From his village in Bajura in western Nepal, the Indian border is much closer than Kathmandu, so that is where Manbir Sanjyal &nbsp;has been going to find work since he was much younger. &nbsp;&nbsp; India is referred to here as कालापहाड, beyond the black mountains. And hundreds of thousands of Nepalis, especially from western Nepal, have for many decades crossed over to work as apple pickers, porters, domestic help or security guards in India.&nbsp; Sanjyal worked in Kumaon, Garhwal, Delhi, Uttarakhand and Uttar Pradesh for years, and eventually he returned to Bajura. Kathmandu may be 800km away, but with better connectivity Sanjyal and many like him do not have to be migrant workers in India — they can be migrant workers in the capital. Sanjyal, now 59, moved to Kathmandu six months ago after farming in Bajura became insufficient to feed his family. He rented a farm in Panga at the western edge of the Valley and grows vegetables to sell in the market. He is doing so well, he plans to get into dairy farming as well. &nbsp; Read also: <a href="https://www.nepalitimes.com/multimedia/weaving-the-fabric-of-a-new-life">Weaving the fabric of a new life</a>, Sahina Shrestha  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230722060748_e38f52fd434eebc0c25c2262b646bf3bbec8c3f837dbf132dfb798cb4db56d10.png" data-media-id="editor_1" data-image-id="20230722060748_e38f52fd434eebc0c25c2262b646bf3bbec8c3f837dbf132dfb798cb4db56d10" data-rendition-name="original" width="700" height="500" loading="lazy" alt="Bajura"> </figure>  “When we were young we toiled in India, now our grandchildren can make a living growing food in our own country,” says Sanjyal, looking out from his greenhouse. “In addition, the grandchildren can get better education and health care here.” Sanjyal’s son Jeevan completed high school in Bajura, and wants to go to college in Kathmandu. Bajura ranks lowest among Nepal’s 77 districts in the human development index. Poverty and poor harvests are endemic in the district because of lack of state support for irrigation. This makes Karnali Province the most food deficit part of Nepal with one of the highest rates of stunting and wasting among children. &nbsp;&nbsp; News of Sanjyal’s success has reached his village in Bajura and inspired other families to also make a move to Kathmandu. Lali Prasad Pandey came to Kathmandu after hearing about his sister’s successful commercial vegetable farming business in Kirtipur. He had worked in Qatar for three years before returning home to Saunegaun in Bajura, where he attempted unsuccessfully to make a living farming.&nbsp; “I did make some money during my time overseas, but it was not enough to cover costs of healthcare or my children’s education,” he says. Pandey has been a vegetable farmer in Kirtipur for six years now, and his neighbours are also farmers from far-western districts like Bajura, Humla, Jumla, Kalikot, Mugu, and Rukum-West.&nbsp; Like Sanjyal, Pandey has set up greenhouses to grow seasonal vegetables and finds a ready market in Kathmandu, even though over the years the profit margin has fallen.&nbsp; Read also: <a href="https://www.nepalitimes.com/multimedia/mothers-of-sarlahi">Mothers of Sarlahi</a>, Marty Logan  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230722030744_5aa5cc9d9f5f7b88eee46980d523617c9060d1fd268d4620f39acc7177f3e893.jpg" data-media-id="editor_3" data-image-id="20230722030744_5aa5cc9d9f5f7b88eee46980d523617c9060d1fd268d4620f39acc7177f3e893" data-rendition-name="original" width="5002" height="3335" loading="lazy" alt="Kathmandu's little Bajura"> </figure>  So, Pandey recently bought four cows to diversify his business, and sells milk door-to-door at Rs100 per litre. The cows also provide fertiliser for his vegetable farming business.&nbsp; “Dairy farming is like having a salaried government job,” Pandey jokes, referring to the secure income it provides.&nbsp; But the extra work also means he and his wife have to work 24/7 on the farm, and there is no time to go home to Bajura. Coming to Kathmandu was a good move, and Pandey has been able to send his children to better schools, and he is happy he does not have to be separated from his family any more.&nbsp; Tilakhuni BK was Pandey’s neighbour in Bajura, and also came to Kathmandu hearing about the favourable business environment and schooling for the children. Read also: <a href="https://www.nepalitimes.com/banner/biodynamic-agripreneurs">Biodynamic agrepreneurs</a>, Sanjib Chaudhary <div class="embed-block"><div><div style="left: 0; width: 100%; height: 0; position: relative; padding-bottom: 56.25%;"><iframe src="//cdn.iframe.ly/api/iframe?url=https%3A%2F%2Fwww.youtube.com%2Fembed%2FYgoOEmwX8HI&key=87ca3314a9fa775b5c3a7726100694b0" style="top: 0; left: 0; width: 100%; height: 100%; position: absolute; border: 0;" allowfullscreen scrolling="no" allow="accelerometer *; clipboard-write *; encrypted-media *; gyroscope *; picture-in-picture *; web-share *;"></iframe></div></div></div> But Tilakhuni has not been as successful with her farm in Kirtipur. Her family invested Rs200,000 on the greenhouses and terraces, but then came the Covid lockdowns. She had to sell her cows, and her husband had to go to Saudi Arabia to supplement their income.&nbsp; Tilakhuni was bargaining with a customer on the phone, and when she hung up complained that she would do all right if she could deal directly with buyers more often. But the middlemen take away most of her margin. &nbsp; While Tilakhuni sells her greenhouse tomatoes at Rs15/kg, middlemen sell them to city wholesalers for Rs50. “We do all the work, but get none of the benefits, no matter how hard we work,” she says.&nbsp; Despite this, life in Kathmandu Valley is still better than in her village Bajura. She says, “I may not be earning as much as I expected, but I am happy with what I have. Whatever hardship we face here is nothing compared to the struggles we had in the village.” Tilakhuni’s priority is that the children get quality education in the city. Her brother, children, and nephew attend school in Kirtipur. Her eldest son has completed his SEE exam, and her daughter is currently in middle school.&nbsp; “The quality of education in the city is much better than that in the village,” says BK’s daughter Ramita. “We get an English medium education here and this improves our chances of going abroad in future.” Read also: <a href="https://www.nepalitimes.com/here-now/down-in-sherpa-s-farm">Down in Sherpa's farm</a>, Sonia Awale  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230722030748_0114ba51ea101b8ca2ab64801df994f199d241e84f5dccc516a5d11ebadd7e30.jpg" data-media-id="editor_7" data-image-id="20230722030748_0114ba51ea101b8ca2ab64801df994f199d241e84f5dccc516a5d11ebadd7e30" data-rendition-name="original" width="5002" height="3335" loading="lazy" alt="Kathmandu's little Bajura"> </figure>  Hearing about Tilakhuni’s work also convinced Deepa BK to move to Kirtipur four months ago. Deepa currently helps Tilakhuni on her farm but is actively thinking of leasing her own vegetable farm. &nbsp; “I came here so that my children do not have to suffer and grow up the way that I did,” says Deepa. “There is no future for the children back home.”&nbsp; Her husband currently works in India, and is now making preparations to move to Kathmandu. Health care is another reason the Bajura families all migrated to Kathmandu, and for a feeling of home, they all live near each other in Kirtipur and Panga.&nbsp; Tilakhuni BK and her husband were both unable to get medical treatment for their ailments in India, but found health care to be better and more accessible in Kathmandu.&nbsp; Manbir Sanjyal requires regular dialysis, but the facility is not available at the Bajura District Hospital in Martadi. So he moved to Kathmandu, but says the state is not fulfilling its responsibility to provide healthcare in rural areas. Lali Prasad Pandey agrees: “Hospitals in Bajura do not meet even basic needs. If the state had made these services available in our home district, we would not have had to move here.”&nbsp; Read also: <a href="https://www.nepalitimes.com/multimedia/my-children-shouldnt-be-farmers">“My children shouldn't be farmers”</a>, Anita Bhetwal

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Kathmandu’s Little Bajura

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d122b9c7e80680e0a98c2jpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Young mothers with their children in Muktikot where child marriage has become more prevalent as subsistence farmers cope with a succession of droughts and floods that have destroyed harvests. All photos: SONAM LAMA</figcaption></figure>“Mulai kyai thaa bhayaanai,” murmurs Birjaman, pain and fatigue etched on his wizened face. He has just made a steep 3-hour climb from his village of Muktikot to a pharmacy carrying his semi-conscious daughter-in-law, Reti.She has post-partum haemorrhage, and has not stopped bleeding. The clinic managed to save her life, but the <a href="https://www.nepalitimes.com/banner/child-marriage-in-nepal-eloped-at-13-mother-by-17/" target="_blank" rel="noopener noreferrer">young mother</a> lost her three-month foetus. Reti was married off at 16, and at 22 already has two children.The midwife says the miscarriage was due to weakness and heavy workload during pregnancy. Reti’s husband is working in India, and she has to do all the household work, raise the children, take care of the livestock, and fetch water herself.At the pharmacy, Gopal Singh says he sees cases like this often. This is the nearest medical stop for the predominantly Dalit village of Muktikot. He says, "This is nothing new around here, we get miscarriages like this daily. Many do not make it. Young mothers are not physically mature for childbearing and couples do not use contraceptives."Marriage before age 20 is punishable by law in Nepal but it is still common. Low female literacy, poverty, discrimination and cultural norms play a role, but <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/child-marriage-in-Nepal,3863" target="_blank" rel="noopener noreferrer">child marriage</a> has become more prevalent as of late, as subsistence farmers cope with a succession of droughts and floods that have destroyed harvests.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d122f9c7e80680e0a98c3jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>Last winter, western Nepal suffered a 6-month drought that was followed by <a href="https://www.nepalitimes.com/banner/wildfires-ravage-nepal-mountains/" target="_blank" rel="noopener noreferrer">wildfires that raged for months</a>. Then, two weeks ago the region was hit by a freak post-monsoon storm that destroyed standing crops. Farmers had been hopeful for a good harvest because of plentiful rain this monsoon, but <a href="https://www.nepalitimes.com/latest/post-monsoon-rain-ruins-nepals-crops/" target="_blank" rel="noopener noreferrer">the unseasonal downpour</a> on 18-19 October unleashed landslides and floods and dashed their hopes.Scientists say global warming has added to the moisture content in the atmosphere, triggering <a href="https://www.nepalitimes.com/banner/himalayan-floods-a-sign-of-worse-to-come/" target="_blank" rel="noopener noreferrer">extreme weather</a> with erratic monsoons, frequent droughts and cloudbursts. Families in food-deficit western Nepal, already in a precarious situation, have been pushed over the edge.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12329c7e80680e0a98c4jpeg.jpg" alt="" width="800" height="600"><figcaption> </figcaption></figure>Already stricken by poverty and caste discrimination, the impact of climate crisis means that more parents now marry off their young daughters, who in turn end up risking their lives due to early pregnancy and poor diet."My father remarried after my mother died, and he married me off at 16 saying I would have a good life after marriage," recalls Reti.Read also: <a href="https://www.nepalitimes.com/banner/climate-change-is-a-disaster-in-the-nepal-himalaya/" target="_blank" rel="noopener noreferrer">Climate crisis is a disaster in the Nepal Himalaya</a>, Sonam Choekyi LamaSubi, 16, is also from the same village. She lost her new born baby two days after home delivery three months ago. She had not had a single pre-natal check-up, was too <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/" target="_blank" rel="noopener noreferrer">undernourished</a> to breast feed properly, and her baby eventually died of hunger.Subi herself bled for more than two weeks after the birth, and even though there were no men to carry her to the health post, she survived. She is still weak and anemic. Subi’s friend Suna is also 16 and expecting her first baby. Afraid that she may have the same complication, she walked five hours to a pharmacy to get iron tablets.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12349c7e80680e0a98c5jpeg.jpg" alt="" width="1500" height="994"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12389c7e80680e0a98c6jpeg.jpg" alt="" width="1500" height="994">Locals gathered in Muktikot. At least one member from each family is currently working in India.Suna’s mother Rauthi married her to a neighbour’s son because the family’s harvest failed after a long drought. She has seven children, all of whom have dropped out of school either to work in India, or to get married and raise their own children. The husbands of both Suna and Subi are also away in India, working to augment family income.Read also: <a href="https://www.nepalitimes.com/editorial/women-and-water/" target="_blank" rel="noopener noreferrer">Women and water</a>, EditorialMost families here have at least one member working in India, and the income they send home was what helped them survive when crops failed. But many Nepalis lost their jobs during the pandemic, so even this fallback option was not there for the past two years.“Life here is tough, and getting tougher. Early marriage is the norm, since it is easier to get our daughters married, so we do not have to feed them,” says Rauthi, two of whose seven children are handicapped and cannot go to school, or work.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d123b9c7e80680e0a98c7jpeg.jpg" alt="" width="1500" height="1125"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d123f9c7e80680e0a98c8jpeg.jpg" alt="" width="1500" height="1125">Children in Muktikot have to walk across steep terrain for three hours roundtrip everyday to go to school.Nearly 40% of girls in Nepal marry before they are 18, while some 14% give birth to their first child before their 19th birthday. Moreover, children of Dalit communities are at higher risk of being <a href="https://www.nepalitimes.com/opinion/too-young-to-marry/" target="_blank" rel="noopener noreferrer">married young</a> because of poverty, discrimination and limited access to resources.Although child marriage is less common than it used to be, it is still prevalent despite laws banning it. Now, the economic crisis due to the pandemic and the climate emergency has exacerbated the situation.This is <a href="https://www.nepalitimes.com/here-now/the-curse-of-being-new-mothers/" target="_blank" rel="noopener noreferrer">evident in Bajura</a>, a district in Nepal with one of the worst development indicators with more than 70% of people living below the poverty line, while Nepal’s national average is 26%.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12429c7e80680e0a98c9jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>Frequent droughts and crop failures in recent years have further impoverished Bajura’s subsistence farmers. As it is, only 9% of the land in the mountainous district is arable, with a mere 1.42% with irrigation facility. Crop yields of barley, wheat, maize and millet harvests have dropped sharply in the past 10 years.Every year the district faces a shortage of 11,000 tonnes food grain, and a World Food Programme (WFP) bulletin classified 85% of the population being <a href="https://www.nepalitimes.com/latest/the-pandemic-of-hunger/" target="_blank" rel="noopener noreferrer">food insecure</a>. Muktikot is one of the villages classified as very vulnerable to deficient nutrition.Even in years with normal harvest, food grown here is enough only to feed families for three months in year. The result is out-migration for work, malnutrition, forced child marriage, high maternal and infant mortality.https://www.youtube.com/watch?v=e6ptI6TJqUgWith farmers so dependent on rain-fed agriculture, their fragile existence is even more precarious because of climate-related extreme weather. A 30-year precipitation data at the nearby Martadimet station shows that total annual rainfall has fallen, there is little winter snow, and even that tends to come with destructive storms.“Rainfall has always been unpredictable in these parts, but these days there is very little winter snow that we need for the spring marsi paddy and buckwheat,” says 65-year-old farmer Brija Bahadur Bam. “And when it does rain, it is so heavy that it washes away the crops.”This all adds up to <a href="https://archive.nepalitimes.com/article/nation/water-table-of-kathmandu-valley-falling-fast-recharge-to-replenish,4100" target="_blank" rel="noopener noreferrer">lower groundwater tables</a>, which means even perennial springs have gone dry. Indira Kandel of the Department of Hydrology and Meteorology says that the rain and snow is then not enough to replenish the aquifers.The link between drought and child marriage has been proven by research in India. Reetika Revathy Subramanian, a PhD student at the University of Cambridge, has studied how drought-induced migration in the caste-ridden Marathwada region of India has increased underage marriage.“The decision for a girl to marry gets shaped by a web of intersecting factors, including poverty, access to education, social pressure and norms, harassment and intimidation, which is further exacerbated by disaster,” she explains.In Nepal’s Bajura district, too, the <a href="https://www.nepalitimes.com/here-now/dalits-disasters-and-discrimination/" target="_blank" rel="noopener noreferrer">Dalit community is more vulnerable</a> to the impact of the climate crisis on agriculture than more privileged groups. “Child marriage is rampant here but it is more likely in families hit hard by food crises and with many children,” says Birban BK of the Nepal Climate Change Support Program (NCCSP).The answer lies in making irrigation available to farmers so they are not affected by erratic rainfall, which is why the NCCSP prioritised building irrigation canals and flood-prevention gabion walls in Bajura.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12469c7e80680e0a98cajpeg.jpg" alt="" width="1510" height="1000"><figcaption> </figcaption></figure>Muktikot got its name from Maoists guerrillas during the insurgency who wanted to show that the Dalit village had been liberated from caste discrimination. The war has been over for 16 years, but life is, if anything, worse for the Dalits here.Village officials and locals believe that the relocation of the entire community is the only way out. Plans are afoot for the rehabilitation of villagers to settlements up the mountains to an altitude of 2,500-3,000m where rainfall is more regular. They can grow cash crops like walnut and <a href="https://www.nepalitimes.com/banner/a-parliamentarians-apple-grove/" target="_blank" rel="noopener noreferrer">apple</a>, but will be needing help accessing the market.“These practices could be diversification of livelihoods and income sources through adopting climate-resilient cash crops, connecting farmers to the markets, promoting agro-forestry and use of bioengineering for infrastructure development,” says Monika Upadhyay of WFP Nepal.Even among Dalits, it is the women from the community who are even more affected by the climate crisis. The shortage of water <a href="http://archive.nepalitimes.com/article/nation/Recharging-the-mountains,3465" target="_blank" rel="noopener noreferrer">adds to their daily drudgery</a>, because they have to walk longer to reach springs that are still functioning.Says Radha Wagle of the Climate Change Management Division at the Ministry of Environment: “In Bajura and other districts, we need climate-resilient and gender-responsive plans because women are more adversely affected by socio-economic, geographical and climatic vulnerability.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12499c7e80680e0a98cbjpeg.jpg" alt="" width="1500" height="994"><figcaption> </figcaption></figure>Nepal aims to implement these measures at local levels by 2030, the same year the government has set to end <a href="https://www.nepalitimes.com/latest/nepal-child-marriages-spike-during-pandemic/" target="_blank" rel="noopener noreferrer">child marriage</a>. But given that the practice is still rampant, it is an ambitious target.Says Subramanian: “It is important to strengthen child marriage prevention groups, village-level committees to work closely with vulnerable families including women and girls in particular.”At nearby Radhamata Secondary School, only 13 of the 113 students in Grade 10 are unmarried. Manshova Buddha, 17, is one of them. She says: “With so many of my friends already married off by their parents, I also feel the pressure. But I am not going to give up on my dreams.”Read also: <a href="https://www.nepalitimes.com/opinion/educating-girls-for-climate-action/" target="_blank" rel="noopener noreferrer">Educating girls for climate action</a>, Helen GrantSome names have been changed.This report was supported by the Road to COP26 campaign implemented by the British Council and funded by UKAID.

How the climate crisis adds to child marriage in Nepal

<figure><img width="1600" height="1200" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129151140/638619ea9c7e80680e0ccccfjpeg.jpg" alt=""/><figcaption>Young children suffering from undernutrition have poorer school achievement, diminished cognitive and language ability, and more behavioural problems. Adults who were malnourished in childhood have less economic productivity and increased incidence of health problems.</figcaption></figure>Malnutrition has long been identified as a major barrier to development in Nepal, and other low-income countries. The solution seems obvious: ensure that children eat enough of a balanced diet so they get the needed proteins, vitamins and minerals.Two recent projects set out to do just that. The first provided animal source foods (meat, fish, eggs and dairy), vegetables and a diverse diet to children in low-income farming households in Nepal’s Banke district. The second helped women in Bajura to grow vegetables in kitchen gardens. Both succeeded, but would have done even better if the beneficiary families did not face so many other obstacles.In Bajura, researchers found that ‘structural barriers’ prevented some women participants, all of who were pregnant or had children two years old or younger, from committing fully to the garden.‘Participants demonstrated high levels of knowledge about the program’s nutrition messages and expressed interest in and motivation to engage in the program,’ wrote the study’s authors. ‘However, access to water, land, and time determined the extent to which their full participation in the program was feasible.’<a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/">Nearly half of Nepali children still malnourished</a>, Sonia Awale <img width="1600" height="1200" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129151140/638619ef9c7e80680e0cccd0jpeg.jpg" alt="">That finding was not surprising, says Pooja Pandey Rana, deputy chief of party for the Suaahara nutrition program, the operational arm of Nepal’s multi-sector nutrition plan. Based at Helen Keller International, which carried out the garden project, Rana was a co-author of the study, ‘Navigating structural barriers to the implementation of agriculture-nutrition programs in Nepal’ published in the journal <a href="https://link.springer.com/article/10.1007/s12571-020-01031-0" data-saferedirecturl="https://www.google.com/url?q=https://link.springer.com/article/10.1007/s12571-020-01031-0&amp;source=gmail&amp;ust=1589177540738000&amp;usg=AFQjCNFVbcRmzXA6g1wjMOG3fB0pgUvJzQ">Food Security</a> in April 2020.<a href="https://www.nepalitimes.com/latest/covid-19-affecting-food-security-in-nepal-wfp/">COVID-19 affecting food security in Nepal: WFP</a>, Nepali Times“We have made massive progress on stunting, on the nutrition indicators. But on the underlying barriers, access to food, to all these resources, I think we can do a lot more and not one project can do everything,” said Rana in a telephone interview. “It also raises the question of what the broader interventions we can do in a nutrition program, and are donors ready to support them. They have their own targets, their own agenda and theory of change.”The study notes that difficulties accessing water were raised in nearly every conversation researchers had with participants and staff and in focus group discussions with female community health volunteers. In some cases, the barrier was the time required to fetch water, in others it was a ban on Dalit villagers using taps or scarcity of water overall.The research suggested solutions to overcome such barriers, at least in the short term. For water, that included ‘micro-irrigation’ equipment (sprinklers and hoses). ‘Enabling households to access such equipment, possibly by subsidising it or through community sharing schemes, could ease access to water and substantially reduce the work burden associated with kitchen garden cultivation for many participants,’ the report said.<a href="http://nepalitimes.com/article/nation/child-undernourishment-a-major-risk-after-the-earthquake,2379" target="blank" rel="noopener noreferrer">You eat what you sow</a>, Sahina ShresthaRana says that phase two of the project has incorporated some such ideas. These include training women farmers on wastewater management and forming village farmer networks so women growers can better negotiate with traders.Overall, she is optimistic, partly because of interest from local governments: “Most of the municipal leaders we’ve interacted with want to do really good, impactful work. But they need support on strategic things, for example who to contact for poultry vaccination. They need these sorts of networks and connections and capacity-building.” <img width="1600" height="1200" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129151140/638619f29c7e80680e0cccd1jpeg.jpg" alt="">In Banke, researchers found that over four years the contribution of diet to developmental status were striking. ‘Even small changes in dietary intake were associated with impressive improvements in child developmental performance,’ wrote the authors in the journal <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/mcn.12964" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/doi/epdf/10.1111/mcn.12964&amp;source=gmail&amp;ust=1589177540739000&amp;usg=AFQjCNHBxK1QHeXh453q39WMO2zTUc8MEg">Maternal &amp; Child Nutrition</a> in January.   But that impact was tempered by household wealth, mother’s education and ‘home environmental quality’ including such things as availability of toys, dolls, and books, interactive activities such as mothers and children reading together, telling stories, and playing, and how often the child was left alone or under the supervision of another child.‘Limited resource environments present many potential hazards to growing children, including poor nutrition, lack of medical care, increased exposure to infections, physical and emotional neglect,stress, and lack of stimulation for cognitive development ... lower educational levels of the parents (particularly the mother) are one of many additional risk factors in impoverished households.’<a href="http://nepalitimes.com/article/nation/the-face-of-hunger-debt-malnutrition,3604" target="blank" rel="noopener noreferrer">The face of hunger</a>, Om Astha Rai‘We found that child developmental scores were significantly associated with household wealth, maternal education, and the home environmental quality’, the authors concluded.Those findings echo the analysis in <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal/&amp;source=gmail&amp;ust=1589177540739000&amp;usg=AFQjCNFcHt-4ZzGFqJg6SysOZykYQjFvvg">another recent study</a>, which concluded that Nepal’s poorest families are 50 years behind its richest households in terms of newborn health. Key risk factors for neonatal mortality were a mother’s lack of a tetanus vaccination, her education status, giving birth before the age of 20, household air pollution, poverty, and having no toilet at home.Rana says she sees hope in the next generation of women, who are different than their mothers: “Almost 70% of them have access to cell phones in Bajura. How do we use that technology to empower them? They want to do more, study more … The progress we’ve made is tremendous in terms of nutrition indicators but adolescence and youth is a missed opportunity — we need to do more.”Read also:<a href="https://archive.nepalitimes.com/article/nation/malnutrition-stunting-wasting,3603">Thought for food</a>, Marty Logan<a href="https://www.nepalitimes.com/banner/junk-food-is-making-nepali-children-shorter/">Junk food is making Nepali children shorter</a>, Marty Logan

Food for thought for Nepal’s nutrition planners

https://youtu.be/FmieAvLuWBoFederalism was supposed to bring the government closer to the people, decentralise medical care and improve <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">public health</a> at the grassroots. But the new three-tier government structure threatens to undo Nepal’s gains in improving health services.The government’s ‘adjustment policy’ in the medical sector, which lets staff to pick their preferred tier of work, has led many to choose the federal level, leaving provinces and municipalities underserved. The biggest losers are the areas already lacking in services: Province 6 (Karnali) and the Far Western Province.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37757&amp;preview=true" target="_blank" rel="noopener">Poor health makes Nepalis poorer</a>, Editorial At the Kolti Primary Health Care Centre in Bajura, there is no doctor, after the one serving here chose to be transferred to Kathmandu. Bajura District Hospital has five doctors but the contracts of three of them will soon expire.“I have not been informed of my new hospital yet, but I am about to be transferred. In two months, there will be a shortage of doctors here,” predicts Chief Medical Officer Rup Chandra BK, adding that all technicians, including a paramedic, a radiographer and health assistants, have been transferred or will be soon.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee <a 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<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66a79c7e80680e059998jpeg.jpg" alt="" width="640" height="427"/>With a population of 135,000 people, Bajura has no private hospitals and only one government hospital, a primary health care centre, and 26 health posts. WHO recommends a doctor-patient ratio of 1:1,000, but here it is 1:150,000, while Kathmandu has a ratio of 1:850.This is nothing new: Far Western Province has long faced medical staff shortages. According to the Department of Health Services Report 2018, only 80% of positions in health facilities were filled, and only 56 of the 142 sanctioned doctor positions were staffed. That number will decrease further after adjustment.According to a list of adjustments of 8th level general practitioners (GPs) by the ministry of health, 36 doctors were serving in Far Western Province, but only 9 of them have chosen to remain. Of the 631 doctors at this level, as many as 326 chose the federal level, which means they are concentrated in Province 3. It is the same story in all other provinces. There are only 14 doctors in Province 6.“Far Western Province has always faced a shortage of doctors. We have a lot of nurses, assistants, and technicians, and even if they are transferred there are others to replace them. But specialist doctors earn a lot in the cities and a government hospital cannot offer them as much. No wonder they do not want to stay here if they have a choice,” says Ramesh Kunwar at the ministry of social welfare in the province.Read also:<a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, Editorial<a href="https://www.nepalitimes.com/here-now/henry-marsh-returns-to-the-institute-created-by-his-neurosurgeon-colleague-upendra-devkota/" target="_blank" rel="noopener">Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota</a><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66a99c7e80680e059999jpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure>The Government Doctors’ Association of Nepal (GODAN) is also unhappy. “From the beginning we have said that the medical sector is different from others and adjustment would result in neglect of underserved regions and migration of doctors to the cities, and we were right,” says Dipendra Pandey, president of GODAN. “We proposed that a federal bridge should be created, so that medical professionals working at the federal level can be sent back to their previous working area.”Ironically<a href="https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/" target="_blank" rel="noopener">, physician Govinda KC</a> had to call off his 17th fast unto death in Dadeldhura because the district hospital did not have proper facilities in case his health deteriorated. KC has been protesting the commercialisation of medical education, which forces doctors to work in the cities to recoup their investments.“If the government does not replace those who are leaving the province, there is going to be a great crisis in healthcare in the Far West,” says Gunaraj Awasthi, chief of the Far West Regional Health Directorate in Dipayal. “It should immediately reinstitute those medical professionals on contract service.”<h2>Neglect kills mothers</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66ad9c7e80680e05999ajpeg.jpg" alt="" width="640" height="427"><figcaption> </figcaption></figure>Lalita Bohora, 27, was ten months pregnant when her husband helped her walk for three days from Kolti to Bajura District Hospital to deliver her baby earlier this year. The staff told her it was a complicated pregnancy and there were no doctors to perform a caesariean section.Bohora was lucky — many other mothers are in no position to walk to the district hospital. Although Nepal’s maternal mortality rate (MMR) has come down drastically from 600 per 100,000 live births two decades ago to 239 today, many mothers in remote districts like Bajura continue to <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">lose their lives</a> just because maternity wards are not staffed, or properly equipped.Read also: <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener">People, Politics, and Placentas</a>, Bikrash Gauchan<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b09c7e80680e05999bjpeg.jpg" alt="" width="643" height="376">Since it started in 1997, the government’s safe motherhood program has provided cash to mothers if they do all four antenatal checkups, and mothers, and medical staff, are given cash incentives for institutional delivery. The number of birthing centres staffed by at least one skilled birth attendant has reached 1,755 nationwide.Despite the progress, Nepal is unlikely to bring MMR down to 125 by next year as planned, or meet the Sustainable Development Goal (SDG) target of 70 by 2030. Nepal’s topography and lack of roads are not the only reasons progress in MMR has stalled. According to a recent survey, half of public health facilities in Nepal lack running water and electricity at all times.Bajura District Hospital is constructing a new building, but it still operates out of an old, partly demolished building, where the operation theatre is a tin shed and there is irregular water supply and  electricity.“We hook up machines to the power supply during complicated operations, and the electricity suddenly goes off — we have to improvise a lot here,” says surgeon Durga Maharjan.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b19c7e80680e05999cjpeg.jpg" alt="" width="640" height="427"></figure>Ward at Bajura District HospitalHaemorrhage during birth used to be the biggest cause of maternal mortality in the 1990s, now it is hospital-borne infections like sepsis. Many older women still think babies should be born at home, and dissuade their daughters-in-law from giving birth at a health facility.“There is still the idea that childbirth is a normal, natural thing, and not something you need to visit a hospital for,” says Latika Maskey at the UN Population Fund (UNFPA).Only 30% of women in Bajura go for all four of the antenatal checkups, while the average for the Far West region is 55%, and nationally it is still a high 44%. Because settlements are scattered in roadless remote Nepal, the government has focused on basic health facilities and birthing centres instead of large well-equipped hospitals, explains Punya Poudel at the safe motherhood program in the ministry of health.“We have a roadmap to reduce MMR to 70 by 2030 by focusing on postnatal checkups, midwives will be trained for delivery and community nurses will visit women at home during ante and postnatal periods,” says Poudel.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151124/636a66b49c7e80680e05999djpeg.jpg" alt="" width="640" height="427"><figcaption> </figcaption></figure>However, many of the new birthing centres are near bigger health facilities, which makes them less useful. There is a concern among health professionals that populist agendas have fuelled construction sprees, and that the birthing centres are not always staffed and ready to provide service.“Simply building birthing centres is not the solution. They should be properly mapped and located where they will be most effective. They should be functional so that at least one person is available 24 hours a day to provide simple delivery services,” says Pavan Agarwal at Bayalpata Hospital in nearby Achham district.Neetu Shrestha of UNFPA says reproductive health should not be limited to treatment of birth as an event. She says: “To improve maternal health, we need to focus on sex education, invest in <a href="https://www.nepalitimes.com/here-now/nepal-far-from-hitting-contraceptive-target/" target="_blank" rel="noopener">family planning</a> knowledge and methods, ante and post-natal care, and address cultural barriers.”

Federalism leaves Nepal’s medical sector ailing

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141124/636a58c19c7e80680e054852jpeg.jpg" alt="" width="1400" height="933"/><figcaption>WELCOME TO THE WORLD: A child sleeps in a hammock while its parents work in a workshop making idols for the Dasain festival in Kupondol. Photo: GOPEN RAI</figcaption></figure>Giving birth is a life or death issue in Nepal. Even though the maternal mortality rate dropped from 1,000 per 100,000 live births 40 years ago to 239 today, inadequate birthing facilities is still a problem. But attention is now also shifting to preventing pregnancies.There is a big <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/">unmet need for contraceptives</a>: nearly a quarter of women surveyed nationwide in 2016 said they were not using birth control, even if they need it. Social stigma, patriarchy, ignorance and lack of access were reasons.Nepal’s contraceptive prevalence rate is 52%, but in remote Bajura it is only 34%. Although progress is being made, we are still a long way from the government’s target of raising the rate to 75% by 2030.Read also: <a href="https://www.nepalitimes.com/?p=33714&amp;preview_nonce=033aa12640&amp;preview=true" target="_blank" rel="noopener">Nepal far from hitting contraceptive target,</a> Sewa BhattaraiAs our reports in this edition from Bajura and Chitwan show, there are cultural hurdles. With <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/" target="_blank" rel="noopener">husbands away working for long periods</a>, their wives are reluctant to use contraceptives because of what others will say. The result: women suffer unwanted pregnancies, <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener">unsafe abortions</a> and ultimately struggle to take care of large families.Almost every woman who visited a hospital in Bajura on a busy day last month had the same story: their husbands were away and they did not use birth control. Some were suffering from botched abortions.More than 800 abortion cases were registered in Bajura last year. Just one hospital in Achham terminated more than 600 pregnancies in one year. Meanwhile, Nepal’s total fertility rate has dropped from 6 in 1960 to near-replacement level at 2.05 today, and the country’s population growth rate is also down from 2.5% in 1990 to 1.1% today. Surveys in Province 2 and Far-western Province have shown a clear correlation between unwanted pregnancies, child marriage and fertility in regions with entrenched patriarchy.Among Nepalis, 21% use injectable contraceptives, 10% are on pills, 10% use condoms, 8% have IUDs and only 3% have implants. Depo-Provera was among the most used injectables, but it was difficult to administer and painful. Now, the government, with donor support, is field-testing in Nawalpur and Sindhuli a lower-dose injectable called Sayana Press, which could make contraceptives more accessible to women.Interventions like these, the government hopes, will reduce unwanted pregnancies, thus preventing unsafe abortions and reducing the number of women who have to take care of larger families.<a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" target="_blank" rel="noopener">Complications during pregnancy or at childbirth</a> are the leading causes of death among girls aged 15-19 in low-income countries like Nepal. Unwanted pregnancies also hamper women’s education and economic independence, and impact their family life, fuelling an intergenerational cycle of poverty and poor health.Read also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">Implant service providers take contraception to Nepal's poor</a>, Rojita Adhikari

Born in Nepal

https://youtu.be/VaSUaALct0oParvati Thapa, 39, looks lost as she wanders into the district hospital in this isolated northwestern corner of Nepal. She and her husband have walked a whole day to get here, and they just found out she is 19 weeks pregnant.Thapa already has three children, and after they were born she lost four sons one after another. After her menstruation stopped, she suspected menopause but now knows she is pregnant for the eighth time.“My husband is away for months at a time, tending cattle in the mountains. Why should I use <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">family planning</a> when we meet so rarely?” asks Thapa, who looks much older than her age.Read also: <a href="https://www.nepalitimes.com/?p=33648&amp;preview_nonce=5c7e9df60a&amp;preview=true" target="_blank" rel="noopener">Born in Nepal</a>, Sewa Bhattarai<a href="https://www.nepalitimes.com/?p=33648&amp;preview_nonce=5c7e9df60a&amp;preview=true" target="_blank" rel="noopener"> </a>Like most women in the remote mountains, Thapa has never used contraceptives. <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/" target="_blank" rel="noopener">Doing so carries a stigma for married women with migrant husbands</a>, and there are misconceptions about the different methods available. The result is that women suffer unwanted pregnancies, <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener">unsafe abortions</a> and end up with large families they are  unable to take care of.Nepal’s contraceptive prevalence rate is 53%, but in Bajura it is only 34%. Although this is a dramatic improvement from 20 years ago, it is still a long way from the government’s target of 75% contraceptive prevalence by 2030. The fact that the use of modern family planning methods has plateaued since 2006 points to futher deterrences.“The family planning rate is really low in Bajura because a lot of the men migrate to India for work,” says nurse Dhankala Khadka at Bajura District Hospital. “If the husband is away and the wife wants to use birth control, she is often questioned about fidelity and may be ostracised by her community. Even husbands do not support them.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141124/636a58de9c7e80680e054862jpeg.jpg" alt="" width="1400" height="970"/><figcaption>Parvati Thapa went to Bajura district hospital suspecting menopause, but found out it was her eighth pregnancy. Photo: MONIKA DEUPALA</figcaption></figure>Almost every woman who visited nurse Khadka on a busy day last month had the same story: their husbands were away and they did not use birth control.There were 804 abortions in Bajura in the past year, which Rohit Giri of Bajura District Hospital says is very high: “Most who come to us are married women with children, and the abortions are due to the lack of birth control, which leads to unwanted pregnancies.”<a style="background-color: #ffffff; letter-spacing: 0.15px;" href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">In Bayalpata Hospital</a> in neighbouring Achham district, the story is much the same — it performed 660 abortions in the past year. Bhawana Rawal, 33, has had two abortions at the hospital in the past five years and admits she does not used birth control.Read also: <a href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/" target="_blank" rel="noopener">Migrating males and population decline</a>, Om Astha Rai“I already have two children, and do not need any more, but I got pregnant twice by accident,” she says. “I still do not want to use contraceptives in future.” Rawal did try a Depo-Provera injection once but says it made her bleed too much. Other women have the same complaint. For those who do not want to use a permanent contraception, many felt pills were a hassle to acquire and take every day, and IUDs hurt.“Unwanted pregnancies often lead to anaemia because women lose so much blood,” says Kalawati Setthi, a nurse at Bayalpata Hospital. Nearly 40% of women in Far-western Nepal were found in a survey to be anaemic — most of them pregnant and <a href="https://www.nepalitimes.com/banner/back-to-the-nipple-in-nepal/" target="_blank" rel="noopener">breastfeeding</a>.The government has put up posters in rural hospitals to encourage contraceptive use but at this rate, it is unlikely that the target of 75% contraceptive use will be reached.<h2>Demand, but no supply</h2>According to the Nepal Demographic and Health Survey (NDHS) 2016, there is a 24% unmet need for family planning in Nepal — a quarter of women who need contraceptives are not using them. A report by Population Services international (PSI) Nepal found that unmarried youth aged 15-24 and married women aged 20-24 are the groups that use contraceptives the least.Married women like Parvati Thapa at a clinic in Bajura last month (left), normally tended to use contraceptives after their first child, and exposure to information about family planning through health workers and current users of family planning, as well as talking about it with husbands or relatives.Unmarried youth were likely to discuss family planning only with their sexual partners and most used condoms over other methods, which were bought and kept by the male partner. In contrast, married women visited health facilities themselves and chose the type of method they wanted.Unmarried youth, especially adolescents, had a higher unmet need and were more vulnerable to stigma associated with family planning. The report argues that the term ‘family planning’ only applies to married women and their plan to have children, whereas there are many contraceptive users who have no intention of having children, or use contraceptives to prevent sexually-transmitted diseases (STDs).Read also: <a href="https://www.nepalitimes.com/banner/child-marriage-in-nepal-eloped-at-13-mother-by-17/" target="_blank" rel="noopener">Child marriage in Nepal, eloped at 13, mother by 17</a>, Sewa BhattaraiWhen a woman goes to a public health facility for contraceptives, a register is filled out, which includes a column for ‘husband’s name’, which is another deterrent for unmarried women. Though the husband’s name is optional, there is no column for the wife’s name when it comes to male contraceptives like condoms or a vasectomy.A report by the UN Population Fund (UNFPA) about sexual and reproductive health says complications in pregnancy and childbirth are the leading cause of death among girls aged 15-19 in low-income countries like Nepal. Unwanted pregnancies also hamper women’s education and economic independence, and impact their family life, fuelling an intergenerational cycle of poverty and poor health.<h2>More choice for family planning</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141124/636a58e19c7e80680e054863jpeg.jpg" alt="" width="1400" height="1029"><figcaption> </figcaption></figure>Although Nepal’s contraceptive prevalence rate has increased dramatically, from 7% in 1981 to nearly 60% today, social taboos, patriarchy and unavailability mean that many women still do not have access to birth control.It usually falls on women to take the initiative, since many men refuse to use condoms or get a vasectomy. Popular contraceptives used to be the pill or Depo-Provera, an injectable that needs refrigeration and must be taken at a clinic, but the dosage is high and the injection painful.Now, women like Shanti Adhikari, 43, in Chitwan, (pictured, right) who have always used Depo-provera for short-term contraception, have a new choice: Sayana Press.Read also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">Implant service providers take contraception to Nepal's poor</a>, Rojita Adhikari<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141124/636a58e49c7e80680e054864jpeg.jpg" alt="" width="524" height="531">Adhikari’s husband, who works as a security guard in India, will be coming home for Dasain, so she is at the health post in Nawalpur for her Depo-Provera progesterone hormone injection, which prevents pregnancy for three months.But auxiliary nurse midwife Sharada Rimal (pictured, left) tells her about Sayana Press. Its advantages over Depo-Provera are that it comes with its own small needle, the dosage is much smaller, it is less painful and can be self-injected.“Everyone in my neighbourhood comes to this health post for contraceptives, but no one told me about this new injection. The needle looks much smaller, I think I will go with this one,” says Adhikari, 43, as Rimal proceeded to inject her in the thigh.Sayana Press, a successor to Depo-Provera, is being launched in Nepal in two districts: Nawalpur and Sindhuli, by the reproductive health agency Ipas Nepal in coordination with the UK’s Department for International Development (DFID) and the Ministry of Health and Population (MoH). The drug has already been tried and approved, and is available for use in 40 European countries.What sets Sayana apart from Depo-Provera is the smaller dosage (104 mg compared to 150), it comes with its own needle, it can be stored at room temperature and is injected sub-cutaneously (just under the skin), rather than in the muscles like <a href="https://archive.nepalitimes.com/article/from-nepali-press/Ftnp-the-curse-of-the-contraceptive,493" target="_blank" rel="noopener">Depo-Provera</a>.Injectable contraceptives are the most popular reversible contraceptive among women, for a variety of reasons. Adhikari says she does not like pills because she has to remember to take them every day, and, because of her age, she wants to be discreet about using them.While most other methods, like IUCDs, implants, condoms and pills, are visible and can be discovered by others, an injection leaves no traces. 52% married couples use contraceptives in Nepal: 8.9% use injectables, 4.6% are on pills, 4.2% use condoms, 1.4% use IUDs and only 3.3% use implants. 9.8% use other traditional methods. Some have gone for permanent contraception, with 14.7% preferring female Sterilization and 5.5% male Sterilization.“Depo-Provera has been in use for 50 years, but it was so popular and effective not much further research was done on it,” explains Lhamo Yangchen Sherpa of Ipas. “But WHO studies found that a much lower dosage was enough.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141124/636a58e69c7e80680e054865jpeg.jpg" alt="" width="478" height="531">Health workers like Rimal confirm that Sayana Press is much easier to inject, more portable and less painful. Though it is self-injectable in some countries, in Nepal, where it has been undergoing trials in 14 health facilities of Nawalpur and Sindhuli since 5 September, it will only be administered by health professionals.Bhim Singh Tinkari of the MoH Family Welfare Division says that since 7% of pregnant women still die from unsafe abortions, making contraceptives easily accessible can save lives. Binod Bindu Sharma of the MoH links contraceptives to women’s choice and empowerment. “The availability of contraceptives is important for women’s rights, since it lets women choose when and how many children to have,” says Sharma, adding that the ministry is making Sayana Press available for free in health facilities.Lisa Honan, head of DFID Nepal, links contraceptives with women’s economic potential, adding that the country can make better use of women in the workforce if they have better choices of contraceptives. “DFID is committed to providing Sayana in any volume in Nepal until 2022 through UNFPA (the UN Population Fund), and would help Nepal scale it up all over the country if the results of the feasibility study are positive.”

Nepal far from hitting contraceptive target

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171116/63692fbf9c7e80680e03c0c0jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Mata Luhar, 55, of Badimalika Municipality, with her granddaughters. After the death of her husband, a shepherd, her two sons now work in Mumbai as security guards. Her name is not included in the list of the poor. Photos: NIMENDRA SHAHI</figcaption></figure>The Poor Household Identity Cards Program was designed as a social safety net for the poorest in the most isolated parts of Nepal, but it has been hijacked by local movers and shakers.The program uses 18 indicies like household fuel, access to education and social status to determine those who live below the poverty line. The pilot phase has been implemented in 25 districts including <a href="http://archive.nepalitimes.com/article/from-nepali-press/Health,4099">Bajura</a> and <a href="https://www.nepalitimes.com/banner/from-nowhere-to-nowhere/">Bajhang</a> here in Province 7.Past surveys showed 64% of people in Bajura living below the poverty line, but that has grown to 71%. Similarly, Bajhang, which had 57% poor in 2009, now has 63% living below the poverty line. Why is this happening if the national poverty rate has gone down from 46% to 24%?The answer: the real number of poor has not grown, it is just that the well-off have gotten their names on the list to claim benefits. Households earning less than Rs19,600 a year fall under Category A extreme <a href="https://archive.nepalitimes.com/regular-columns/guest-editorial/leapfrogging-poverty-in-Nepal-guest-editorial,960">poverty</a>. Those with less than Rs31,600 fall into the Category B, and Category C covers those who earn less than Rs40,000 a year.Even people who earned Rs25,000 a month and with property in the cities got themselves into the Category A list of the poorest. When asked, all of them said they have no idea who put them there. Most of the real poor are not listed, and even if they are, they fall in Category B or C.Janak Raj Giri is a well-known Bajura lawmaker from the NC, and even served as assistant minister for land reform in the Deuba government in 2002. His ID number in the poorest category is 266240. Giri says he has no idea how his name got there: "My mother was at home during the data collection, I was away. I do not know anything.”Rajit Bika is a sharecropper in Giri’s farm, but is not in the list or poor. Bika is a member of Haliya community of former slaves.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171116/63692fc39c7e80680e03c0c1jpeg.jpg" alt="" width="689" height="704"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171116/63692fc59c7e80680e03c0c2jpeg.jpg" alt="" width="690" height="704"><figcaption> </figcaption></figure>Ajay Bahadur Malla’s ID number is 269556. Far from being poor, he has served as UML District DDC member twice. Last year, he stood for the chair of Himali Rural Municipality, but was defeated and now runs a welding workshop and a transport company in Martadi. He also claimed he had no idea how he came to be classified as poor.Narabir Kami is the father of Rupchandra Biswakarma, a physician who heads the Bajura District Health Office. His name is listed in Category B (ID Number 216020). When asked, Biswakarma said, "I do not know how my father’s name got there. If true, I will have it removed.”It is the same story with accountant Khambir Buda, health coordinator Bhakta Kaila, Brij Bahadur Bam the father of school principal Prakash Bahadur Bam, and Ratna Bahadur Malla, the father of another teacher Dev Kumari.The list of well off people on the poverty list is a long one. The government prepared it after a survey and issued ID cards for those categorised as poor. Though the full benefits have not been announced, up to Rs50,000 will be provided for medical expenses and a Rs25,000 insurance to poor households with five members. It will pay 100% insurance premium for Category A, 75% for Category B and 50% of the fee for Category C poor.It has been ten years since the government banned <a href="http://archive.nepalitimes.com/article/nation/Modern-day-domestic-slaves-domestic-workers,3785">bonded laborers</a>, and although 1,500 Haliyas have been identified in Bajura, they have not been resettled and have received no compensation. Many still plough the fields of their former masters, and are not in the list of poor. Accountant Khambir Budha has got himself registered as a Category C poor, but Birkha Bhiyal, who works in his farm is not included.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171116/63692fc79c7e80680e03c0c3jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>The situation in neighbouring Bajhang is no different. When he heard that his neighbours Dhan Bahadur Sunar and Pyaru Sunar were among the Category C poor, Gagan Badi was surprised because they are his employers.“How can this happen? They are landowners, since when were they poor? Maybe they paid off people to be declared poor,” said Gagan Badi, visibly irate.The Badi community in Bajhang are often victims of loan sharks who charge exorbitant interest, doctor documents and forge signatures. Yet, they are now ‘poor’, while the farmers they exploit are not on the list. In fact, four landless Badi families who beg on the streets are not in the list.The abuse of the poverty list is widespread in both districts. Rana Bahadur Kathayat heads the Bajhang District Post Office, owns a four-storey house in Chainpur, has his own vehicle and property. But he is listed as Category C poor.“I don’t understand on what basis they collected the data,” says Municipality chair Akkal Dhami, “the rich people are listed as poor while the poor are not listed.”Principal Wakil Bahadur Singh of Bannichaur School is the richest man in the village. He owns houses in Mahendranagar and Dhangadi and property in Kathmandu, Kanchanpur and Bajhang. He is Category A.It became so embarrassing that Bungal Municpality has stopped the distribution of IDs for the poor. “All the rich people from here have been enlisted as Category A, it is a travesty,” says Mayor Dhan Bahadur Bista.Other <a href="http://archive.nepalitimes.com/article/nation/trial-error-democracy,3713">local bodies</a> in Bajhang have also held back ID distribution. Barka Rokaya, Chair of Khaptad Chhanna Municipality said IDs will be handed out only after a through verification of the beneficiaries. Says Govind Malla of Himali Municipality of Bajura district: “The list has excluded the poor people. It is dominated by well-off people. We will correct the list.”Additional reporting by Basant Pratap Singh in Bajhang for Centre for Investigative Journalism- Nepal.Read also : <a href="https://archive.nepalitimes.com/article/editorial/Nepal-%20Multidimensional-Poverty-Index,4115">28.6%</a>, Editorial Readers writeBreathtaking moral and financial corruption. Couldn't have happened without local authority's complicity.- <a href="https://www.facebook.com/dipankar1?fref=ufi">Dipankar De Sarkar</a>Excellent work by the journalist! Depressing to the extreme. The faces and dress of those who have been excluded tell the story of their pressing need for some support. Shame on the well-off for exploiting the system to their own advantage.-<a href="https://www.facebook.com/profile.php?id=100009545858803&amp;fref=ufi">Sam Cowan</a>I am amazed at how people try to act innocent by saying I didn´t know I was listed there. But I have a feeling the same people will stand in a queue to collect the benefit. It's almost comical how everyone tries to come clean. The person responsible for collecting the data has a lot to answer for. Also great work on the part of journalist who broke the story.-<a href="https://www.facebook.com/samyek.shrestha?fref=ufi&amp;rc=p">Samyek Shrestha</a>So the fake poor claim not to know how their name got in the list... have they been using the facilities granted to their respective ID categories? If so, then they should be made to pay back all they have received; if they are honest, they would have told the authorities there was a mistake.-<a href="https://www.facebook.com/kalps.para?fref=ufi">Kalps Para</a>This is so commonplace in India-- those known as BPL families are the richer ones in the villages whereas the poorest one have the APL cards. I am not surprised that being a neighbor, Nepal is following suit. There should have been in-depth learning to understand the process in order to omit such situations before something is implemented. In this case, a study of this system in the neighboring country could have been done and a better plan could be devised to avoid such things.-<a id="js_ml" dir="ltr" href="https://www.facebook.com/namsnanu?fref=ufi&amp;rc=p" target="_self" data-ft="{&quot;tn&quot;:&quot;;&quot;}" data-hovercard="/ajax/hovercard/hovercard.php?id=1110662181&amp;extragetparams=%7B%22is_public%22%3Atrue%2C%22hc_location%22%3A%22ufi%22%7D" aria-describedby="u_12_1" aria-owns="">Namrata Sharma</a>

Nepal’s fake poor

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922ea9c7e80680e03a154jpeg.jpg" alt="" width="1000" height="750"/><figcaption>A villager in Maspur, Humla weaves a doko basket from strips of bamboo.</figcaption></figure>“Jai grihasthi” is a greeting heard often in the <a href="http://archive.nepalitimes.com/blogs/kundadixit/2013/03/13/not-so-far-west/" target="_blank" rel="noopener">Far West</a> and <a href="https://www.nepalitimes.com/banner/the-karnali-on-canvas/" target="_blank" rel="noopener">Karnali </a>regions of Nepal, and is a way to wish each other success in life, livelihood, household and family.Here in Maspur village above Kawadi Khola, on the border between <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/northwestern-tip-of-nepal-Humla,3430" target="_blank" rel="noopener">Humla </a>and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Badimalika-a-ridge-too-far,3328" target="_blank" rel="noopener">Bajura </a>districts, a strenuous two-day walk from the nearest road, it is a daily struggle for people to meet basic needs.Historically, people here flourished as traders, using goats and sheep as pack animals to carry grain from the plains up to Tibet, and bartering it for salt on the plateau. But the region now suffers from <a href="http://archive.nepalitimes.com/news.php?id=18119#.W6zEjXszaUk" target="_blank" rel="noopener">food insecurity</a>, health problems, and lack of livelihood options.The reasons include the end of the Tibet trade, the emergence of roads and markets, a decrease in livestock numbers caused by new grazing restrictions, the destruction of local infrastructure during the <a href="http://archive.nepalitimes.com/news.php?id=15778#.W6zKwnszaUk" target="_blank" rel="noopener">Maoist insurgency</a>, and an increase in population.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922ed9c7e80680e03a155jpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922f09c7e80680e03a156jpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922f49c7e80680e03a157jpeg.jpg" alt="" width="1000" height="750"><figcaption> </figcaption></figure>Most now farm for a living, but agricultural yields are low because of the steep terrain, lack of irrigation, destruction of crops by pests, and antiquated technology. Most families can grow enough food to last only four or five months of the year. For the remaining, they must purchase or borrow food. But cash is scarce, so people rely heavily on subsidised food and loans.The nearest health post is a two-day walk away, time that farmers cannot afford, particularly during the busy harvest seasons. <a href="https://archive.nepalitimes.com/page/resistance-to-live-saving-drugs-threatens-to-set-back-progress-in-nepal" target="_blank" rel="noopener">Tuberculosis </a>and gastrointestinal illnesses are pervasive and exacerbate the symptoms of <a href="https://archive.nepalitimes.com/article/nation/malnutrition-stunting-wasting,3603" target="_blank" rel="noopener">malnutrition</a>. Many homes do not have <a href="https://www.nepalitimes.com/opinion/where-to-take-a-dump/" target="_blank" rel="noopener">toilets</a>, and hygiene is poor.Women and the 'lower' castes are especially disadvantaged. Women have limited mobility and control over household resources, and Dalits have very little land or education, and suffer discrimination.“I do not even know if we are Nepali citizens ... we Dalits are neglected and oppressed. We have little property, nobody looks after us, not the government, not the organisations, not the gods,” says Romalal Lwaar.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922f69c7e80680e03a158jpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922f99c7e80680e03a159jpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636922fd9c7e80680e03a15ajpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure>Kathmandu has neglected this part of Nepal, abandoning its people. The elected village council chairman Bagdal Malla said, “We have little budget, but a lot of work to be done. We do not have roads, and transport makes things expensive.”Everyone’s priority here is more roads so farmers have access to services and markets. Roads will also make it easier for government and NGO staff to be more effective.Said local Rajbahadur Budha, “We have a lot of resources, from our fields and natural resources. If there was a road, we could sell them. There would be more people travelling here, and more business. Without the road, there is no development.”As roads and markets become more accessible, communities here need to add value to their products so they are marketable. Some possibilities include cultivation and processing of medicinal and aromatic plants and high-value mushrooms or herbs, production of wool handicrafts, cheese, honey, and sustainable harvesting and processing of forest products. These activities need minimal external inputs, and can be achieved through skills trainings, mentorship, and micro-grants.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636923009c7e80680e03a15bjpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636923039c7e80680e03a15cjpeg.jpg" alt="" width="1000" height="750"><figcaption> </figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636923069c7e80680e03a15djpeg.jpg" alt="" width="800" height="1067"><figcaption> </figcaption></figure>Subsistence farmers need help to improve work efficiency and reduce the labour burden. Harvests can be increased with irrigation, <a href="https://nepalitimes.atavist.com/" target="_blank" rel="noopener">bio-pesticides</a> recharging-the-mountains-, greenhouses, and community seed banks. Improved technology such as better water mills, electricity, reliable mobile network, and fuel-efficient stoves will make work easier.There is an urgent need for <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">better health care</a> and education. Existing health posts need maintenance and medicines, and additional health posts are required in remote areas. Hygiene education and encouraging women to use health services for deliveries and check-ups are also important.Women and members of ‘lower’ castes must be prioritised in these activities and in accessing technologies, micro-loans, and other resources.Currently, service delivery and other development activities are sporadic and ad-hoc. Sufficient resources must be allocated to allow for long-term, consistent engagement with the community. Outcomes should be regularly monitored and evaluated for lasting improvements.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107161120/636923089c7e80680e03a15ejpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure>As Nepal urbanises, fewer and fewer people in the rest of the country understand the struggles in places like Maspur village. The first step to rectifying this is education and awareness of the living conditions of rural Nepalis and the acknowledgement that they, too, have the right to a secure and healthy life.It is only when the needs and hopes of Nepalis who have been historically and systematically disempowered are properly incorporated into national policies and development plans that we can wish the people in places like the Kawadi Khola valley ‘Jai grihasti’.Jocelyn Powelson is a Fulbright researcher from the United States who spent three months in Humla this year

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