parts of Nepal where there are no roads,” says Suk Bahadur.Indeed, despite the spread of basic health care in Nepal, emergency treatment and procedures like mending broken bones or caesarean sections are not yet available in rural areas. This means families have to sell property or borrow from moneylenders to be able to afford treatment in the cities. Studies have shown that many Nepali families are driven to poverty if relatives are referred to private hospitals.Unmet surgical needs in remote districts remain a major public health issue in Nepal, according to a recent study in 39 remote area hospitals commissioned by the Nick Simons Institute (NSI).One day this week, an informal survey of patients at the government-run Bir and Teaching Hospitals in Kathmandu showed that a majority of the patients were from remote districts, some as far away as Piuthan and Jajarkot.The NSI study shows that except for caesarean sections in Dolakha, Lamjung and Panchthar, very few government hospitals elsewhere were able to do simple operations of the abdominal cavity, or even mend broken bones.Nepal’s surgery rate falls well below the Lancet Commission target of 5,000 operations per 100,000 population. If the goal is to have a surgical facility within two-hour travel distance for patients, at present only a third of the population can reach an orthopaedic surgeon, and only 22% have access to abdominal surgery.However, the survey reaffirms that the presence of a medical general practitioner (MDGPs who can perform caesarean sections and other relatively simple surgical procedures) can change this. District hospitals with resident MDGPs can eliminate the need for patients to make expensive and extended trips to the cities for treatment.The minimum personnel at a district hospital should include an MDGP, obstretrics doctor, anaesthesia assistant, staff nurse and biomedical technician. However, Nepal’s density of hospitals with such staffing is very low (0.4-3.1 per 100,000) as against the Lancet Commission target of 20 per 100,000 population.“In the long run we need specialists but placing three of them in each district hospital will take a long time. For the next 5-10 years, MDGPs will be the answer to solve surgical problems throughout the country,” explains Anil Shrestha, NSI’s Executive Director.The study recommends an MDGP-led generalist surgical team with proper staff, drugs and equipment to upgrade emergency surgical care in all district hospitals.Adds Shrestha: “The government has to strengthen strategically located district hospitals and make them functional to take care of surgical needs throughout the year. It is entirely possible to do.”Sonia Awale in KavreRead also:<a href="https://www.nepalitimes.com/editorial/poor-health/">Poor health</a>, Editorial <a href="http://archive.nepalitimes.com/news.php?id=17650#.Wrydky5ubIV">Resurrection Accham</a>,  Paavan Mathema<a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">Boy walked eight days to treat broken arm</a>,  Tsering Dolker Gurung<a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">Free-for-all health</a>,  Duncan Maru and Roshan Bista

Marty Logan

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State of the art rural hospital

As someone born and raised in Patan, I knew that the city was rich in art, architecture and intangible heritage. But I never realised just how rich, and how little I knew about its hidden treasures until this book. Yala Mhasika/Exploring Lalitpur/Lalitpurko Chinari is published by the Lalitpur Chamber of Commerce &amp; Industry and introduces the city to the world, as well as to its own inhabitants. Lalitpur is popularly known as Patan, probably because of the pastures for livestock in its outskirts. Its original name in Nepal Bhasa is Yala, and is a blend of urban and rural, old and new.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_700fb4c7b27d78813f69347846403c492cd1d54e2f62e4ec097013714c4a2022.jpg" data-media-id="editor_0" data-image-id="20260101120152_700fb4c7b27d78813f69347846403c492cd1d54e2f62e4ec097013714c4a2022" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Patan Dhoka</figcaption> </figure>  Like other kingdoms in the valley of Swoniga, the dense urban cluster of houses, temples, monasteries were situated along the higher ground, while the farmlands were on the slopes leading to the rivers below. This unique townscape combined an urban lifestyle within a distinctly agriculture-based rural setting. The fertile soil, replenished by organic nutrients washed down from the streets above, as well as Kathmandu’s location on the ancient trade route between India and Tibet, provided the Valley’s kingdoms with prosperity – and thus the flourishing of art and culture over centuries. Most of Yala’s residents were farmers, traders, or artisans. Chinese visitors who came to Nepal in the 6th century saw that there were more traders than farmers, and more temples than houses. An entire street is inhabited by the descendants of Lhasa traders. Arniko is supposed to have been born in Yala.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_0fb490355fac9b8252c9abfbf5ef1bbac844b29103744a421eb6ef6dbc77dff7.jpg" data-media-id="editor_1" data-image-id="20260101120152_0fb490355fac9b8252c9abfbf5ef1bbac844b29103744a421eb6ef6dbc77dff7" data-rendition-name="original" width="2000" height="1332" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Kwonti area which houses five-storey Kumbeshwar temple dedicated to Shiva and Baglamukhi temple dedicated to Dasa Mahavidya shakti peeth.</figcaption> </figure>  Nepal exported goods and even minted coins for Tibet, and had a virtual monopoly of the major trans-Himalayan trade routes. This prosperity was reflected in monuments and shrines like the Kwa Baha Golden Temple. More so than the other three kingdoms of Swoniga, architecture flourished in Yala making it the centre for metal, stone and wood craft. The name Lalitpur means ‘city of fine art’ but with its sense of community, it might as well be a city of fine living. Legend also has it that the name Lalitpur comes from a farmer called Lalit who helped bring the rain god Karunamaya from Assam when the Valley was suffering a prolonged drought. Lalit’s shoulder beam stands to this day in Jhatapol. Disasters, invasion and <a href="https://nepalitimes.com/here-now/life-in-a-time-of-cholera">epidemics</a> were a recurring theme in Patan.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_b33b1024cb7a46f49fea35ecc9afa2740895907059d7a43c8bd6c463b1be05e7.jpg" data-media-id="editor_3" data-image-id="20260101120152_b33b1024cb7a46f49fea35ecc9afa2740895907059d7a43c8bd6c463b1be05e7" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Ajima of Haugal Tole which is the oldest stone scripture in Nepal with the Gaja Laxmi in Chyasal.</figcaption> </figure>  The book was put together by the heritage expert team of Rosha Bajracharya, Sunil Pandey and Anil Chitrakar and provides a socio-economic and political history of Patan – how it was always food surplus, thanks to sustainable farming until recently. Ground and drone images by Photo Venture Nepal in the book give us a rare new perspective on Patan. There is an entire chapter on the chariot festival of Karunamaya (Machhindranath), a community-managed festival with Barahi carpenters assembling the woodwork, vine engineers Yamva weaving rope and rattan for the 25m tall chariot, and Ghaku drivers controlling the speed and brakes as the structure rolls through narrow streets in the annual festival.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_d27b23aeb4548b0b64ab8ed20f40baa331060498c6b5443e2cb999b876c670af.jpg" data-media-id="editor_4" data-image-id="20260101120152_d27b23aeb4548b0b64ab8ed20f40baa331060498c6b5443e2cb999b876c670af" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Te Bahal in Patan which houses Karunamaya six months a year.</figcaption> </figure>  WALKING, WORSHIPPING The book can help in exploring Patan along five routes starting in Patan Dhoka, Pulchok, Shankhamul, Mahaboudha and Lagankhel with maps and details of the baha and bahil, shrines, ponds, open spaces, dhyochenn, courtyards and phalcha along the way. Because of its coffee-table size and heft, however, the guidebook is not practical to carry around. And despite detailed descriptions of the past and present of each site, readers are left wanting to know more about those places. It is proof of Patan’s vast treasures that even this book barely scratches the surface.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_31a597b7dc1bcc9f67b4f6a66b8c1c0e0a9406727389699e6aed9ac6c3c50901.jpg" data-media-id="editor_5" data-image-id="20260101120152_31a597b7dc1bcc9f67b4f6a66b8c1c0e0a9406727389699e6aed9ac6c3c50901" data-rendition-name="original" width="2000" height="1332" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Patukodom where visitors can view what remains of the ancient Kirant palace.</figcaption> </figure>  Some of the lesser-known must-visit sites include Patukodom which is all that remains of a palace of the original Kirat inhabitants of Patan. An archaeological dig here would surely unearth hitherto unknown facets of pre-Newa Patan. Then there are the slightly out of the way shrines like Mahabouha, a replica of a temple in Bodhgaya which houses 3,341 terracotta Buddhas with 90 big statues and which took 35 years and four generations to complete.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_ffb657dc254f707dc1755f6f13b1ef67bb7183b6573da9678c54482129fb3878.jpg" data-media-id="editor_6" data-image-id="20260101120152_ffb657dc254f707dc1755f6f13b1ef67bb7183b6573da9678c54482129fb3878" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Mahaboudha is a replica of a temple in Bodhgaya.</figcaption> </figure>  In a recent Patan by Night heritage walk, we learnt that Pim Bahal was the labour of love of a lakhe demon (now popularised as masked dancer) who had fallen for a local girl, and he dug the pond so she would not have to walk to a faraway spout to collect water. Nearby is the Charumati Chaitya, built by the daughter of Emperor Ashoka when she visited the Valley in the 3rd century BCE to spread Buddhism in Nepal. Interestingly, if Kathmandu is a city of temples, Patan is the centre of monasteries which represent a unique Tantric melding of Buddhist and Hindu forms. Examples are: the Tadham Cuka with relocated Licchavi-era chaityas symbolic of the four major events in Buddha’s life, Ajima of Haugal Tole which is the oldest stone scripture in Nepal with the Gaja Laxmi in Chyasal, and Bignantak Ganesa temple which is a manifestation of Shiva mingled with Vajrayana Buddhism.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_17a500e77f06b9881f684329e41d3482f6f6a639ffb929d8bb44e5af7934c61c.jpg" data-media-id="editor_7" data-image-id="20260101120152_17a500e77f06b9881f684329e41d3482f6f6a639ffb929d8bb44e5af7934c61c" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Bignantak Ganesa temple.</figcaption> </figure>  &nbsp;Besides spatial descriptions, the book also explains the temporal by curating a detailed cultural calendar of Lalitpur with dates and places of jatra, rituals, devotional dances and festivals that weave the agricultural cycle with the zodiac.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_b8e1cc03653fea85dec84a7abee4fd594c35c6ad553769f37905eb5b38774e08.jpg" data-media-id="editor_8" data-image-id="20260101120152_b8e1cc03653fea85dec84a7abee4fd594c35c6ad553769f37905eb5b38774e08" data-rendition-name="original" width="2000" height="1125" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Mipwa Lakhe of Patan which create fire in mid aid during performance.</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120152_442e10bff842214e8c7522ebf6e63663599768db73bb57d999deff9de1b59375.jpg" data-media-id="editor_9" data-image-id="20260101120152_442e10bff842214e8c7522ebf6e63663599768db73bb57d999deff9de1b59375" data-rendition-name="original" width="2000" height="1333" loading="lazy" alt="Exploring Lalitpur book review"> <figcaption>Gan pyakhan or Astamatrika dance which is performed in Patan Darbar Squre during Dasain. </figcaption> </figure>  The very last chapter is dedicated to water and nature, what sustains lives and civilisations, and how Lalitpur continues to be the city it is because of the water supply system our ancestors left behind which function still, despite encroachment and pollution. ‘In the history of the world cities have been built, they thrived for some time and then became archaeological sites because they were not able to maintain the quality of air, water, and its soil,’ the authors write. ‘This led these cities to depopulate and ultimately die and are only referred to in history books. Lalitpur is not going to make the same mistake.’ &nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260104080132_3f403388d57da82b499d6c489a8f095002bf69f11e515e92fa96fb5ca3af69e9.jpg" data-media-id="editor_10" data-image-id="20260104080132_3f403388d57da82b499d6c489a8f095002bf69f11e515e92fa96fb5ca3af69e9" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Exploring Lalitpur"> </figure>

YALA

One of the few Newa towns situated outside Kathmandu Valley, Panauti still evokes the feeling of a place frozen in time.&nbsp; Largely untouched by haphazard urbanisation, this town 32km east of Kathmandu used to be a kingdom revered for the sacred confluence of the Punyamati and Rosi rivers.&nbsp; The Bramhayani temple is the site of a 12 yearly Makar Mela which is attended by devotees from as far away as India.&nbsp; Panauti’s crumbling monuments were restored in the 1990s by the French government. Temples, resting places, traditional homes were rebuilt and locals trained to revive their craft. Panauti and France marked 50 years of cooperation in September.&nbsp; However, the priceless murals on the temple walls are fading and need urgent restitution. Now, these crumbling wall paintings are meticulously documented in the Wall Paintings of Panauti and Their Context.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260106090116_31f6acf06ef879037fec8274b85153eab4468566abf71616490679bf8468b85d.jpg" data-media-id="editor_0" data-image-id="20260106090116_31f6acf06ef879037fec8274b85153eab4468566abf71616490679bf8468b85d" data-rendition-name="original" width="1596" height="1074" loading="lazy" alt="Panauti murals"> </figure>  In his foreword, French researcher Gérard Toffin writes about some of the earliest wall paintings from the Malla period in Kathmandu, including a 17th century mural depicting the procession of Rato Machhindranath which has since been restored.&nbsp; Several other pieces still exist but in a pitiful state, defaced by scratches. ‘They were painted on a plaster coating made of soil, husks, or limestone, which were applied to the bricks making up the walls,’ Toffin notes.&nbsp; The book delves into the cult of Asta Matrika among Newa of all castes and classes, the first of which is Bramhayani. These all-pervading deities are linked to Shaktism which focuses on the importance of the female principle and together, combine the forces of life, sex and fertility with that of death and eros. The deities are painted on the wall, carved on the stone or moulded into metallic statues.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260106090120_836efd2b0a569d8ec0fb2c6651a29b8f2dd8f8f75b72e27bb86b0bfc0ad8461f.jpg" data-media-id="editor_1" data-image-id="20260106090120_836efd2b0a569d8ec0fb2c6651a29b8f2dd8f8f75b72e27bb86b0bfc0ad8461f" data-rendition-name="original" width="1074" height="1434" loading="lazy" alt="Panauti murals"> </figure>  Riddhi Baba Pradhan, former director general of the Department of Archaeology who oversaw the restoration of Panauti 30 years ago, writes that a colourful wall painting depicting Buddha's past life at the Chabahil Chaitya built or restored during the reign of Lichhavi king Vrisdev in the 3rd century might be the earliest mural in Nepal. As for Panauti, a fragment from a 400-year-old scroll which illustrates a scene of Triveni Ghat with Dalinchok Hill in the background is likely the oldest. But that relic is currently at the Virginia Museum of Fine Arts in the United States.&nbsp; Pradhan recalls first encountering wall paintings inside Bramhayani temple which were deteriorated by smoke, leaky roof, dust, vermilion, sprinkles of animal blood and lack of maintenance. The team led by chemist Bhimvar Singh Thapa treated the wall paintings and some of the details were recovered including the paintings of Astamatrika and Asta Bhairav on the east, west and southern walls.&nbsp; PAINTINGS ARE NOT VISIBLE The murals were painted during the reign of the last Malla King of Bhaktapur Ranjit Malla and Queen Viswalaxmi Devi 300 years ago. But 40 years after the restoration, Pradhan notes that the murals are again in poor condition: ‘The paintings are not visible, the plaster is severely damaged and the surface has peeled off … electrical wires hang haphazardly inside the temple.’ The second lot of murals at Ghat Sattal are thought to have been commissioned during the late Malla period or the beginning of the Shah dynasty. Exterior walls depict incarnations of Lord Vishnu as well as Sesh Narayan, Ganesh, a scene of Samundra Manthan, of angels Maya, Moha, Ganga. Their attributes, dresses, ornaments, facial expressions, body postures are all skilfully represented but in a deteriorated condition.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260106090116_88d06703ae23a271905d81f35056d41df92cbbc4b9966fac3f34821659e585a8.jpg" data-media-id="editor_2" data-image-id="20260106090116_88d06703ae23a271905d81f35056d41df92cbbc4b9966fac3f34821659e585a8" data-rendition-name="original" width="588" height="862" loading="lazy" alt="Panauti murals "> </figure>  The wall paintings of Bramhayani Dyochhen are 90% degraded even though they were restored and repaired 40 years ago by the Panauti Integrated Project. Compared to other artefacts, wall paintings are more delicate to external factors, and if not preserved an important part of Nepal’s heritage will be lost.&nbsp; Furthermore, most of the wall paintings in Nepal are temperas, and not frescos. Tempera is painted with water-soluble mineral or vegetable pigments fixed with glue on the cow dung clay plaster on the brick walls. While Nepal’s focus has been on the repatriation of stolen artefacts from abroad, religious and cultural objects within the country like the Panauti murals need urgent attention.&nbsp; This slim publication by Panauti Municipality is an important call to begin the work before it is too late.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260101120124_d0efa1e57b2710a206beb37c7e934ac34e694afc278985934eac2fc52124a92c.jpg" data-media-id="editor_3" data-image-id="20260101120124_d0efa1e57b2710a206beb37c7e934ac34e694afc278985934eac2fc52124a92c" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Wall Paintings of Panauti"> </figure>

Saving Panauti's murals

In 2025, Nepal’s Ministry of Tourism <a href="https://nepalitimes.com/news/the-everest-industry" target="_blank">added six new 8,000m peaks </a>to those listed on its website. These are subsidiary summits of <a href="https://explorersweb.com/kangchenjungas-challenging-confusing-subpeaks/" target="_blank">Kangchenjunga</a> and <a href="https://explorersweb.com/through-the-unknown-to-the-impossible-lhotse-middle/" target="_blank">Lhotse</a>, which some view as insufficiently independent to be called separate peaks. In 2024, the international mountaineering federation (UIAA) responded to a request by the Nepal Mountaineering Association (NMA) and the government to officially recognise these peaks. While recognising that ‘there is no one definition of a “mountain” or a “peak” or a “top” or “point” in topographic terms’, and encouraging further debate the UIAA’s opinion was that the 8,000m peaks should continue to the ‘Classic 14’, first completed by Reinhold Messner in 1986. The degree of prominence and isolation of <a href="https://www.climbing.com/news/new-8000-meter-mountains-nepal/?scope=initial" target="_blank">the six new peaks </a>varies, with Yalung Kang having the strongest claim to being a separate peak with a prominence of 135m, but they are all separate enough to be included on some peak-bagging lists. The UIAA’s own list of 4,000m summits in the European Alps includes Punta Giordani with a prominence of only 6m. Whatever the case for the six peaks being geographically separate mountains, they represent significant climbing challenges. They are not minor tops that can simply be ‘bagged’ on route to a main summit. In the case of <a href="https://explorersweb.com/through-the-unknown-to-the-impossible-lhotse-middle/" target="_blank">Lhotse Middle and Lhotse Shar</a>, no one has ever managed to traverse between them and Lhotse itself.  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260107080144_881321a6e46818beb7bbd4fe6f21589d89d19bf77ae8218474d373ef7ab0c431.png" data-media-id="editor_5" data-image-id="20260107080144_881321a6e46818beb7bbd4fe6f21589d89d19bf77ae8218474d373ef7ab0c431" data-rendition-name="original" width="2888" height="1590" loading="lazy" alt="New 8,000ers"><figcaption>Nepal’s 8 existing 8,000ers: Chomolungma 8,848.86, Kangchenjunga 8,586, Lhotse 8,516, Makalu 8,485, Manaslu 8,163, Dhaulagiri 8,167, Annapurna 8,091, Cho Oyu 8,201. Photo: GOOGLE EARTH PRO</figcaption></figure>   <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260107080144_27bf905c1a559c46819dc96ca33d22c27fc301d415fc034f26b8acd105c12da7.png" data-media-id="editor_6" data-image-id="20260107080144_27bf905c1a559c46819dc96ca33d22c27fc301d415fc034f26b8acd105c12da7" data-rendition-name="original" width="1750" height="976" loading="lazy" alt="New 8,000ers"><figcaption>Nepal has listed six additional 8,000ers: Yalung Kang (8,505, Yalung Kang West 8,077, Kanchenjunga Central (8,473, Kanchenjunga South 8,476, Lhotse Middle 8,410, and Lhotse Shar 8,400. Photo: KUNDA DIXIT</figcaption></figure>  Several fine routes have already been climbed on these mountains, such as Slovenians Andrej Štremfelj and Marko Prezelj’s alpine style ascent of the South-West Ridge of Kangchenjunga South. The six peaks have not yet achieved universal acceptance, but it is possible that climbing an expanded list of 20 eight-thousanders could become a new mountaineering challenge, just as the 14 classic peaks are today. It is therefore interesting to analyse who is currently closest to achieving this goal, using data from The Himalayan Database and other Internet research. The first conclusion of my analysis is that these six additional peaks have received far less attention than the classic 14 eight-thousanders. One of them, Yalung Kang West, has never been climbed or even attempted: probably because it is a subsidiary peak of <a href="https://explorersweb.com/kangchenjungas-challenging-confusing-subpeaks/" target="_blank">Yalung Kang</a> which is itself a subsidiary peak. The other five peaks have seen a total of 138 ascents. Just 101 people have ever climbed one or more of the additional peaks, which compares with 354 people who climbed Everest on a single day: 23 May 2019. Russian Evgeni Vinogradski is unique in having climbed five of the six new peaks. He has also climbed six of the classic 8,000ers, giving him a total of 11 out of the 20 peaks on the expanded list. Vinogradski is now 80 and is unlikely to increase this total. Several other former Soviet climbers have climbed three of the new peaks, having participated in the 1989 traverse of the four main summits of Kangchenjunga. This includes two legends of Soviet climbing: Kazakh Anatoli Boukreev and Ukrainian Sergey Bershov, each of whom has climbed 13 out of the 20 peaks on the extended list. Boukreev died attempting Annapurna in 1997. Bershov, one of the only men to have ever climbed Lhotse South Face, is now 78 and, although he was in good form when I met him in Chamonix last summer, he is unlikely to further extend his tally. The addition of the new peaks does not take any of these climbers beyond the total of 14 peaks achieved by the 76 climbers who have completed the classic ‘Himalayan Crown’. Of those who have climbed all 14 classic eight-thousanders, only one, <a href="https://nepalitimes.com/here-now/um-hong-gil-s-project-impossible" target="_blank">Korean Um Hong-Gil</a>, has climbed any of the six additional peaks.  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20260107080144_5651fc6445f5e5fd838f28e1eac1da45da136b309a4a00db1e4aafa7d4836251.png" data-media-id="editor_9" data-image-id="20260107080144_5651fc6445f5e5fd838f28e1eac1da45da136b309a4a00db1e4aafa7d4836251" data-rendition-name="original" width="2142" height="1310" loading="lazy" alt="New 8,000ers"><figcaption>Only one mountaineer, Korean Um Hong-Gil, has climbed any of the six additional peaks.</figcaption></figure>  Um climbed both Lhotse Shar and Yalung Kang, giving him a total of 16 summits. He required four attempts to climb Lhotse Shar, including one attempt in which he turned back just 100m from the summit following the deaths of two teammates. He finally succeeded in 2007 via a route up the Lhotse South Face. If a race to climb all 20 eight-thousanders were to begin, Um is currently in the lead. <a href="https://www.himalayandatabase.com/" target="_blank">The Himalayan Database</a> also lists two additional mountains in Nepal not included among the peaks announced by the Ministry of Tourism: Annapurna Central and Annapurna East. If these are included, bringing the total to 22 peaks, a few additional climbers deserve mention. Poles Piotr Pustelnik and the great Jerzy Kukuczka have both climbed all 14 classic eight-thousanders as well as Annapurna East, giving them 15 out of 22. Swiss climber Erhard Loretan climbed all 14 as well, and both Annapurna subsidiary summits, giving him a total of 16 out of 22 peaks. Annapurna East has a greater prominence than some of the 6 new peaks proposed by Nepal, but Broad Peak Central in the Karakoram has the greatest prominence of any subsidiary 8000m summit. Kukuczka has also climbed Broad Peak Central, so if the list is extended to 23 peaks, he has 16, equal with Loretan and Um. Then, there is a case for Shishapangma Central in China, which further complicates the task of coming up with a definite extended list. At the moment, these subsidiary summits are not attracting a lot of attention: of the 138 summit climbs on them, only 12 occurred in the last 25 years and none since 2011. Most climbers like to have some wide recognition of a target before investing time and money in trying to achieve it, and this may make it hard to build interest. But as completing the classic 8,000m peaks starts to become a rather frequent occurrence, some may be attracted to the longer list. If this new challenge catches on, as the Ministry of Tourism presumably hopes, how long will it be before someone passes Um Hong-Gil’s total and how long before someone climbs all 20 or 22 or 23 summits? <a href="https://nepalitimes.com/opinion/comment/dispelling-myths-about-climbing" target="_blank">Edward Morgan</a> is a British author and climber based in Switzerland. His first book, Lhotse South Face - The Wall of Legends, has been published in several languages and his second book, Chasing Mallory's Dream is due out in the UK this year.

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YALA

Saving Panauti's murals

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