The Embassy of Japan in Kathmandu is providing Bayalpata Hospital in Achham district to install up-to-date medical equipment as part of its effort to improve healthcare in remote parts of Nepal. The contract for the assistance was signed on Friday between the new Japanese Ambassador Maeda Toru and Kunda Dixit, the Chair of Nyaya Health Nepal which runs the hospital at Bayalpata.&nbsp; Nyaya Health Nepal was set up in 2008 to improve rural healthcare, and has since provided free world class treatment with specialised care free of cost to 1.3 million patients in the far west region of the country.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100116_0c4fea12fa18ebd1952dde7abe53e9de7a6371b8364b6a7ad00ec72267935eb8.jpg" data-media-id="editor_0" data-image-id="20250131100116_0c4fea12fa18ebd1952dde7abe53e9de7a6371b8364b6a7ad00ec72267935eb8" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100116_898086105d50414e81d5a78bf4b436f8ee1005b876fa7deb28988a9bbf625948.jpg" data-media-id="editor_1" data-image-id="20250131100116_898086105d50414e81d5a78bf4b436f8ee1005b876fa7deb28988a9bbf625948" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>  In that time, the medical need of the region has changed from mainly infectious diseases to lifestyle-related chronic ailments as well as an increase in trauma patients.&nbsp; "I have learnt that Nyaya Health Nepal is improving access to healthcare for underserved communities in rural Nepal, including providing free medical services at Bayalpata Hospital in one of the most remote areas of the country,” Ambassador Toru said at the signing ceremony. “The hospital is the core medical institution in the Achham district and surrounding areas, especially for critical surgeries."  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131140128_6307d1200c5eecb01964be3a6d6428719d8eee30b801a48c201ad9efe8ae875d.jpg" data-media-id="editor_2" data-image-id="20250131140128_6307d1200c5eecb01964be3a6d6428719d8eee30b801a48c201ad9efe8ae875d" data-rendition-name="original" width="1179" height="1159" loading="lazy" alt="Japanese aid to Bayalpata Hospital NT"> <figcaption>Photo: EMBASSY OF JAPAN</figcaption> </figure>  The $66,263 contract is under the Grant Assistance for Grassroots Human Security Project (GGP) of the Japanese government, and will finance the purchase of a Digital X-ray flat panel unit, USG Machine, &nbsp;and C-arm imaging device that produces high resolution x-ray images of patients in real time.&nbsp; “The grant will help our surgeons and doctors at Bayalpata provide more timely diagnosis, more reliable surgeries and treatment,” Dixit said. "In the last 15 years, the need of the people of Sudurpaschim Province has changed from infectious diseases to chronic ailments and trauma, and the hospital has tried to adapt accordingly in these underserved parts where access and affordability of quality healthcare is a big challenge." &nbsp;&nbsp; Nyaya Health Nepal runs Bayalpata under its Integrated Municipal Healthcare model where community nurses go house-to-house to monitor the status of family members and record it all under its Electronic Health Record (EHR) system. Patients then have to spend money to go to hospital only if it is really needed.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100112_bddac95af4869c0cfe696e2f1d804466f956cfe4f8afe8f6da73d444d638b8e4.jpg" data-media-id="editor_3" data-image-id="20250131100112_bddac95af4869c0cfe696e2f1d804466f956cfe4f8afe8f6da73d444d638b8e4" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100112_ec263a04c02ee334986bda08910632e8f1795f7bbfc4cfe5a0b74c6df672696c.jpg" data-media-id="editor_4" data-image-id="20250131100112_ec263a04c02ee334986bda08910632e8f1795f7bbfc4cfe5a0b74c6df672696c" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>  Nyaya Health Nepal has deployed its EHR in district hospitals in Karnali Province as well, and handed over Charikot Hospital in Dolakha after the 2015 earthquake before handing it over to the Bagmati Province in 2019.&nbsp; Toru, who has been in Nepal for only three weeks, said that the project will provide better medical services to the people of Sudurpaschim and Karnali provinces through trauma care and orthopedic surgeries at Bayalpata hospital.&nbsp; Added Dixit: "This support will go a long way in strengthening our hospital care. Medical equipment are extremely important, especially digital x-ray, as more and more patients come in for trauma care and emergencies."

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Japanese aid for Bayalpata Hospital

It is nearing 6PM and Mandeep Pathak is on the daily evening round of the in-patient ward at <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital">Bayalpata Hospital</a> in Achham District. The section is crowded with patients young and old.&nbsp; Most have respiratory problems, women with limbs broken in falls from cliffs, some have diabetes, and there is a psychosis patient in an isolation ward. There is wailing from the delivery room of the maternity ward. Pathak’s mobile phone buzzes. He listens, and rushes off to the emergency room. A crowded tractor has fallen off the road and there are mass casualties. The wounded soon arrive, and Bayalpata’s staff go into practised triage mode.&nbsp; The team declares a 12-year-old boy dead on arrival. Others are rushed into x-ray and readied for splints and plaster casts. Some are discharged after treatment to join crowds of waiting relatives outside. Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f.jpg" data-media-id="editor_2" data-image-id="20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f" data-rendition-name="original" width="1400" height="823" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Orthopaedic oncologist Mandeep Pathak consulting a patient at Bayalpata. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  Patients in this isolated hospital in a corner of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">one of Nepal’s most remote districts</a> are from all over Sudur Paschim and Karnali Provinces. One 8-year-old girl with a broken arm has been brought here by her father from Humla, after walking four days to get to a road. In the 14 years since it was established, word has spread that Bayalpata provides high quality service free of cost, and the hospital is treating 100,000 patients a year with a team of dedicated staff, surgery, lab, pharmacy and a high dependency unit.&nbsp; In the maternity ward is a 35-year-old new mother who is quietly taking her supper. She has a shining smile as her husband fusses over her. They are now happy parents of twin boys, their fourth and fifth children.&nbsp; A few beds away is another young mother recuperating from a caesarean delivery. The husband is not happy — the baby is a girl and they already have two daughters. Hospital staff try to persuade him to get a vasectomy, but he still wants to try for a son.&nbsp; Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, Editorial Unlike private hospitals in Nepal, some of which have up to 80% caesarean deliveries, at Bayalpata most births are natural. Doctors do caesareans only on complicated deliveries, or on referral patients. In one recent case a 17-year-old mother died <a href="https://www.nepalitimes.com/here-now/born-by-the-roadside-in-nepal">on the way</a> to Bayalpata from Bajura district. She had twins, only one of whom survived. Another woman who was 30 weeks pregnant suffered a stillbirth, but because it was a girl, the mother-in-law and husband did not look too perturbed.&nbsp; A mother who gave birth after a difficult delivery was nearly bleeding to death from postpartum haemorrhage. While doctors tried frantically to save her life, the family was celebrating the birth of a son.&nbsp; Despite improved literacy, patriarchy is still entrenched in these remote mountains of far west Nepal. Boys are sent to school while girls help with house chores and raise their little brothers. When children fall sick, the boys are likely to be taken to an expensive private hospital in Dhangadi, while girls are brought to free institutions like Bayalpata. Read also: <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">This is how to upgrade Nepal’s rural health</a>, Sewa Bhattarai <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%2FCJzWlnYd0ZM&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> “The paradox here is that girls are getting world-class treatment while boys have to settle for less than optimal healthcare at private facilities,” says Mandeep Pathak, one of few orthopaedic oncologists in Nepal who has been working at Bayalpata for eight years. Pathak examines a 14-year-old girl from Mugu on whom he operated to remove a benign but complicated tumour that had restricted her mobility for the past two years. As he does his evening rounds, Pathak tells us: “Our patients are among the poorest and neediest and from the <a href="https://www.nepalitimes.com/editorial/devolution-for-development">remotest part of the country</a>. They would not have got a correct diagnosis, let alone get timely and affordable treatment otherwise.”&nbsp; The only cost families have to bear is for transport to the hospital. The hospital even provides free food for one relative accompanying the patient. Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar Budathoki  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e.jpg" data-media-id="editor_10" data-image-id="20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Program Associate Bhawana Bogati during a community visit.</figcaption> </figure>  <h2>Community Care</h2> Bayalpata Hospital is managed by the non-profit <a href="https://www.nyayahealthnepal.org">Nyaya Health Nepal (NHN)</a> in partnership with the provincial and municipal governments.&nbsp; Although the hospital gets much of the attention, NHN’s emphasis is on the community that provides door-to-door care to families in Achham. There are up to two <a href="https://www.nepalitimes.com/news/enlisting-female-health-volunteers-to-fight-covid-19-b4qlgy1e">Community Health Workers (CHW) </a>for every ward who regularly visit families to monitor the condition of pregnant women, provide ante-natal care, or check up on those with chronic conditions. This reduces the pressure on the hospital, and also saves families money.&nbsp; CHW can even assist while community nurses perform lab tests including for HIV, hepatitis, urine, sugar, protein, pH level, haemoglobin so patients do not have to come to hospital. The nurses even provide psycho-social counselling, since mental health is still not discussed openly. Aside from healthcare, the female CHWs also demonstrate the important role women can play in this socially conservative society. Jamuna Saud, a 24-year-old CHW, is visiting families in the village of Patalkot, and recording data of patients on her Electronic Health Record app that provides physicians at Bayalpata with instant information on the medical condition of patients in case they need to be taken to hospital. “We are still a male-dominated society here, as you can see, but things are improving,” says Saud, as she climbs up the trail to another family’s homestead. “I have seen families sending daughters to school because they see us being respected for our job. They are starting to treat their own daughters better.” Read also: <a href="https://www.nepalitimes.com/banner/altruistic-healthcare-models-in-nepal">Altruistic healthcare models in Nepal</a>, Yugeshwor Koirala and Yugottam Koirala  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae.jpg" data-media-id="editor_14" data-image-id="20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Bayalpata Hospital"> <figcaption>In 14 years, Bayalpata hospital has treated 1.2 million patients free of cost. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  The work of NHN’s community health program is already seen in Achham district’s health parameters. After a dip during the pandemic, institutional deliveries have climbed again to 80%, and this has sharply reduced <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal">maternal and child mortality</a>.&nbsp; “Mother and child health is our main focus and ensuring that we follow the progress of pregnant women means most now go to Bayalpata to deliver,” says Program Associate Bhawana Bogati, 28.&nbsp; The hospital which recently marked its 15th anniversary has so far treated 1.2 million people free of cost, and sustainability continues to be the biggest challenge for Bayalpata’s public-private partnership with the local government. Half the annual budget still comes from international donors. But more than anything else, Bayalpata is a working example that free quality medical care is possible. Other government district hospitals have larger budgets, treat fewer patients and charge fees. Given the remoteness of Achham, the other challenge is retention of doctors and paramedics. Flights to Sanfebagar are unreliable, and a jeep ride to Dhangadi takes 10 hours. Says surgeon Bhaskar Pant of HAMS Hospital in Kathmandu and a board member of NHN: “Bayalpata is a rural lifeline, we need hospitals like these in the remotest corners of Nepal and to run them we need medical staff who are willing to be posted here.” &nbsp;&nbsp; Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health">Taking wealth out of health</a>, Anita Shrestha Jamuna Saud  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301.jpg" data-media-id="editor_17" data-image-id="20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  Her baby son is only nine months old, but Community Health Worker (CHW) Jamuna Saud is already back to making door-to-door visits to advise other expecting mothers about safe delivery. Her visit today to Patalkot village, a 3 hour drive through rough roads from Bayalpata, is hindered by a sudden thunderstorm, but she is not bothered. “You need to eat for two now, it will not be good if you skip meals,” says Saud as she counsels Pabitra Auji who is six months pregnant with her first baby and looks undernourished. “Fruits, leafy vegetables, meat and egg, and don’t forget to take your iron capsules.”&nbsp; Saud has been a CHW for four years. She had originally wanted to be a doctor or a nurse, and was a class topper in school, but her family could not afford medical school fees. Moreover, young women in her community were expected to get married, not go to college. “Mine was the only family in the neighbourhood that let girls go to school,” recalls Saud. “But my parents passed away when I was in the 9th grade and my brothers were not planning to educate me further. I cried until they admitted me to +2.” Saud moved to Sanfebagar and paid her own way through college, supporting herself by doing odd jobs. She is happy to have been accepted by Bayalpata’s <a href="https://archive.nepalitimes.com/news.php?id=19559">community health program</a>, and feels a personal sense of achievement that childhood diarrhoea, malnutrition and respiratory infections among babies is decreasing, while more women accept family planning advice. Over the years, Saud has seen changes among women like her in Achham. Girls are no longer restricted to just doing housework and producing babies. She says, “I am proud to have contributed to raising the living standard of people here even if by the tiniest bit.” Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial Ramita Bogati  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7.jpg" data-media-id="editor_20" data-image-id="20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  The story of Florence Nightingale was the inspiration for Ramita Bogati, who always wanted to be a nurse herself. Back in her village, girls were actively discouraged from going to school, and were married young so as not to be a drain on the family. “My parents did not actually want to send me to a school but my mother’s side of the family were educated, and many of them were in medicine,” says Bogati. “But I had to prove myself to change my father’s perceptions about what women should be allowed to do.” Today, Bogati is one of 10 Community Health Nurses at Bayalpata overseeing 70 community health workers with her colleagues. Her passion for the job and the importance of the service she provides is all the encouragement she needs. She does not envy her staff nurse classmates who have flown to Australia and other countries. &nbsp; On a typical day, Bogati is involved in early detection of chronic and infectious diseases, tuberculosis and hypertension so that the poorest in the community do not have to borrow money for treatment or, worse, have their lives shortened due to the lack of diagnosis and treatment. Bogati has seen tangible <a href="https://archive.nepalitimes.com/news.php?id=14071">impact</a> of her work in birth spacing. In the past, women here used to give birth to as many as 15 children, and most died young. Now, they give birth to fewer but healthier children. “As a nurse, the concept of community health was new to me but I have seen that we need to look beyond those who are able to come to Bayalpata. If they cannot come to hospital, the hospital needs to go to them.” Read more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

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Nepal’s rural lifeline

<figure><img width="1641" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84419c7e80680e067784jpeg.jpg" alt=""/><figcaption>Services provided from outside of OPD due to Covid cases. Photos: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s rural health system, already underfunded, understaffed and overstretched, is struggling with the enormous added burden of the Covid-19 pandemic.  Having barely coped with the first wave last year, hospitals in the remote mountains of Far-Western Province have found that the variants in the second wave are much more lethal, there are many more patients than before, and more of them require hospitalisation.  In Achham district the administration declared a lockdown on 3 May, but by then the virus was already spreading within families and house-to-house. Till the day before the lockdown, people were still arriving by the busloads from India, Kathmandu and other cities. Testing and tracing were lax, and they were mingling in the markets.  On Sunday, Nepal added 8,850 new confirmed infections, bringing total active cases to 88,160. There were 52 fatalities but 26 more died at home. Kathmandu reported 4,198 cases in the last 24 hours. There are 832 people in ICU across the country, and 267 patients on ventilator support. In the village of Jaygad of Achham, for example, an annual fair with large crowds was being held even as 13 out of 15 sample antigen tests came out positive. The virus was spreading into the remotest villages. “We have increased awareness programs and testing, and local governments have become more active in the recent days and taken more ownership of testing and information dissemination,” says Janakraj Dhungana at Achham’s District Health Office.  But many wonder whether it is too late to be disseminating information through loudspeakers on masking and distancing, when patients and families throng ill-equipped hospitals. Dhungana himself admits that there was not enough testing and isolation because of a shortage of kits.  Like other districts of Far-Western Province, the caseload in Achham is increasing, with 2,183 positive cases and 17 deaths so far. Of this, 511 positive cases and 6 deaths are during this second wave.  The vaccination drive was also suspended after 3,000 medical personnel and community health workers were inoculated. But 15,000 senior citizens in Achham alone still have not got their second doses yet.  <figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84449c7e80680e067785jpeg.jpg" alt=""><figcaption> </figcaption></figure>The government has now asked all hospitals to also treat Covid-19 patients. Bayalpata Hospital in Achham, which is run by the non-profit Nyaya Health Nepal in partnership with the local government, was not a designated Covid-19 hospital during the first wave. This year, it is treating a flood of Covid-19 cases.“We had set aside an entire wing for coronavirus cases, but there has been such a surge in the past week that we have turned the emergency room into a Covid ward,” says Mandeep Pathak, medical director at Bayalpata Hospital. “We converted five rooms set aside for drug-resistant tuberculosis treatment for Covid patients.”Bayalpata is currently treating 26 patients with Covid-19, all of them with low oxygen saturation levels, but new cases are being admitted every day. The hospital has also had to reassign eight rooms for Covid-19 patients, including for 14 of its own staff who have tested positive. In Dadeldhura Hospital a four-hour drive to the west, all 31 beds are full with Covid-19 patients, and although there are only five ICU beds, 13 patients are receiving intensive care. In the neighbouring district of Doti, it is the same story.“Even if we have beds, we have no oxygen, it is a vicious cycle,” says Jagdish Bista, Medical Superintendent at Dadeldhura District Hospital. “The most urgent need now is oxygen, and we are also running out of PPEs.” But what worries the doctor more is the 50-70% positivity rate of testing, and what this means for the next two weeks.For the time being, the nursing staff shortage has been alleviated with new transfers. But Dadeldhura Hospital’s oxygen plant cannot cope with demand, and there are difficulties to get cylinders refilled in Nepalganj and Dhangadi. Covid-19 has taken precedence over other cases, apart from emergencies and deliveries. Most patients are in the 30-year-old range, and those turned away seek help in Dhangadi’s Seti Hospital, which is also inundated.Patients who can get to hospital and get admitted in this remote region are the lucky ones. Local municipalities have built isolation centres, but most are empty because there is no oxygen and no medical personnel, says Devraj Devkota of Panchadeval Binayak municipality. <figure><img width="1753" height="2409" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84479c7e80680e067786jpeg.jpg" alt=""><figcaption> </figcaption></figure>“Our people prefer to either isolate at home or try to get to a hospital if their condition deteriorates,” he adds. “We have had no help from Kathmandu.”But Nepal’s cities, including in the capital, are also out of hospital beds and oxygen, so there is little hope for outside help. In fact, a reverse flow is starting: critical Covid-19 patients in Kathmandu are being helicoptered to Jhapa or Kaski where there are still hospital beds with oxygen.The need in every municipality in the far west is the same: oxygen cylinders, pulse oximeters and testing kits, and additional hospital beds for serious cases.Says Achham’s District Health Officer Dhungana: “Oxygen is a problem. We depend on Dhangadi and Nepalganj to refill cylinders. They get used up fast, which has made it a logistical challenge.” There is also a critical shortage of staff. Despite vacancy notices, there were few applicants for specialised medical personnel even pre-pandemic. For example, although the District Hospital in Mangalsen has ventilators, there is no one to run them, and there isn’t enough oxygen.Patient referrals to city hospitals offering critical care, or just beds with oxygen, are also complicated. They are also overwhelmed, and there are few ambulances with oxygen for the 8-12 hour journey across mountain highways. Ambulances are expensive, and helicopter air lifts are even more costly. Despite this, desperate families have taken loans to try to save family members in critical conditions by air lifting them to city hospitals—often too late. Then there are all the other non-Covid trauma patients needing urgent surgery, or maternity cases. With its free treatment, Bayalpata Hospital has served more than 1 million patients from Achham and six surrounding districts of Karnali and Far-West Provinces in the past 12 years. Separating Covid-19 and other cases is a challenge for doctors like Mandeep Pathak (pictured right) who do not like to turn patients away. Even though the height of the pandemic this week, the orthopaedic surgeon has performed 15 operations, including on a 13-year-old boy from Kalikot with a fractured leg. In the past month, Bayalpata Hospital has performed 77 deliveries, of which eight were caesarean sections. “The staff adjust, innovate, accommodate, reallocate, adapt and have kept working right through the pandemic,” Pathak says. <img width="1906" height="1398" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b844b9c7e80680e067787jpeg.jpg" alt="">New health protocols have been adapted to minimise disruptions, and Bayalpata is seeking resources to help with the crisis. There is fear that regular services will be increasingly impacted as the pandemic peaks.  The lockdown also means that families may wait till the very last moment to take patients to hospitals, by when it is usually too late. Bayalpata Hospital has therefore modified some of its regular services to remote care via phone calls. Bayalpata Hospital’s community health program, for example, that provides regular group antenatal care to pregnant women has been severely impacted. While the program was offered throughout the first wave, it has been interrupted during the second wave, and staff have had to resort to phone-based counselling and follow-up unless in case of emergencies.  The fear is that far-flung and traditionally neglected districts like Achham will be the last to get test kits, PPEs, oxygen, hospital beds and eventually vaccines. The progress Nepal has made over decades in rural healthcare is being undone by the pandemic.  For offers of assistance to hospitals in Far-Western Nepal, contact: Bayalpata Hospital: <a target="_blank" rel="noopener noreferrer">srijana.devkota@nyayahealthnepal.org</a> +977 9851093920   Dadeldhura Hospital: +977 9858753201 (Dr Jagadish Bista) <a href="https://give2asia.org/covid-19-pandemic-response-nepal/" target="_blank" rel="noopener noreferrer">https://give2asia.org/covid-19-pandemic-response-nepal/</a>

At the Covid-19 frontlines in rural Nepal

<figure><img width="1641" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec639c7e80680e09ad61jpeg.jpg" alt=""/><figcaption>Services provided from outside of OPD due to Covid cases. Photos: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s rural health system, already underfunded, understaffed and overstretched, is struggling with the enormous added burden of the Covid-19 pandemic.  Having barely coped with the first wave last year, hospitals in the remote mountains of Far-Western Province have found that the variants in the second wave are much more lethal, there are many more patients than before, and more of them require hospitalisation.  In Achham district the administration declared a lockdown on 3 May, but by then the virus was already spreading within families and house-to-house. Till the day before the lockdown, people were still arriving by the busloads from India, Kathmandu and other cities. Testing and tracing were lax, and they were mingling in the markets.  On Sunday, Nepal added 8,850 new confirmed infections, bringing total active cases to 88,160. There were 52 fatalities but 26 more died at home. Kathmandu reported 4,198 cases in the last 24 hours. There are 832 people in ICU across the country, and 267 patients on ventilator support. In the village of Jaygad of Achham, for example, an annual fair with large crowds was being held even as 13 out of 15 sample antigen tests came out positive. The virus was spreading into the remotest villages. “We have increased awareness programs and testing, and local governments have become more active in the recent days and taken more ownership of testing and information dissemination,” says Janakraj Dhungana at Achham’s District Health Office.  But many wonder whether it is too late to be disseminating information through loudspeakers on masking and distancing, when patients and families throng ill-equipped hospitals. Dhungana himself admits that there was not enough testing and isolation because of a shortage of kits.  Like other districts of Far-Western Province, the caseload in Achham is increasing, with 2,183 positive cases and 17 deaths so far. Of this, 511 positive cases and 6 deaths are during this second wave.  The vaccination drive was also suspended after 3,000 medical personnel and community health workers were inoculated. But 15,000 senior citizens in Achham alone still have not got their second doses yet.  <figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec669c7e80680e09ad62jpeg.jpg" alt=""><figcaption>Bayalpata Hospital in Achham run by the non-profit Nyaya Health Nepal is treating a flood of Covid-19 cases.</figcaption></figure>The government has now asked all hospitals to also treat Covid-19 patients. Bayalpata Hospital in Achham, which is run by the non-profit Nyaya Health Nepal in partnership with the local government, was not a designated Covid-19 hospital during the first wave. This year, it is treating a flood of Covid-19 cases.“We had set aside an entire wing for coronavirus cases, but there has been such a surge in the past week that we have turned the emergency room into a Covid ward,” says Mandeep Pathak, medical director at Bayalpata Hospital. “We converted five rooms set aside for drug-resistant tuberculosis treatment for Covid patients.”Bayalpata is currently treating 26 patients with Covid-19, all of them with low oxygen saturation levels, but new cases are being admitted every day. The hospital has also had to reassign eight rooms for Covid-19 patients, including for 14 of its own staff who have tested positive. In Dadeldhura Hospital a four-hour drive to the west, all 31 beds are full with Covid-19 patients, and although there are only five ICU beds, 13 patients are receiving intensive care. In the neighbouring district of Doti, it is the same story.“Even if we have beds, we have no oxygen, it is a vicious cycle,” says Jagdish Bista, Medical Superintendent at Dadeldhura District Hospital. “The most urgent need now is oxygen, and we are also running out of PPEs.” But what worries the doctor more is the 50-70% positivity rate of testing, and what this means for the next two weeks.For the time being, the nursing staff shortage has been alleviated with new transfers. But Dadeldhura Hospital’s oxygen plant cannot cope with demand, and there are difficulties to get cylinders refilled in Nepalganj and Dhangadi. Covid-19 has taken precedence over other cases, apart from emergencies and deliveries. Most patients are in the 30-year-old range, and those turned away seek help in Dhangadi’s Seti Hospital, which is also inundated.Patients who can get to hospital and get admitted in this remote region are the lucky ones. Local municipalities have built isolation centres, but most are empty because there is no oxygen and no medical personnel, says Devraj Devkota of Panchadeval Binayak municipality. <figure><img width="1753" height="2409" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec699c7e80680e09ad63jpeg.jpg" alt=""><figcaption>Achham District made this urgent plea for equipment last week.</figcaption></figure>“Our people prefer to either isolate at home or try to get to a hospital if their condition deteriorates,” he adds. “We have had no help from Kathmandu.”But Nepal’s cities, including in the capital, are also out of hospital beds and oxygen, so there is little hope for outside help. In fact, a reverse flow is starting: critical Covid-19 patients in Kathmandu are being helicoptered to Jhapa or Kaski where there are still hospital beds with oxygen.The need in every municipality in the far west is the same: oxygen cylinders, pulse oximeters and testing kits, and additional hospital beds for serious cases.Says Achham’s District Health Officer Dhungana: “Oxygen is a problem. We depend on Dhangadi and Nepalganj to refill cylinders. They get used up fast, which has made it a logistical challenge.” There is also a critical shortage of staff. Despite vacancy notices, there were few applicants for specialised medical personnel even pre-pandemic. For example, although the District Hospital in Mangalsen has ventilators, there is no one to run them, and there isn’t enough oxygen.Patient referrals to city hospitals offering critical care, or just beds with oxygen, are also complicated. They are also overwhelmed, and there are few ambulances with oxygen for the 8-12 hour journey across mountain highways. Ambulances are expensive, and helicopter air lifts are even more costly. Despite this, desperate families have taken loans to try to save family members in critical conditions by air lifting them to city hospitals—often too late. Then there are all the other non-Covid trauma patients needing urgent surgery, or maternity cases. With its free treatment, Bayalpata Hospital has served more than 1 million patients from Achham and six surrounding districts of Karnali and Far-West Provinces in the past 12 years. Separating Covid-19 and other cases is a challenge for doctors like Mandeep Pathak (pictured right) who do not like to turn patients away. Even though the height of the pandemic this week, the orthopaedic surgeon has performed 15 operations, including on a 13-year-old boy from Kalikot with a fractured leg. In the past month, Bayalpata Hospital has performed 77 deliveries, of which eight were caesarean sections. “The staff adjust, innovate, accommodate, reallocate, adapt and have kept working right through the pandemic,” Pathak says. <img width="1906" height="1398" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec6c9c7e80680e09ad64jpeg.jpg" alt="">New health protocols have been adapted to minimise disruptions, and Bayalpata is seeking resources to help with the crisis. There is fear that regular services will be increasingly impacted as the pandemic peaks.  The lockdown also means that families may wait till the very last moment to take patients to hospitals, by when it is usually too late. Bayalpata Hospital has therefore modified some of its regular services to remote care via phone calls. Bayalpata Hospital’s community health program, for example, that provides regular group antenatal care to pregnant women has been severely impacted. While the program was offered throughout the first wave, it has been interrupted during the second wave, and staff have had to resort to phone-based counselling and follow-up unless in case of emergencies.  The fear is that far-flung and traditionally neglected districts like Achham will be the last to get test kits, PPEs, oxygen, hospital beds and eventually vaccines. The progress Nepal has made over decades in rural healthcare is being undone by the pandemic.  For offers of assistance to hospitals in Far-Western Nepal, contact: Bayalpata Hospital: <a target="_blank" rel="noopener noreferrer">srijana.devkota@nyayahealthnepal.org</a> +977 9851093920   Dadeldhura Hospital: +977 9858753201 (Dr Jagadish Bista) <a href="https://give2asia.org/covid-19-pandemic-response-nepal/" target="_blank" rel="noopener noreferrer">https://give2asia.org/covid-19-pandemic-response-nepal/</a>

<figure><img width="1570" height="940" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be2179c7e80680e083e89jpeg.jpg" alt=""/><figcaption>Charikot Hospital in 2015 after it was upgraded from a primary health care centre by Nyaya Health Nepal. Photo: Nyaya Health Nepal. </figcaption></figure>In one of the few arrangements of its kind in Nepal, a public-private partnership initiative has handed over to the local government the management of Charikot Hospital which had been run by a private non-profit organisation <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/building-back-better-health-facilities,2980" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/article/Nepali-Times-Buzz/building-back-better-health-facilities,2980&amp;source=gmail&amp;ust=1606125430794000&amp;usg=AOvVaw0J3sDGN8guCJPn5fY-UA5M">ever since the earthquake five years ago</a>. Bhimeswar Municipality took over the hospital from the group Nyaya Health Nepal on 30 October in an innovative and successful DBOT (Design, Build, Operate, Transition) model which is significant in Nepal’s new federal structure where local governments take on more responsibility for grassroots healthcare delivery.This is especially remarkable considering that improving public sector healthcare, especially in rural areas, has been a challenge in Nepal. The country’s already under-resourced healthcare is also under strain because of the Covid-19 pandemic. Nyaya Health signed an agreement with the Ministry of Health in 2015 to rebuild the <a href="https://archive.nepalitimes.com/article/nation/earthquake-survivors-waiting-to-rebuild,2566" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/earthquake-survivors-waiting-to-rebuild,2566&amp;source=gmail&amp;ust=1606125430794000&amp;usg=AOvVaw19bLuxfgcmw9SWnbrzetxq">damaged healthcare facilities</a> in Dolakha and upgrade the primary healthcare centre in Charikot into a full-fledged hospital. The organisation was building on its experience in Achham where it manages <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/&amp;source=gmail&amp;ust=1606125430794000&amp;usg=AOvVaw1qCyHqyny7Q3qtyJjYIfZS">Bayalpata Hospital</a> under a similar partnership model since 2009. Although there are other similar activities in Nepal’s public health sector, especially in the distribution of healthcare products, there are only a handful examples of partnerships that are for overall management of health institutions. The government's readiness to adopt innovations that have been put in place through the partnership is unique, and unprecedented. <figure><img width="1500" height="805" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be21a9c7e80680e083e8ajpeg.jpg" alt=""><figcaption></figcaption></figure>The transfer of management has been smooth -- Bhimeswar Municipality has retained 40 hospital employees recruited by Nyaya Health, and will continue the internal management procedures, monitoring of quality service, and a digital health information system.In the past five years, Nyaya Health provided more than 335,000 people in Dolakha with direct free health care, repaired 19 earthquake damaged health posts, and handed them over to the local government ensuring the delivery of health services. <figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be21c9c7e80680e083e8bjpeg.jpg" alt=""><figcaption>The handover ceremony of the Charikot Hospital on 30 October to the Bhimeswar Municpality by Nyaya Health Nepal after a unique private-public partnership project. All Photos: NHN</figcaption></figure>The hospital also saw the introduction of digital patient records, development of a performance based system for staff, training and development, expansion of community health and mental health services, addition of infrastructure, equipment and services, and for the past eight months has been at the forefront of an effective Covid-19 response.As a result, Dolakha’s overall health indicators such as the rate for institutional delivery, neonatal mortality and other parameters have seen marked improvements in the catchment area population in the past five years. <figure><img width="799" height="533" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be21f9c7e80680e083e8cjpeg.jpg" alt=""><figcaption></figcaption></figure><figure><img width="1086" height="724" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be2229c7e80680e083e8djpeg.jpg" alt=""><figcaption></figcaption></figure>Patients in the maternity ward of the Charikot Hospital of Dolakha District where the mother child survival rate has improved in the past five years.What was unique was that the Government of Nepal and Nyaya Health Nepal both invested in strengthening healthcare during the partnership period – the government with a community hospital grant, medicine and equipment, human resources and Nyaya Health put in $6.8 million and managed treatment and care in the hospital.Recently, the Bagmati Province government declared Charikot Hospital a ‘provincial hospital’ and this paved the way for additional local investment from the continuity of ongoing services. Under Nepal’s federal structure, every municipality is allotted a budget specifically to improve the local health system. This has increased access to health care, and raised the health status of the local population. Dolakha’s health care system thus literally ‘built back better’ after the earthquake.Under the terms of the handover, Nyaya Health Nepal transferred to Bhimeswar Municipality all fixed assets and consumables worth Rs62.67 million, its digital systems, and the ownership of all data collected for service management and quality improvement.Even after the handover, Nyaya Health Nepal will continue back stopping the Municipality in some areas like technical assistance in managing the Electronic Health Record (EHR), monitoring and evaluation, and service improvement till the end of this fiscal year. Nyaya Health, in turn can use data from the hospital for research, including for ongoing projects.Specialist services with consultants have also been arranged keeping in view the needs of the patients. The federal or provincial governments need to manage the necessary Rs2.5 million per month for specialist care, which are beyond the coverage of basic health services.The municipality has set up an inter-municipal fund to ensure access to care, particularly for the underprivileged at Charikot Hospital, which is providing services also as a referral hospital for the surrounding municipalities and districts.This handover proves that strengthening healthcare is possible only through a multi-dimensional partnership with short-term support, innovation in healthcare delivery and management, long-term planning and resource management. Ultimately, it is the government’s responsibility to ensure healthcare for all, and partnerships like these are useful to jump-start the process. Nepal has established itself as a modern progressive and welfare state, with the Constitution pledging to make basic healthcare a fundamental right of all citizens. In Dolakha, we took a path of a partnership between the government and a non-government entity to lay the foundation of accessible healthcare for all. The central and local governments have now taken the lead for its continuation. We hope that this will be an example for other municipalities and provincial governments that are trying to strengthen health services, and are seeking a model to follow. <img width="122" height="150" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be2259c7e80680e083e8ejpeg.jpg" alt=""><img width="122" height="150" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be2269c7e80680e083e8fjpeg.jpg" alt="">Bharat Bahadur KC is the Mayor of Bhimeswar Municipality and SP Kalaunee is Executive Director of Nyaya Health Nepal. <a href="mailto:spkalaunee@gmail.com">spkalaunee@gmail.com</a>

Unique hospital handover in Dolakha

<figure><img width="1050" height="626" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a779c7e80680e064761jpeg.jpg" alt=""/><figcaption>Nepalis crossing the border into the country through the Gauriphanta checkpost in Dhangadi, Far Western Nepal. Photos: DINESH KHABAR</figcaption></figure>A week before Nepal declared a <a href="https://www.nepalitimes.com/latest/nepal-covid-19-lockdown-extended-till-7-april/" target="_blank" rel="noopener">nationwide lockdown</a> to prevent imported COVID-19 cases, close to half a million Nepali migrant workers from India crossed the border into the country without any screening.  Another 1.5 million people left Kathmandu Valley for their home districts as the government announced that all long-distance buses would stop plying after 6AM on 17 March.Tens of thousands of Nepali workers driven out of their jobs in Indian cities are still trapped across the border in India – prevented from returning to their own country as the government tries to decide where to quarantine them.Darchula police records show that 128, 022 people entered Nepal before the border was sealed, there now hundreds camping out on the banks of the Mahakali River. Health desks at border checkpoints were equipped only with thermometers. <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/">Enlisting female health volunteers to fight COVID-19</a>, Ramu Sapkota and Mukesh Pokhrel“It is easier to track people travelling by air, since they are fewer and the airport has the equipment for thermal screening,” says Sher Bahadur Pun, infectious disease specialist at the Sukraraj Tropical and Infectious Disease Hospital in Kathmandu. “Local governments should not waste any time to track down such individuals and place them under quarantine immediately.”But that is easier said than done. The Health Ministry has not even been able to carry out contact tracing of the four Nepalis who flew into Kathmandu from the Gulf and Europe in March who have tested positive for coronavirus. Local governments in rural Nepal have no record of people who have come home, and are just starting to collect information of recent returnees.  <img width="640" height="295" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a799c7e80680e064762jpeg.jpg" alt="">“If anyone is infected here, it is going to be a disaster. All we have are thermometers,” says Padam Giri, mayor of the Budhinanda municipality in Bajura, one of the remotest districts in northwestern Nepal. Four individuals who returned to Sunchhahari from India recently have been placed in isolation. Of the 46 people who arrived in Bajura from Mahendranagar after the lockdown, 16 are currently in quarantine at the district headquarters in Martadi.Adds vice-chair of the Sunchhahari Rural Municipality in Rolpa Pabitra Gharti Magar: “So far no one has shown any symptoms, but if anyone did, we do not even have test kits.” The mountainous districts of western Nepal are considered to be the most vulnerable because every family has at least one worker in India who has now returned. It was also western Nepal which was worst hit in Nepal by the HIV/AIDS epidemic in the 1990s as migrant males brought the disease home and spread it to their wives.<a href="https://www.nepalitimes.com/here-now/nepali-workers-overseas-toil-through-the-pandemic/">Nepali workers overseas toil through the pandemic</a>, Upasana KhadkaMahendra Bahadur Shah, chair of the Barekot Rural Municipality in Jajarkot admits that they failed to keep records of people returning from India because they did not initially take the pandemic seriously. Many migrant workers who entered Nepal though the Gaidachauki checkpoint before it was closed are from Bajhang, Doti, Baitadi and Dadeldhura districts.Historically neglected by the central government in Kathmandu, western Nepal has chronic suffered food shortages and epidemics. People from the region make up the highest number of returnees. Even though only one case of the novel coronavirus has been confirmed in the region and is in hospital in Dhangadi, public health experts say the virus is out there. <img width="640" height="372" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a7b9c7e80680e064763jpeg.jpg" alt="">“Hundreds of thousands of people have returned to western Nepal from Maharastra, Delhi and Bihar, which are the hardest-hit COVID-19 states in India. The one case in Dhangadi is only the tip of the iceberg,” says Bikash Gauchan, medical director at Bayalpata Hospital in Achham.Bayalpata has set up a fever clinic, and 10 isolation beds have been added. The hospital has a stock of 20 precious personal protection equipment, and is producing masks locally for staff. Municipalities, district police offices and hospitals are all on red alert for a possible outbreak of COVID-19 in the region. Adds Gauchan: “We have a few ventilators in the entire western Nepal, and a limited stock of oxygen. We will not be able to do anything if the situation is to turn for worse, but if we contact traced and isolated possibly infected people we might be able to buy some time.” Back in Kathmandu, Sher Bahadur Pun at the Teku hospital says the returnees might have already had extensive interaction with their family members and hence need to be isolated and placed under home quarantine."Even if only one person is infected, who may or may not have a symptom, there is a high chance that the pandemic will spread across the village where there is a lack of reliable healthcare services and people are not aware that they need visit the doctor even if they have a slight fever,” Pun says.Among the general public, there is now a sense of panic, and migrant returnees are being stigmatised, turning villagers against each other. Even people who die of other causes are rumoured to have died of the coronavirus. Public health experts want greater public awareness, physical distancing and expanding the so far limited testing for COVID-19.Warns Pun: “If the coronavirus has entered the country unchecked through the border, then we could have a ticking time bomb in our hands.”

Returnees may be taking coronavirus to rural Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66739c7e80680e059980jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>There used to be a time when the main public health threat in Nepal was from infectious diseases like <a href="https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, encephalitis, <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a> and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener">renal failure</a> and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">poor health</a> is making Nepalis poorer.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 style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37821&amp;preview_nonce=9ce6a7c55d&amp;preview=true" target="_blank" rel="noopener">Federalism leaves Nepal’s medical sector ailing,</a> Sewa BhattaraiAlso, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">stunting and wasting among children</a> due to malnutrition.In addition, <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">worsening air pollution</a> has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.Read also:<a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all of the change in world health"</a><a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialNepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a> or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.To meet these challenges, Nepal desperately needs <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">affordable and accessible medical care</a>. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.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 is not as easy as it looks</a>, Sonia Awale<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 BhattaraiA survey last year showed that half of all <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical expenditure of Nepalis families</a> is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">commentary this week</a>, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.Parts of the scheme are being tried out in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a> (which last week <a href="https://www.nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award/" target="_blank" rel="noopener">won the Global Architecture Festival award</a> in Amsterdam for its design). Insurance reimbursement 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. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government  can no longer keep passing the buck on providing universal insurance for its citizens.<h2>10 years ago this week</h2>Nepali Times <a href="http://archive.nepalitimes.com/issue/480" target="_blank" rel="noopener">issue #480 of 11-17 December 2009</a> carried an <a href="http://archive.nepalitimes.com/news.php?id=16572#.XfId7ZMzaUk" target="_blank" rel="noopener">interview on page 1 with Baburam Bhattarai</a>, who was then vice-chair of the Maoist party.  Excerpts:‘From the very beginning, we have said that the basis of the federal system should be nationality. In Marxist terms, nationality means a common language, geography, economy and psychological make-up. A group of people that shares these qualities is called a nationality.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66769c7e80680e059981jpeg.jpg" alt="" width="392" height="600">On this basis we have proposed to constitute federal autonomous units in Nepal and we also practised this during the People’s War. Since the very beginning we have been consistent that federalism should be along the lines of nationality.’

POOR HEALTH MAKES NEPALIS POORER

<figure><img width="3510" height="1500" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a651f9c7e80680e059913jpeg.jpg" alt=""/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>Nepal’s <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">Bayalpata Hospital</a> has won an international award in the Health Category at the World Architecture Festival held in Amsterdam on Thursday.The hospital in <a href="http://archive.nepalitimes.com/news.php?id=17650#.Xens94Mza72">Nepal’s Achham district</a> is a public-private partnership between the group Nyaya Health and the Nepal government, and is built almost entirely using rammed earth technology using locally available material with an ambitious zero carbon construction.‘This is an example of when architecture provides more than a building. Although modest in scale and architectural expression is delivers a massive leap in healthcare provision in a region with scarce resources,’ jury members of the Global Architecture Festival said in their citation. ‘A great example of an architect listening closely and responding intelligently to site and situation. The building is rooted in its site through its use of onsite materials and has impeccable zero carbon design credentials.’ <img width="1500" height="1125" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a65229c7e80680e059914jpeg.jpg" alt="">Bayalpata was <a href="http://archive.nepalitimes.com/news.php?id=17650#.XensoYMza71">started by visionary Nepali and American public health experts in 2009</a>, and took over a defunct government hospital to show that accessible and free medical care was possible in a rural Nepal district that had the highest maternal and child mortality and lowest lifespan.Today, the hospital <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/upgrading-health-care-through-public-private-partnership-model,582">treats 100,000 patients a year</a> from Achham and six surrounding mountain districts. Paid for mostly by crowd-funding, the $4 million three-phase expansion of Bayalpata Hospital with its <a href="https://www.nepalitimes.com/banner/starting-nepals-green-school-movement/">state-of-the-art architecture</a> was completed earlier this year.“Our specs were to use local materials as much as possible, keep energy costs low, and respect the local context,” explains Arun Rimal, a Nepali architect with the US-based Office of Structural Design (OSD). “The rammed earth uses local clay and sand from the river. The thick walls give thermal mass for insulation, and the skylights optimise sunlight and ventilation.”  <img width="4416" height="3312" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a65279c7e80680e059915jpeg.jpg" alt="">The reliance on local material turned out to be a huge advantage because the project faced unforeseen logistical problems due to the 2015 earthquake and Blockade. However, the four-year construction was delayed by just six months because it did not rely too much on bricks, steel and other imported material. The facility has a <a href="http://archive.nepalitimes.com/news.php?id=5877#.XWZGkOMzaUk">rainwater harvesting system</a>, treats its wastewater and has a network of greywater-irrigated terraces and bioswales to control erosion and recharge the acquifer. A 100kw solar array on the roof meets most of the hospital’s electricity needs, even powering the facility’s only air conditioning unit in the surgical ward. “It was a deliberate design decision to work with the natural environment as much as possible and also to address the cultural context,” says Tyler Survant from Sharon Davis Design in New York, which also conceptualised the unique Women’s Opportunity Centre in Rwanda. “We had to plan for a different kind of hospital from the West: here you have patients and relatives who have travelled for days on foot to get here.” <img width="640" height="828" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a652b9c7e80680e059916jpeg.jpg" alt="">Bayalpata has public outdoor spaces and canopied courtyards to serve as comfortable waiting areas, while the operating theatres and wards are recessed. Unlike in the US, staff housing also had to be integrated into the facility since it has fulltime resident doctors, who live with their families.

Bayalpata Hospital in Nepal wins global design award

https://www.youtube.com/watch?v=FQ0-JH097iA&amp;feature=youtu.beDeukali Shahi, 26, looks relieved after delivering a healthy baby girl, but her calmness belies her traumatic childbirth. Her eyes fill with tears as she speaks haltingly of the previous baby she lost and the desperation she felt this time to reach the hospital fast enough so this one would live.Soon, Shahi is overcome with grief and cannot say more. Her sister-in-law Tulaja fills in the rest of the story. The baby was in breech position, but the family did not know this until Deukali was already in labour. They took her to a nearby healthpost, where the nurse said there was nothing they could do. They went on to the district hospital in Mangalsen, which did not have a surgeon to perform a caesarean.“We drove another four hours and arrived here at two in the night, and the doctors operated on her,” Tulaja said. “Now we have a healthy baby girl.”Deukali lost her first child due to the same complication, but the family did not know why the baby would not come out. In these remote mountains of Achham, home delivery is the norm and the district has one of the highest maternal mortality rates in Nepal.Read also: <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">State of the art rural hospital</a>, Marty Logan<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54559c7e80680e0523a4jpeg.jpg" alt="" width="2000" height="1333"/><figcaption>Photos: MONIKA DEUPALA</figcaption></figure>All that is changing with Bayalpata Hospital, which serves as the informal referral hospital for <a href="http://archive.nepalitimes.com/news.php?id=17650#.XWY3DeMzbIV" target="_blank" rel="noopener">Achham </a>and six surrounding districts. The government hospital is managed by the non-profit Possible Health (formerly <a href="http://archive.nepalitimes.com/news.php?id=17650#.XWY-WeMzaUk" target="_blank" rel="noopener">Nyaya Health</a>) as a private-public-partnership, and now serves 100,000 patients per year.Bayalpata’s safe <a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" target="_blank" rel="noopener">motherhood</a> program is accessible at any hour of the day. In the severely understaffed Far West region, Possible is practising an experimental model of healthcare that has become a lifeline for thousands of people in nearby districts. Province 7, which includes Achham, has 13 public hospitals, 16 primary health care centres and 376 health posts, but most of these are under-equipped, under-staffed and under-funded. Aside from government neglect, geography is a further <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener">challenge in these mountains</a>. Patients like Deukali have to walk or travel for days to reach a proper hospital like Bayalpata.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54589c7e80680e0523a5jpeg.jpg" alt="" width="2000" height="855">The World Health Organiaation recommends a doctor-patient ratio of 1:1,000, and while it is 1:850 in Kathmandu Valley, the rate is 1:150,000 in rural areas. A recent report by the Nepal Government shows that 20% of staff positions in the healthcare system are not filled.When Nyaya Health took up an abandoned government hospital in Bayalpata 10 years ago, there were no doctors for the people living in the area. The unmet need was so great that the newly-opened hospital could not cope with demand, and soon expanded its facilities. (See box below)“Nepal’s per capita income is very low, and more than 70% of Nepalis <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">cannot afford private healthcare</a>. So a model like this, which makes healthcare free and accessible, is very necessary in Nepal today,” says Bikash Gauchan, medical director of Bayalpata Hospital.With grants from the government and donations from philanthropic individuals and organisations, the hospital provides free medical care to up to 500 patients a day, covering a catchment of 230,000 people in Achham’s neighbouring districts.“The perception in Nepal is that a PPP model is meant to bring in investment for large-scale infrastructure projects like <a href="https://www.nepalitimes.com/opinion/climate-risk-to-hydropower-investment/" target="_blank" rel="noopener">hydropower</a>. When we proposed a model where hospitals would utilise the government funding they deserve, it went against the grain and people found it hard to understand,” says SP Kalaunee, executive director of Nyaya Health Nepal. “But we want to get the best of both worlds: use government funding and resources, but enhance them with our knowledge, skills and management expertise.”Among many things that make Bayalpata different from the average government hospital is its Integrated Healthcare System, <a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener">digitising patient records</a>. The software is unique in Nepal and allows the facility to track the health of patients including pregnant women, children under two and those with chronic diseases. Community health workers reach out to these patients door-to-door instead of waiting for them to get so sick that they have to travel to hospital.“Each of us meets patients in our village once in 1-3 months, as per the need,” says community health worker Dwarika Rawal. “I meet women of <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">reproductive age and talk to them about family planning</a>, tell them about the different methods available. I also check the weight and health of children below 5, and counsel their parents about child health and hygiene.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a545c9c7e80680e0523a6jpeg.jpg" alt="" width="3000" height="2000">Rawal also follows up with patients living with chronic diseases such as <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener">diabetes</a>, <a href="https://archive.nepalitimes.com/article/nation/ending-AIDS-in-Nepal,2707" target="_blank" rel="noopener">HIV</a>, <a href="https://www.nepalitimes.com/banner/nepal-tb-cases-grossly-underestimated/" target="_blank" rel="noopener">TB</a>, high blood pressure and <a href="https://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener">mental disorders</a>, including to see if they are taking their medicines.In the past decade, health indicators in this region have shown a marked improvement because of Bayalpata Hospital, even surpassing targets in Nepal’s National Health Strategy (NHSS) for 2020 and the UN’s Sustainable Development Goals (SDGs) 2030. In the Sanfebagar area, institutional deliveries have gone up to 96%, compared to the NHSS target of 70% and the SDGs’ 90%. Neonatal mortality has fallen to 6 per 1,000 live births, a third of the NHSS target (18), and half of the SDGs target (12).Eventually, Possible hopes to not just improve service to its patients, but push through its Integrated Healthcare System, which would make local governments more responsible for providing overall healthcare rather than just operating a particular medical facility.“What makes our model successful is more accountability, and that is what is needed in our public healthcare system. We do not necessarily need more health facilities, we need to make them functional: make sure that the staff are always available, the medicines are stocked and the equipment functions as it is supposed to,” says Kalaunee. “Public healthcare needs to incorporate the use of technology and outreach to become comprehensive.”<h2>Building a rural hospital from scratch</h2><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a545f9c7e80680e0523a7jpeg.jpg" alt="" width="3456" height="2592">When a group of Nepali and American public health students set up Nyaya Health and took over an abandoned district hospital in remote Achham district in 2009, there was not a single doctor for over 250,000 people.Ravaged by government neglect and endemic<a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener"> TB</a> and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/stigma-ostracisation-for-HIV-patients-remain-in-western-nepal,1724" target="_blank" rel="noopener">HIV/AIDS</a>, the region had some of the worst child and maternal mortality rates in Nepal, and the shortest lifespan. Subsistence farmers moved to India to work most of the year so they could support families back home.Soon, <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/upgrading-health-care-through-public-private-partnership-model,582" target="_blank" rel="noopener">Bayalpata</a> was treating 12,000 people a year out of two rooms, and today it sees 100,000 patients from Achham and six surrounding districts. Renamed Possible, the organisation needed to expand to cater to the huge unmet healthcare demand of Far West Nepal.Paid for mostly by crowd-funding the $4 million three-phase expansion of Bayalpata Hospital is now complete. Coming round the bend on the highway from Surkhet, the modern facility with its <a href="https://www.nepalitimes.com/banner/starting-nepals-green-school-movement/" target="_blank" rel="noopener">state-of-the-art architecture</a> seems like a mirage in the middle of nowhere.Today, Bayalpata Regional Hospital is not just unique for its successful model of a private-public-partnership for rural medical care, but also for its distinctive design using rammed earth technology.An obsolete government facility is now one of the most modern and eco-friendly hospitals in Nepal, providing accessible and affordable health care to the most underserved part of the country.“Our specs were to use local materials as much as possible, keep energy costs low, and respect the local context,” explains Arun Rimal, a Nepali architect with the US-based Office of Structural Design (OSD). “The rammed earth uses local clay and sand from the river. The thick walls give thermal mass for insulation, and the skylights optimise sunlight and ventilation.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54639c7e80680e0523a8jpeg.jpg" alt="" width="2550" height="3300">The reliance on local material turned out to be a huge advantage because the project faced unforeseen logistical problems due to the 2015 earthquake and Blockade. However, the four-year construction was delayed by just six months because it did not rely too much on bricks, steel and other imported material.The facility has a <a href="http://archive.nepalitimes.com/news.php?id=5877#.XWZGkOMzaUk" target="_blank" rel="noopener">rainwater harvesting system</a>, treats its wastewater and has a network of greywater-irrigated terraces and bioswales to control erosion and recharge the acquifer. A 100kw solar array on the roof meets most of the hospital’s electricity needs, even powering the facility’s only air conditioning unit in the surgical ward.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54679c7e80680e0523a9jpeg.jpg" alt="" width="4416" height="3312">“It was a deliberate design decision to work with the natural environment as much as possible and also to address the cultural context,” says Tyler Survant from Sharon Davis Design in New York, which also conceptualised the unique Women's Opportunity Centre in Rwanda. “We had to plan for a different kind of hospital from the West: here you have patients and relatives who have travelled for days on foot to get here.”Bayalpata has public outdoor spaces and canopied courtyards to serve as comfortable waiting areas, while the operating theatres and wards are recessed. Unlike in the US, staff housing also had to be integrated into the facility since it has fulltime resident doctors, who live with their families.Bayalpata has been shortlisted for the World Architecture Festival 2019, and besides providing vital medical care for much of the Far West, it is sure to become a landmark for sustainability in Nepal’s architectural landscape.

This is how to upgrade Nepal's rural health

Just few days into office, President Donald Trump has brought about a work-stop to ongoing USAID supported projects and complete stop to new grants or aids. The executive order was justified under Trump’s ‘America First’ promise, and it has shaken up recipient countries, including Nepal. Since 1951, USAID has provided $1.5 billion in aid to Nepal. The breakdown for recent years is $105.94 million for 2020-21 and US$ 125 million in 2018-19. In 2022, USAID and Nepal signed a five-year Development Objective Agreement worth $659 million (pictured, above).&nbsp; Some of the key sectors where USAID has supported and supports Nepal with aid include health, education, agriculture, infrastructure; economic growth, humanitarian aid and women and children empowerment. All of these projects will be affected, and grants disbursement suspended. According to USAID’s Country Development Cooperation Strategy (December 2020-December 2025), the overall goal of the USAID’s development cooperation in Nepal is to realise ‘A more self-reliant, prosperous, and inclusive Nepal that delivers improved democratic governance and health and education outcomes.’ Four identified development objectives are:&nbsp; i) More Effective, Participatory, and Equitable Democratic Ecosystem ii) Broad-Based and Inclusive Economic Growth Fostered iii) Inclusive Health and Education Systems Strengthened iv) More Equitable and Improved Natural Resources and Disaster Risk. Under these development goal and objectives as per the data available under Government of Nepal’s Aid Management Platform (AMP) there are currently USAID supported 21 key projects ongoing in Nepal.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250126090140_0bd9163cb9826464409887995eb8f2eff42c7cf1269610c3761773cde59ff52c.jpg" data-media-id="editor_0" data-image-id="20250126090140_0bd9163cb9826464409887995eb8f2eff42c7cf1269610c3761773cde59ff52c" data-rendition-name="original" width="1005" height="825" loading="lazy" alt="USAID fund in nepal after Trump"> </figure>  These 21 projects with some data missing totals a commitment of $178,140,467 from 2021-2029 in Nepal. Of these commitments $89,115,031 (about half) have already been disbursed. With Trump’s executive order the rest of the 50% is now going to be on hold until the review is completed and further decisions are made by the new US administration.&nbsp; Most development goals of USAID in Nepal are embedded with key principles like ‘equity’ and ‘inclusive’. With the Trump government’s aversion to the previous emphasis on Gender, Equity, Inclusion and Accessibility (GEIA) principles, projects focusing on those issues will be hit hardest. USAID upheld policies and actions that promoted equal access and opportunities for all people, with an emphasis on the Tarai, gender issues, family health and through contractors on human rights and democracy. The impact on Nepal’s development aid will be substantial, affecting livelihoods in incomes generated by USAID supported projects. Individual independent consulants already received notices over the weekend that the work they were &nbsp;doing under a USAID contract is subject to work-stop now.&nbsp; The question is whether the 5-year Country Development Cooperation Strategy for Nepal that finishes by end-2025 will go ahead. And when the new post-2025 Strategy is formulated, it is certain that the Trump’s administration will not entertain GDEI, which so far has been people-centered and not political.&nbsp; Kishor Pradhan is an independent development consultant concentrating on development information and knowledge management issues. <a href="mailto:kishorpradhanktm@gmail.com" target="_blank">kishorpradhanktm@gmail.com</a>

How USAID cut affects Nepal

They are rare, they are elusive and they are so well camouflaged, they are difficult to see, even when they are right there. That is why <a href="https://nepalitimes.com/opinion/comment/nepal-brings-back-the-snow-leopard">snow leopards</a> are called the ‘Ghosts of the Himalaya’. And because they are also regarded as being sacred, they are called ‘God’s Pets’.&nbsp; Nepal has <a href="https://nepalitimes.com/news/does-nepal-really-have-too-many-tigers">tripled its tiger population</a> in 12 years since 2010. There have been successive years with zero rhino poaching and the numbers have bounded back. But few know about the country’s success story with snow leopard conservation. Preliminary data from an on-going census shows that Nepal ranks fourth among the 12 snow leopard range countries in central and South Asia. This is despite the country having just 2% of the total area where snow leopards can be found.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070148_0f22a5439d56e5db58d8f65789ee4ff5e87a29c898d5e8cbff60bf8f1814af4b.jpg" data-media-id="editor_2" data-image-id="20250127070148_0f22a5439d56e5db58d8f65789ee4ff5e87a29c898d5e8cbff60bf8f1814af4b" data-rendition-name="original" width="1311" height="724" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>Despite possessing just 2% of the snow leopard range across Central and South Asia, Nepal has the fourth highest number of elusive mammals in the world. Photo: TASHI R GHALE </figcaption> </figure>  Nepal also leads in <a href="https://nepalitimes.com/news/satellite-tracking-snow-leopards-in-nepal-to-study-climate-impact">snow leopard research</a>. Less than 3% of the snow leopard range has been studied through camera traps and genetic studies, but it is Nepal that has done the most. <a href="https://nepalitimes.com/here-now/nepal-leads-in-snow-leopard-study">Over 100 Years of Snow Leopard Research</a> by the World Wildlife Fund (WWF) in 2021 showed that 74% of the snow leopard habitat in northern Nepal has been the subject of research into the species. “We are leading globally when it comes to snow leopard conservation and study, starting from 2013 in Kanchenjunga using GPS to study their habitat,” says <a href="https://nepalitimes.com/here-now/conversation-with-mr-conservation">Ghana S Gurung of WWF Nepal</a>. “We also found via camera traps they went as high as 5,800m and as low as 2,600m.” There are an estimated 300-500 snow leopards across high mountain Nepal with Dolpo, Manang and <a href="https://nepalitimes.com/banner/participating-to-save-kangchenjunga">Kangchenjunga</a> the main hotpots for the endangered species. Unlike with tigers and rhinos which are poached by wildlife traffickers, snow leopard killings are mostly retaliatory for killing livestock. Snow leopards attack yaks, sheep and goats of herding communities in the mountains. One of the most effective methods to protect the species from traps and poisoning is to help local communities build mesh wire corrals. The San Francisco-based <a href="https://snowleopardconservancy.org/">Snow Leopard Conservancy</a> through the Nepal group <a href="https://www.mountainspirit.org.np/">Mountain Spirit</a> has designed and tested portable corrals that can move with herders.&nbsp; “They move all year around so that the livestock have enough pasture to graze on, which is why it was important that our improved corrals could be dismantled and moved around,” explains Shailendra Thakali of the Snow Leopard Conservancy. The team consulted herders in Manang and Mustang while developing the corrals based on traditional design, with a stone base but wire mesh on the sides and the roof as well as strong wire gates for secure closure. They are also using fox lights to deter activities at night.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012803018_4a166ea1124008cfcf551ffd59c5841acb2bc9c443d9fbe56490b280492eb441.png" data-media-id="editor_9" data-image-id="2025012803018_4a166ea1124008cfcf551ffd59c5841acb2bc9c443d9fbe56490b280492eb441" data-rendition-name="original" width="2244" height="1246" loading="lazy" alt="corraling"> <figcaption>Improved corrals in Manang and Mustang made up fo mesh wires to protect livestock from snow leopard attacks. Photo: PURNA MAN SHRESTHA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070152_009bc57c5d2244a393a8423d56098f921ed29b8d0a60a9c15422dd58615b5e5b.jpg" data-media-id="editor_10" data-image-id="20250127070152_009bc57c5d2244a393a8423d56098f921ed29b8d0a60a9c15422dd58615b5e5b" data-rendition-name="original" width="4032" height="3024" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>The corrals are portable allowing herders to move them as they take livestock for grazing in high Himalayan pastures. Photo: PURNA MAN SHRESTHA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070152_3b84ce156de1ed1deea79d23a15c1a3dfa5a412dca3644deec1333bda7f91cd0.jpg" data-media-id="editor_11" data-image-id="20250127070152_3b84ce156de1ed1deea79d23a15c1a3dfa5a412dca3644deec1333bda7f91cd0" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>Local herders in Manang and Mustang were consulted while developing improved corrals. Photo: BRIAN PENISTON</figcaption> </figure>  Tourism and agriculture in Manang and <a href="https://nepalitimes.com/here-now/comings-and-goings-in-mustang">Mustang</a> dropped during the pandemic, and the Conservancy also helped herder communities with alternative livelihoods.&nbsp; “We trained them in basic hotel business such as lodge management skills but more importantly to restore abandoned pastures by planting jimbu which is highly valued for cooking in Kathmandu and Pokhara,” says Brian Peniston, also with the Snow Leopard Conservancy. “The tourist figures have now increased considerably and this has directly benefited 1,000 households in three municipalities.” <a href="https://www.wwfnepal.org/">WWF Nepal</a> has also collaborated with the Department of National Parks and Wildlife Conservation (DPNWC) to train locals in Dolpo and Kangchenjunga to make their own mesh wire corrals with subsidies on raw materials.&nbsp; WWF has partnered with Amchi traditional medicine practitioners to promote conservation of snow leopard in mountain communities where people trust faith healers. School eco-clubs also involve youth in conservation.&nbsp; “We must trust communities and promote local ownership when it comes to wildlife conservation, and if it were not for the communities there, snow leopards would be long gone,” says Gurung of WWF Nepal. “It is important to revive the belief that snow leopards are sacred because they are god’s pets, tie them up with the spiritual, cultural and traditional belief of the people.” Community-managed livestock insurance schemes have attained zero retaliatory killings in Kangchenjunga where WWF and the government has sent up an endowment worth Rs10 million to compensate herders for snow leopard kills. A similar scheme is being implemented in Dolpo which has double the density of snow leopards compared to Kanchenjunga.&nbsp; But the compensation mechanism is cumbersome and often inefficient. Claimants need to provide photographic evidence with tags of the livestock still attached but snow leopards often go for the head and tags are lost. The evidence has to be submitted promptly, and this is difficult for herders in isolated villages.&nbsp; Insurance agents are based in headquarters like Chame in Manang and are not willing to travel all the way up. Similarly, photographic evidence needs to be assessed by veterinarians who are also reluctant to go to remote areas that take up days. “The compensation policy hasn’t changed in the last 20 years,” says <a href="https://nepalitimes.com/review/snow-leopard-redux">Tashi R Ghale</a>, high-altitude wildlife photographer and conservationist. “Here in Manang, herders would get Rs6,000 in compensation for a yak when the market rate was Rs20,000. The market rate is now Rs150,000 but they still get only Rs6,000. Even then, they have to wait for months.” Brian Peniston feels improving and tailoring compensation suitable to the landscape is of utmost priority, and the schemes need to be more accessible and effective as well as herder friendly. He adds, “Local governments should be handed authority in these matters, and it should be equal parts trust and verify. It is over-verification at the moment.” Climate breakdown has added to the challenge of snow leopard conservation. Either blizzards or winter droughts mean fewer prey for the mountain cats, this in turn has also led to leopards preying on livestock. Usually, the wild prey to livestock ratio in a snow leopard diet is 70:30. Blue sheep (pictured below) are the main prey species for snow leopards, but there is now competition with lowland spotted leopards which have moved up the mountains, while the Himalayan wolf has descended. The prey density may not have decreased, but predator species have more than doubled.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070156_f23ed8414be46782c90df4198d46c30f423d63d59f97343f89760283011c7c0b.jpg" data-media-id="editor_15" data-image-id="20250127070156_f23ed8414be46782c90df4198d46c30f423d63d59f97343f89760283011c7c0b" data-rendition-name="original" width="1400" height="1050" loading="lazy" alt="snow leopard conservation in Nepal"> <figcaption>The climate crisis has meant that lowland spotted leopards which have moved up the mountains, while the Himalayan wolf has descended, leading to a reduced number of blue sleep which is one of the main prey species for snow leopards. Photo: SHAILENDRA THAKALI</figcaption> </figure>  Other disrupters include <a href="https://nepalitimes.com/multimedia/the-human-cost-of-nepal-s-yarsa-gold-rush">overharvesting of yarsagumba</a> and increased movement in this fragile landscape, with adverse impacts on all wildlife, not just snow leopards. Expansion of the road network to the remotest corners of the country is another concern, adding to the risk of human-wildlife conflict and poaching.&nbsp; “There has been much research on snow leopard behaviour in the last 30 years but what we haven’t done nearly enough is study human behaviour,” says Peniston. Despite the challenges, the rebound of snow leopard populations has increased the opportunity to <a href="https://nepalitimes.com/banner/trekking-to-save-nepals-snow-leopards">snow leopard viewing eco-tourism</a>, as is being practiced in Dolpo.&nbsp; Says <a href="https://nepalitimes.com/review/ice-to-water-alv4lorf">Tashi R Ghale</a>: “Local communities here in Manang and Dolpo are doing what they can, but the Nepal Tourism Board needs to step in to promote snow leopard trekking and tourism. The co-benefits would motivate communities to protect the big cats.” &nbsp;&nbsp;&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070156_698d64632273185cecbcaca626c7c49861ba54a0930119843792572f01114942.jpg" data-media-id="editor_19" data-image-id="20250127070156_698d64632273185cecbcaca626c7c49861ba54a0930119843792572f01114942" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="snow leopard conservation in Nepal"> <figcaption>FIND ME: Elusive in nature, snow leopard sightings are rare and often only detected on camera traps (below). Spot the snow leopard in this picture taken by conservationist Tshiring Lhamu Lama in Dolpo, a hotspot for big cats in Nepal. Photos: TSHIRING LHAMU LAMA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012708018_42acdb2ba0c5941b1c3a89ede1bac048808d6424f4c70aadb68df6ab5176bbb6.jpg" data-media-id="editor_20" data-image-id="2025012708018_42acdb2ba0c5941b1c3a89ede1bac048808d6424f4c70aadb68df6ab5176bbb6" data-rendition-name="original" width="2041" height="1314" loading="lazy" alt="Snow leopard conservation in Nepal"> </figure>  &nbsp;

Ghosts of the Himalaya

In December, the Nepal government announced it would not allow a Beijing-appointed Tibetan spiritual leader, the Panchen Lama, to attend a Buddhist conference in Kathmandu. Immigration at the airport was put on high alert to ensure he did not try to sneak in.&nbsp; Coming soon after Prime Minister K P Oli’s visit to China, that decision underscored Nepal’s precarious tight-rope act in addressing religio-political sensitivities in its relations with China. The Panchen Lama episode can be seen as a test for Nepal’s handling of the succession of the Dalai Lama, who turns 90 in July. “When the time comes to find a successor to the Dalai Lama, Nepal will face a larger policy dilemma,” predicts Sudheer Sharma, author of two recent books on Nepal-China relations. “The government is still unclear what it will do if the successor is chosen from the Tibetan community in Nepal, or from China or India.” <a href="https://nepalitimes.com/news/dalai-lama-gets-block-of-glacial-ice">The Dalai Lama</a> is the spiritual leader of Tibetan Buddhism and a symbol of Tibetan identity; he is revered as the manifestation of Avalokitesvara, the Bodhisattva of Compassion. He was born in 1935 in northeastern Tibet and was formally recognised as the Dalai Lama in 1940.&nbsp; He has been living in exile in Dharamsala for the past 65 years after fleeing Lhasa following the Chinese takeover. He has been allowed to make a low-profile visit to Lumbini only once in 1987, and never after that due to objections from China.&nbsp; Nepal does not have a national strategy to handle the presence of <a href="https://nepalitimes.com/news/nepal-s-sherpas-mourn-tengboche-abbott">religious leaders</a>. If there are policies, they are ad-hoc or undeclared, depending on the government of the day in Kathmandu. The Nepal government, under Chinese pressure, even prevents public celebrations marking the Dalai Lama’s birthday on 6 July. “The Dalai Lama’s attempts to visit Nepal again have been stopped &nbsp;since Nepal thinks he is not only a religious leader, but a political figure as well,” says Sharma. “There is no discussion in Nepal’s political circles regarding the succession of the Dalai Lama. The topic is regarded as a non-issue.”&nbsp; Over the years, the Dalai Lama has made various statements regarding his succession. At times, he has suggested that he will write a will to select a successor from within the Tibetan community. On other occasions, he has hinted that the next Dalai Lama could be chosen from a “free country”, and could even be a woman.&nbsp; The Panchen Lama succession in 1995 could provide a hint about how the post-Dalai Lama era will play out. The Panchen Lama is the second most important spiritual leader in Tibetan Buddhism, and heads the <a href="https://archive.nepalitimes.com/news.php?id=18580">Tashilhunpo Monastery in Xigatse</a>, the epicentre of the 7 January earthquake, located 250km away from Lhasa.&nbsp; The Panchen Lama traditionally has the role of finding the next Dalai Lama, but the previous Panchen Lama (Lobsang Trinley Lhundrup Choekyi Gyaltsen) has been missing since 1995, after the Chinese installed their own candidate (Gyaltsen Norbu). The present Panchen Lama’s visits are carefully planned, and he has made only one foreign visit so far, to Thailand. “Nepal did not permit Panchen Lama’s visit as he is Chinese Communist Party-appointed, thus making him a political figure,” says Amish Mulmi, author of the book All Roads Lead North.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250124090148_3bb3d803c04c34657d0ac9759ca904073f75734a446506f8a57e50178b381c00.jpg" data-media-id="editor_3" data-image-id="20250124090148_3bb3d803c04c34657d0ac9759ca904073f75734a446506f8a57e50178b381c00" data-rendition-name="original" width="1087" height="697" loading="lazy" alt="Dalai Lama NT"> </figure>  What China was trying to do through the Panchen Lama’s visit for the Nanhai Conference in Kathmandu last month was to project its soft power, and perhaps prepare the ground for the Dalai Lama succession. But the ban raised the question of what Nepal will do if there is a visit by Hindutva figures from India at events in Nepal.&nbsp; Religious leaders and figures from various faiths regularly visit Nepal for devotional events, meetings and conferences. Their trips are often significant for promoting dialogue and cultural exchange, and cannot be banned under the Constitution. “We did the Nanhai Conference, and in future religious leaders will definitely visit Nepal. The question arises whether or not to allow them to engage in political activities or not,” says Mulmi. “Religion has always been political. So Nepal must not take easy decisions and must think it through.” Although Nepal and Tibet fought wars in the past two centuries, they share deep-rooted and ancient cultural, religious and trade ties. After the Chinese annexation of Tibet 70 years ago, Kathmandu gradually started dealing directly with Beijing.&nbsp; Today, Nepal is the only country with a consulate in Lhasa, a city from where the only direct international flight is to Kathmandu. Over the years, these ties have evolved, with shifts in trade dynamics and people-to-people interactions reflecting broader regional and global changes. Despite this, the historical bond between Nepal and Tibet remains a significant aspect of present-day bilateral relations with China, and this is why the selection of the next Dalai Lama has resonance here. “It is clear that China has been trying to adopt Tibetan Buddhism as a soft power. It is trying to co-opt Tibetan Buddhism on the lines of China’s ambitions and narratives,” explains Mulmi.&nbsp; The Dalai Lama’s <a href="https://archive.nepalitimes.com/news.php?id=14733">considerable following</a> in Nepal, India, Europe and the United States is an irritant for Beijing. Recent Sino-American tensions have therefore given the spiritual ownership of Tibetan Buddhism a geopolitical dimension, and in this the Dalai Lama succession will become an important factor.&nbsp; Relations between Washington and Beijing during the second Trump term will have a bearing on this. As a buffer state between India and China, Nepal has historically tried to maintain equidistance between the two powers.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012308014_95372c819980513e21490c3abe2aa8e712af6c89c5829e04d5f57880ad4f2a23.jpg" data-media-id="editor_5" data-image-id="2025012308014_95372c819980513e21490c3abe2aa8e712af6c89c5829e04d5f57880ad4f2a23" data-rendition-name="original" width="2500" height="1000" loading="lazy" alt="What (or who) after the Dalai Lama NT"> <figcaption>THEIR HOLINESSES: The Dalai Lama, who will be 90 in July (left), and China-installed Panchen Lama (above). Traditionally, it is the Panchen Lama who has a role in finding a new Dalai Lama. Photos: TENZIN CHOEJOR (left) / CHINAN NEWS SERVICE (right)</figcaption> </figure>  But China has rarely stuck its neck out for Nepal. Despite repeated requests for military help during its war with the British East India Company in 1814-16, the emperor in Beijing refused.&nbsp; Explains Sudheer Sharma: “China did not want to get involved with the British. They thought of their own national interests then, and they are thinking of their own national interests now with India.” During the Khampa Uprising in the 1960s, Kathmandu was also squeezed between American support for the guerrillas and China’s objections to Nepal being used as a base. But with the Nixon-Mao rapprochement in 1972, the Americans stopped helping the Khampas. Nepal then yielded to pressure from Mao Zedong to mount a military campaign to drive them out.&nbsp; Nepal was left to manage and host Tibetan refugees, and balance that with China’s security concerns. Explains Amish Mulmi: “Nepal has pretty much done everything China has asked to do, including deporting Tibetans. China doesn’t need to be insecure, but Nepal needs to maintain a careful balance.” Today, despite Donald Trump’s chest-thumping and <a href="https://nepalitimes.com/editorial/trump-s-second-coming">threats of a tariff war against Beijing</a>, he and Chinese President Xi Jinping are on the same page regarding democracy and freedoms. Which may mean Washington could once more leave the Tibetans in a lurch, and this could have a direct bearing on the Dalai Lama succession sequence. The United States' shifting foreign policy has often been criticised for leaving allies and partners to fend for themselves. Trump may revive his pressure on Japan, Korea and Taiwan to pay for the US defence umbrella.&nbsp; Nepal’s stance on the Tibetan community relies on marking boundaries and offering protection. During Chinese President Xi Jinping’s visit to Nepal, China proposed that Nepal sign an extradition treaty which Nepal politely refused. “Nepal has tactfully not let the Chinese side extend a longer hand on the Tibetan issue,” says Sharma. “Possibly, we are learning our lessons from history.” The question of who will choose the successor to the Dalai Lama will be decided by geopolitics, and China’s increased stature as a global economic power.&nbsp; Beijing could insist on sticking to tradition to let its candidate for the Panchen Lama make the final decision. This would allow it to move the seat of the Dalai Lama from Dharamshala back to Lhasa. The present Dalai Lama could also appoint his own candidate, but that person will not be allowed into Tibet by China. In that case, we may have a situation where there are two Dalai Lamas.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127030140_c9048725407641601bc68568db19e48197154cd6396f39d67ab113d94c26e675.jpg" data-media-id="editor_7" data-image-id="20250127030140_c9048725407641601bc68568db19e48197154cd6396f39d67ab113d94c26e675" data-rendition-name="original" width="1910" height="757" loading="lazy" alt="Voice for the Voiceless Dalai Lama"> <figcaption>Dalai Lama's latest book Voice for the Voiceless details his dealings with China over the last seven decades. </figcaption> </figure>

What (or who) after the Dalai Lama?

Between the 1980s and 2000s, over 5,000 <a href="https://download.ssrn.com/11/01/06/ssrn_id1736064_code1383023.pdf?response-content-disposition=inline&amp;X-Amz-Security-Token=IQoJb3JpZ2luX2VjEBkaCXVzLWVhc3QtMSJIMEYCIQCiYUc7BuJ7zaDn%2BOTCFOWBgNKqYarnapqY%2FWZbamFVsgIhAOC%2FPFXHR9Dx6xTicWMj5%2BJXdIEGZ7LxKRyjrCe61Ng9KsYFCPL%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEQBBoMMzA4NDc1MzAxMjU3IgzWD1Y1XNz2kaOS3jEqmgX0TbxyBTTrZrpd%2B5N72pFzJAwc%2BxTF8Dc0GnVG2tUGUYyxBt1YmfEqAw5cdOuRCZV23SSKkJwndg9IwI3yrjZGBp9XKxg4lK4Vq0Qy9RMmma5hNCVnA2T0MwGghlnmkgWPZA5ouZPiKFAecf4PE5qml2fu1wj72LEAig5R77cN6nC6%2BxTcygMiuiHrR9yZB4RyvTD9s58avGqUcn9hcIUdku3ydvAGVEgczzgEMCesRMtSgqzHz3E9bju9QLR5RpcDRp0wptfQ89uGXgyBGLCX%2BAl6uareSxQCSaDOthP4PmswWI7y7kBJbQp1pZq8r56Yoa3Qf5WVtmxbsWmDtbOsaSBa0yB6EIS8RKFGeQ%2Bcz%2BnEsOoPHIS%2BqO1k1%2BQuihjN0T66SnWFo8rl8Cv2g4GghY9p9DR3wopBJ6cE%2FtDJMY%2BZ03LkUwS%2Fc7ckyaRpfPX5g6Bb9J56a%2BNA5lnIV5o%2Fpjp%2BZJaVIvEzciyzzTwP58wznmcy3xppvK%2BwXBzBR96cPMXKTdNv9%2FqJ5jlnsgSRJpHWE3UyHbFucwQYXi19i7mCglFSuSkkL5Tg9nQWvXpuP9Z9VmMlQfQ%2F%2FpsfA6KlL81K3UK%2Bp%2FJB2mxQD9SYexZvAf1g21NUSF%2F8I19orsNrT6LutAnoJU%2FOTgO3qMbdgnR%2FuBytI3POnQAEIfbG0Za%2FrEDJ9j8CEbasNXsBMqkx8JKGRG2PUHMRC2xl5Z%2BNIbpsqGB8t%2BvAt40osDpgZStiyeiGdC1nMakUzZtBjWlttzoirCdemwPKJ8M%2BEohj2%2BLEN92yaOKdFewns0gjh%2BUxcotGvBo%2F7QZFappBNjLlR0PyanjcuB4MndEQjeIrd67ntscTKiLDI%2FfzwCHulsl6nbMpewpWFAYwg67guwY6sAGb3VJ2q%2F36hWhrVa8igP2hswnnLlcIU2uhOZa5ge2hCXkUYhL1BcSJfoWy2LwrWCXtdFo%2BT7KMU3p6O3jySdxSop8F4iO%2BJBiXVjSiXm%2FqZo3ri8sVwUgo4ksJI%2BT4AbfK3D3VGYapBgU5LdX%2FjkNwSVoR1vz4vMIyF56i7MKeYG1nFLgc0l9cIjrQI6eY869uIbgZ1XKqqBsuavCbYjSbSy7dMP0QSym%2FgmoWILGE0Q%3D%3D&amp;X-Amz-Algorithm=AWS4-HMAC-SHA256&amp;X-Amz-Date=20250103T172339Z&amp;X-Amz-SignedHeaders=host&amp;X-Amz-Expires=300&amp;X-Amz-Credential=ASIAUPUUPRWE65YAH56X%2F20250103%2Fus-east-1%2Fs3%2Faws4_request&amp;X-Amz-Signature=9b654b526e0779da4fa9f54e2fcde04ac9f7e91fb50d4f8094b1039ebb19e21b&amp;abstractId=1736064">Nepali children were adopted abroad</a>, primarily to the United States, France, and Spain. While international adoption was intended to provide vulnerable children with better opportunities, child trafficking and irregular practices prompted Nepal to suspend adoptions in 2007, and overhaul its policies. By 2010, stricter regulations aligned with the <a href="https://www.hcch.net/en/instruments/conventions/specialised-sections/intercountry-adoption">Hague Adoption Convention</a> drastically reduced adoption numbers. Today, many of these children, now adults, are returning to Nepal in search of their roots, only to encounter a society that no longer recognises them, legally or socially. Behind the statistics lie the <a href="http://hdl.handle.net/1854/LU-01GRNPPXAC1Z3AETV9HARNCG5Q">deeply personal and emotional journey</a> of adoptees returning to reconnect with their past, seek family, and rediscover a sense of belonging. These stories reflect a broader struggle for identity and the complexities of bridging two worlds. Maya Adopted at 9 by a family in Barcelona, Maya carried fragmented memories of her early life in Nepal including the painful recollection of the day her mother and sister vanished, leaving her and her younger siblings behind. She had faint images of her mother, elder sister, and the village where she once lived. In June 2017, Maya came to Nepal accompanied by Chandra Kala and two friends, Jay and Vikram. With only a few photographs of her mother Tulsi, her elder sister Pargati, and her brother-in-law Kamal, along with a street name, Maya arrived in Birendranagar after a 20-hour bus ride from Kathmandu. “Now that we’re close, I feel like I can’t face them,” she confessed to Chandra Kala, wrestling with anxiety about what she might uncover. “I’m nervous. I don’t know if I’ll recognise them or if they’ll recognise me. I don’t know how they’ll react or what they’ll say. And then there’s him [Kamal]. I have such bad memories of him. I don’t know if I can handle this.” Chandra Kala reassured her, reminding her of her courage and the importance of this moment. Maya and her companions asked around the town with little success until a shopkeeper recognised Kamal and directed them to a nearby village. Jay went to confirm and returned excitedly, shouting, “It’s her! It’s your sister!” Maya froze, paralysed by fear and anticipation but she pushed ahead. At the village, Maya’s sister Pargati initially struggled to recognise her. Jay introduced Maya: “Do you recognise her? This is your younger sister. She’s come all the way from Spain to find you.” Slowly, realisation dawned, and the two women embraced, bridging the decades of separation with tears and disbelief. The next day, Maya met her mother Tulsi in an emotionally overwhelming reunion. Tulsi rushed into the room and embraced Maya tightly, sobbing uncontrollably: “Mero chhora-chhori, gaye, gaye… my children they went, they went …” Once the tears subsided, Tulsi and Pargati began recounting the heartbreaking circumstances of their separation. After the death of her husband, Tulsi faced relentless judgment in their village when Kamal stayed with the family before his marriage to Pargati. The villagers accused Tulsi of impropriety, calling her पापी (sinful) and demanded that the family leave. “We didn’t want to leave, but the village didn’t want us here,” explained Pargati. “We left intending to bring you and your siblings later. But when we returned, you were gone.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120140_da7482d222e0a03b783c5e1df25536ed416d7b7475442e7fd40e54451572142e.jpg" data-media-id="editor_3" data-image-id="20250103120140_da7482d222e0a03b783c5e1df25536ed416d7b7475442e7fd40e54451572142e" data-rendition-name="original" width="384" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>An adoptee and companion return to Bal Mandir in Kathmandu after 19 years. Photo: CHANDRA KALA CLEMENTE-MARTINEZ</figcaption> </figure>  Tulsi recalled how she had entrusted Maya and her siblings to relatives, hoping they would be cared for temporarily. However, when she returned, the children had been sent away without her knowledge. “I only trusted them because I had no other choice,” Tulsi said through tears. “I didn’t know they would send my children away. What kind of mother does that make me? They called me a bad mother, but what else could I have done?” The reunion brought healing and answers but it also exposed the societal pressures that had fractured Maya’s family. Despite the challenges, Maya spent the rest of her visit bonding with her sister, nieces, and younger half-sister, Sunita, slowly bridging the gaps created by time and distance. Maya’s journey was a testament to the courage required to confront the past, the pain of uncovering difficult truths, and the hope of rebuilding connections once lost. Her story highlights the enduring emotional complexity faced by adoptees navigating their history and identity. Ashmita Unlike some adoptees whose main focus is reuniting with their biological family, 26-year-old Ashmita’s priority has been to uncover the institutional details surrounding her adoption. She wanted to understand what the orphanage and the government knew about her background and why so much information seemed concealed. “I just want to know where I come from,” she said. “Even if I never find my biological family, having a better sense of the places and people connected to my story would mean so much.” For many adoptees, returning to Nepal is not just about reconnecting emotionally, it is about seeking formal recognition as members of the Nepali community. However, the legal framework in Nepal often fails to acknowledge their unique status.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120144_bf0158b7829cf5db44382d7386d3b123032adad3f9e10e28096b80cd09170ba6.jpg" data-media-id="editor_4" data-image-id="20250103120144_bf0158b7829cf5db44382d7386d3b123032adad3f9e10e28096b80cd09170ba6" data-rendition-name="original" width="384" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>A mother reunites with her don after 18 years. Photo: CHANDRA KALA CLEMENTE-MARTINEZ</figcaption> </figure>  In Nepali law, adoptees are left in limbo: their birth parents are not considered legal parents, and their ties to the country are effectively erased upon adoption. This lack of recognition creates significant hurdles, particularly in two key areas: accessing pre-adoption records and obtaining Non-Resident Nepali (NRN) status. Despite international norms like the Convention on the Rights of the Child, which guarantees the right to know one’s origins, institutions often refuse to cooperate. Orphanages and non-profits in Nepal, which hold critical pre-adoption records such as birth certificates and citizenship documents, frequently withhold this information, reflecting the systemic reluctance to provide transparency. In numerous cases, records that should include family names, addresses, or relinquishment agreements were either incomplete or falsified. These practices not only prevent adoptees from reclaiming their histories but also perpetuate their disconnection from their heritage. Ashmita’s initial requests for information from her adoption agency were met with delays and incomplete responses. When she turned to the orphanage where she spent her early years, she encountered even greater resistance. At one point, the director of the orphanage issued veiled threats. Nevertheless, Ashmita persisted and managed to find the name of the individual who had brought her to the orphanage. However, the person had disappeared, leaving yet another gap in her story. A breakthrough came when Ashmita accessed a police report that suggested she might have been born in a different municipality than the one in her adoption records, prompting her to seek help from local authorities. The police took an interest in her case and began investigating possible connections to her birth family. While progress was slow, they meticulously followed leads to help her trace her origins. “It’s not easy,” Ashmita said of the process. “But every small step feels like I’m piecing something back together.” She also noted that societal perceptions could add to the difficulty. At times, she felt questioned about her identity and her right to seek answers. “People have asked me why I care so much or even suggested that I’m not Nepali anymore because I was adopted abroad,” she reflected. Ashmita’s story is a complex account of persistence in the face of institutional and personal challenges. While her search has not yet provided all the answers she seeks, it continues to offer her insights into her early life and the systems that shaped her adoption journey. &nbsp;“These records are sealed for a reason. They are not meant to be reopened,” said a government official. Even an NGO representative said: “It’s better for everyone if the past remains in the past.” An orphanage director asked: “Why are you asking these questions? This is not your place anymore.” Hari Prasad Sacré The Non-Resident Nepali (NRN) card is a lifeline for Nepali diaspora members, granting them residency and property rights in Nepal. Yet, adoptees are notably excluded from this framework. While the law stipulates eligibility for individuals whose parents or grandparents were Nepali citizens, it makes no provision for adoptees whose legal ties to their Nepali parents were severed by adoption. When Hari Prasad Sacré, a Nepali adoptee, sought to obtain an NRN card at the Nepal Embassy in Belgium, he encountered officials unfamiliar with processing an NRN request from an adoptee. His case was the first of its kind, setting a precedent but also highlighting the systemic barriers adoptees face. "You are not eligible; your surname is Sacré, it is not a Nepali name," an embassy staff said.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120140_9bdc24b7e34930059f895048ab7dc0ad3ca23b16907c572f01a8d5404a5feac5.jpg" data-media-id="editor_5" data-image-id="20250103120140_9bdc24b7e34930059f895048ab7dc0ad3ca23b16907c572f01a8d5404a5feac5" data-rendition-name="original" width="446" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>Hari Prasad Sacré receives tika from his father Khul Prasad Adhikari during Dasain, a few weeks after receiving his NRN card. Photo: HARI PRASAD SACRÉ</figcaption> </figure>  Sacré’s situation was legally ambiguous. Although his biological parents, including his father, Khul Prasad Adhikari, are alive and he maintains contact with them, he no longer had “legal” ties to Nepal due to the adoption process. Carrying a Belgian surname the embassy staff was initially convinced the adoptee couldn’t claim Nepali origin. Nepali law, which does not recognise biological parents as legal guardians once a child is adopted, created complications for the NRN application. To navigate this complexity, Sacré relied on a testimony from his father. Issued by a local government body in Kaski, the testimony affirmed that Hari had been put up for adoption and was of Nepali origin. While this enabled the embassy to approve his NRN card, the process was unnecessarily protracted and emotionally charged, highlighting the inadequacy of current policies to accommodate the unique situations of adoptees. Sacré’s case represents a rare instance where biological parents were alive and willing to provide testimony, but many adoptees are not as fortunate. A large number of adoptees were declared “orphans” during the adoption process, even when their parents were alive. This severed their legal ties to Nepal, stripping them of documentation that could later prove their origin. For others, the absence of living biological relatives or access to their original adoption records creates insurmountable barriers. Without clear documentation or a family member to vouch for their Nepali heritage, adoptees are excluded from the NRN framework. This denies them the rights and privileges afforded by the card, including property rights, legal recognition, and a formal connection to their homeland. Current laws fail to account for the complexities of adoptees’ legal status, leaving them disconnected from their cultural and legal heritage. Adoption papers, as evidence of Nepali descent, should be accepted as proof, granting adoptees rightful access to the NRN card and ensuring their inclusion in Nepal’s diaspora. Such reforms are crucial to ensure that all adoptees, regardless of their circumstances, can reclaim their heritage and establish a sense of belonging in Nepali society. Without these changes, the systemic exclusion of adoptees will persist, perpetuating inequities and denying them the opportunity to step up as active members of the Nepali diaspora. Sacré’s case serves as both a precedent and a call to action. It exemplifies the challenges and triumphs of adoptees navigating complex bureaucracies and advocates for a more inclusive and equitable approach to reconnecting adoptees with their homeland. Nepal can draw inspiration from South Korea, where the government has actively supported the reintegration of adoptees into their society. The F4 visa, established through efforts by organisations like the Global Overseas Adoptees’ Link (GOA'L), grants adoptees the right to live and work in Korea, while dual citizenship acknowledges their dual identity as members of the diaspora and their country of origin. GOA’L further fosters reconnection by offering language classes and cultural exchange programs, creating opportunities for meaningful reintegration and belonging. As Nepal refines its NRN citizenship framework, explicitly including adoptees could address the severance of legal and cultural ties caused by international adoption. Such inclusion would provide adoptees a pathway to residency, citizenship, and rights, enabling them to reconnect with their heritage. Complementing this with programs for language acquisition, cultural immersion, and historical education would honour Nepal’s responsibility to the approximately 5,000 children sent abroad. Nepal could establish a dedicated organisation similar to South Korea’s GOA’L and help adoptees access pre-adoption records, navigate legal processes, and engage in cultural exchange initiatives. It would also serve as a bridge between adoptees and Nepali society, fostering mutual understanding and collaboration. This article is based on doctoral studies by <a href="http://hdl.handle.net/1854/LU-01H4Z85GPS63ZWDJ3WB2E6KS70">Hari Prasad Sacré</a> and <a href="https://www.tandfonline.com/doi/full/10.1080/10357823.2022.2142932">Chandra Kala Clemente-Martínez</a>. Hari Prasad Sacré, PhD, is a postdoctoral researcher at Ghent University in Belgium, specialising in cultural translation, multilingualism, and identity in education. His PhD, Reading Illiteracy, explored fractured multilingualism and illiteracy in displaced identities such as adoptees, with work published in leading journals like Critical Arts and the European Journal for Cultural Studies. Chandra Kala Clemente-Martínez, PhD, is a postdoctoral researcher at the AFIN Research Group, Autonomous University of Barcelona, with a PhD in Social Anthropology. Her research focuses on family strategies, reproductive decisions, and adoption, with extensive fieldwork in Spain and Nepal examining adoptee reunions and related governance and rights.