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

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Taking wealth out of health

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219c9c7e80680e0c02c6jpeg.jpg" alt="" width="1000" height="662"/>This year’s health budget kept the contribution to health insurance of the previous year's allocation of Rs7.5 billion. However, the plan to hand over the institutional management of health insurance programs to the private sector through the Ministry of Finance defeats the fundamental goal of the health security.This is not entirely surprising, of course, because the Health Ministry had passed a <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">narrow and poorly thought model of health security</a> for Nepal, and there were already concerns that it would eventually be handed over to the private sector and traded as a commodity.A private company can contribute to a health insurance program. But can they really contribute to national public health security, understand equity, expand <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">access to the poorest and the most marginalised</a> population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">National health insurance not as easy</a>, Sonia AwaleThe private sector has a role in contributing to achieving Universal Health Coverage by mainly serving the affluent. The poor neither can afford private health insurance nor access expensive private hospitals. Even if they are admitted to hospitals, they have to bear <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">catastrophic expenses</a> pushing them into the vicious cycle of poverty.The private insurance companies only pool the resource, they do not share the risk for those who cannot afford to pay the premium. It will be naïve to assume that such companies could be easily maneuvered to deliver services as a fair-price approach. There are around 20 registered private health insurance companies and 366 private hospitals in Nepal, and some are <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling health insurance at exorbitant premiums</a> many times higher than the current premium cap.There are six national health security indexes: prevent, detect, response, health, norms, and risk. During the pandemic, insurance companies got richer by <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling fake insurance schemes</a> while the hospital profits bulged through expensive Covid treatment. Very few hospitals treated Covid patients with a humanitarian approach. None of their technical advancements helped effectively prevent, detect, and respond to the pandemic.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219f9c7e80680e0c02c7jpeg.jpg" alt="" width="1641" height="1000"><figcaption> </figcaption></figure>The current health insurance program has identified the elderly, completely disabled, leprosy, Multi-Drug Resistant TB patients, people living with HIV, and ultra-poor as target populations to waive their premium. Though not adequate, this is an equity approach.But none of these target populations are <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">eligible for private health insurance</a>, or they will have to pay a much higher premium. It will be unwise to assume that these companies will change overnight and be equitable. They are powerful enough to influence government policy and have the power to bend them to suit their commercial interests.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, EditorialInstead, the government should <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">strengthen the Health Insurance Board</a> and explore ways to integrate health security with the broader social security scheme. In the short term, there are urgent but straightforward reforms like recruiting adequate and skilled human resources, strengthening the organisational systems, revising the design of service purchase strategy and equity, and gradually, having effective providers/purchasers split for better implementation.Ultimately, the program will benefit by forming a broader and more robust social security structure, co-incidentally introduced at the same time by the government. It would be able to absorb costs by pooling tax-based health care contributions and merging subsidies given to the treatment of cancer, renal failure, and other chorionic diseases under one integrated umbrella.But the current government does not appear serious about <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">reforming health insurance</a>, and simply does not understand the fundamental principles of health security. Health insurance is not just limited to providing health care, but is a part of broader health security.Read also:  <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe idea that health security can be strengthened by passing the buck to the private sector amounts to abandoning the constitutional commitment to provide health care, not as a service but as a citizen's fundamental right. The Nepal government is a signatory to achieving the health targets of the Sustainable Development Goals.As argued by Nepali Congress leader Gagan Thapa, who is one of the pioneers who <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">pushed health insurance</a> in Nepal, they contribute to strengthening the health system, strive for healthy populations, cushion the poor and provide them access to health services. It is a vehicle for mobilising adequate health resources, enhancing health security, and ultimately achieving Universal Health Coverage.These goals cannot be met by trading the people's health as mere commodities.Gaj Gurung has a PhD in public health from Chulalongkorn University and Sushil Koirala is a public health expert. Both are based in Bangkok.Read more: <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

Dangers of privatising health insurance in Nepal

https://www.youtube.com/watch?v=Czp7hVr4LTkHenry Marsh is a pioneering English neurosurgeon and the author of two widely acclaimed memoirs, Do No Harm: Stories of Life, Death and Brain Surgery and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/book-review-Admissions-Henry-Marsh-Neurosurgeon,4055" target="_blank" rel="noopener">Admissions: A life in brain surgery</a>. He was a colleague and friend of the <a href="https://www.nepalitimes.com/here-now/upendra-devkotas-lives/" target="_blank" rel="noopener">late Upendra Devkota</a>. Nepali Times caught up with Marsh at the <a href="http://www.neuro.org.np/" target="_blank" rel="noopener">Upendra Devkota Memorial National Institute Of Neurological And Allied Sciences</a> in Kathmandu, where he teaches post-retirement.Excerpts:Nepali Times: How did your involvement in Nepal start?Henry Marsh: Professor Devkota and I were neurosurgical trainees together in London more than 35 years ago. We became quite good friends then, and when I retired from working fulltime for the <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nhs.uk/" target="_blank" rel="noopener">National Health Service in Britain </a>four year ago, I really wasn’t ready to stop working. I wrote to the professor, who’s known to all his English friends as Dev, and I said, “Would you like me to come out to Kathmandu and help train some of your team?” and he said,“Please come”. This is now my fifth visit over the last four years. <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/from-the-nepali-press/i-want-to-live-my-last-among-friends/" target="_blank" rel="noopener">Tragically he died last year</a>, and everything therefore changed profoundly.Why were you drawn to Nepal?I was drawn because I like seeing the world. A lot of the potential privileges you have as a doctor is that you have a specialised set of skills which transfer over the world and English is really the international language of medicine.The great privilege of working in a cooperative professional way is that you get a much better insight into the country than if you are merely a tourist. For me, it is true travel but it is work – it is not easy always, and if you come to a country like Nepal to help your colleagues, you have to come again. You can’t just sort of dive in and then dive out again. It calls for a fairly major commitment, both in terms of time and financially and sort of emotionally as well.What do you remember most about Dr Upendra Devkota?The man was just this little ball of fire – he was extraordinarily energetic. There was never a dull moment with him. He was an extraordinarily dynamic person and to create an entire specialist neurosurgical hospital more or less from scratch was a quite extraordinary achievement.The problem with great dynamic individuals is the succession problem and of course none of us expected him to die at the relatively young age he did and really quite suddenly. I remember before his illness, sitting down with him in his beautiful garden and saying “What happens if you drop dead tomorrow? What will happen to the hospital?” Fortunately, he had some very good trainees and in recent years he had been giving them more and more, not exactly independence, but they were doing more and more of the work so they were fortunately able to take over the workload when he fell ill and they’ve coped remarkably well.I was involved a bit in helping them get better and training them. I take some personal pride in that as well. I was watching one of the senior ones here doing a very difficult operation a few days ago and it really was a joy to watch. He was using a microscope and he was doing a very difficult case – I was watching on a computer monitor and he really did it very beautifully. As a trainer, any senior doctors will tell you in a funny sort of way you get more pleasure from all the people you’ve trained and seeing their success rather than all the, in my case tens and thousands, patients I’ve treated over the years of my career. <figure><img width="2622" height="1612" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664a9c7e80680e059972jpeg.jpg" alt=""/><figcaption>Henry Marsh. Photo: SAKINA ABIDI</figcaption></figure>What are the challenges of specialisation in Nepal?It’s not unique to Nepal by any way, but the problem is this: if you have a relatively impoverished government and if people are reluctant to pay taxes, it’s very hard for the government to be able to afford good quality healthcare.Therefore, doctors working in expensive specialist areas like neurosurgery end up setting up their own private hospitals. This has happened in India, in Sudan which I know well, it’s happening in Ukraine and it’s happening here. You then end up with all these separate private hospitals which are basically locked in economic competition against each other. They all profess to be all working happily together for the greater good but it’s very difficult – they have to make a profit to survive and this sets doctors against each other.Now all surgeons, we all know that the more we do of a particular sort of surgery the better we get. If that workload is divided up and split between many different departments and different surgeons, no one person is really going to become very good at dealing with it.If you look at what’s happening in Europe and America, super specialisation is the game. I trained along with Professor Devkota in what’s called general neurosurgeon – I could do everything. But in recent years, we all stopped doing that, we became more and more specialised. I ended up specialising mainly in brain tumour surgery and even then, in particular sorts of brain tumours, which means I became very, very expert in that particular sort of case. That is not happening in Nepal.Do you have any solutions?I’m not here to tell people what to do because I don’t know. What I do know is that all healthcare systems reflect the underlying culture of the country. If there is a solution – it has to come from the people living in that country.Could you touch on the over-commercialisation of healthcare in Nepal?With all medicine, there’s a problem – is medicine a vocation or is it a business?Our judgement is easily distorted, unconsciously, and if you know you’re going to make a lot of money by treating the patient, or if you know your hospital needs to make money to survive, that’s probably on an unconscious level going to distort your judgement of whether to operate or not. Ultimately, with commercial healthcare, the patient becomes the means to the end of making money. With the other extreme, if doctors are only paid fixed salaries in a state system, in theory at least, the end of everything you’re doing is for the wellbeing of the patients and making money is not relevant.Read Also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor Health,</a> Editorial <figure><img width="500" height="574" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664d9c7e80680e059973jpeg.jpg" alt=""><figcaption>Henry Marsh training Nepali surgeons at the Neuro Hospital in Bansbari, Kathmandu in 2017. Photo: ESCAPMEDIA</figcaption></figure>What has your experience been like working with the hospital here?I think it’s a wonderful hospital. I love coming here. It’s not always easy for me, for various reasons, but I have absolutely no hesitation in wanting to help as much as I can. Clearly the transitional period following Professor Devkota’s death was very difficult. He was very famous, and it was like a magnetic attraction: patients came from all over Nepal to see him, often without neurosurgical problems. Inevitably now, with the change of staff, it’s been a difficult transitional period. What strikes me is the way the hospital’s survived. One might have thought it would completely collapse once he had gone but that’s not the case at all. How do we implement affordable and accessible healthcare in rural areas in Nepal?I’m not a public health expert. A major problem in Nepal, apart from the poverty, is poor infrastructure. In Europe, you can get patients fairly quickly from rural areas to central hospitals. That is often impossible in Nepal. You have to compromise, and you have to have more peripheral small hospitals out in the rural communities than you would in wealthier countries with more favourable terrain.Nepal has many problems. If you wanted to design a country to have difficult problems, Nepal is that. We all know being landlocked is a major problem for economic development. Having all these mountains and <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener">adverse geographical features makes life difficult </a>as well.Read Also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Policies-for-the-people,3640" target="_blank" rel="noopener">Policies for the people</a>, Marty Logan<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" 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 KalauneeWhat are some of the values you want to pass on to the younger generation of surgeons?Firstly, to ask for help and not try to think you know everything because we don’t know everything. As young doctors, we’re often very anxious and frightened and we have to pretend to patients that we’re better than we are. We often end up pretending to ourselves as a way of boosting our self-confidence. It can be easier. I speak from personal experience; I can think of many patients who came to harm because I made this mistake. I didn’t ask for help from someone more experienced than myself.My message to young doctors is it is OK to feel frightened. That’s the nature of the work. You can’t be a good doctor, particularly when you’re young and fairly inexperienced, without being anxious and frightened. Don’t feel ashamed to say "I don’t know", not to the poor old patient, but don’t feel ashamed to say to a senior colleague “I need your help”.The other advice I give to young doctors, apart from ask for help, is listen to patients. So many doctors, including myself when I was younger, just sort of talk at patients rather than talk with them. Purely in terms of making a diagnosis and making the right decisions, listening to the patient’s story is very important. I’ve worked all over the world and medical systems vary all over the world. Doctors vary all over the world. As far as I can tell though, we’re all the same as patients: we’re frightened, we’re anxious, we want to be treated with respect. We want to be treated with respect and doctors are often bad at doing that – particularly in rather hierarchal societies like Nepal.

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Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota

For many decades it was an accepted truth that Nepal’s main public health threat was from infectious diseases, and the most cost-effective way to address that was through prevention. In other words, the first line of defence against communicable diseases was communication.Whether it was gastric infections caused by contaminated water, respiratory ailments due to cold and pollution, or diseases spread by insect vectors like malaria – the goal was to spread public awareness about prevention. Radio jingles about oral rehydration salts or acute respiratory infections in children indirectly helped save millions of lives over the years.Many of these challenges remain. Despite dramatic progress, many Nepalis still lack safe drinking water – not just in the roadless hinterland but right here in the heart of the capital. There are frequent <a href="http://archive.nepalitimes.com/article/nation/%20jajarkot-open-defecation-free,2023">cholera</a> epidemics. Children’s lungs are still affected by indoor smoke from wood fires. Malaria is on the comeback due to resistance and there is an annual epidemic of dengue and encephalitis.Yet, compounding these endemic infections, there is now an <a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">increasing burden of non-communicable diseases and injuries</a> (NCDI). New lifestyle-related cardio-vascular afflictions, chronic obstructive pulmonary disease (COPD) caused by <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/every-breath-we-take-air%20pollution,3536">pollution</a>, or <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486">mental health disorders</a> have added to the burden of disease and disability. <a href="http://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">South Asians are already genetically susceptible to diabetes</a>, and now there are new risk factors due to migration to urban centres. While the world average for prevalence of both types of diabetes is 8%, more than 14% of people in urban centres like Dharan have diabetes – even though the prevalence for rural Taplejung, for instance, is only 1%.A study by The Nepal NCDI Poverty Commission released this week shows that the burden of NCDIs has doubled in the last 25 years. More than half of all death and disability today are caused by NCDIs, with nearly 15% caused by injuries in conflict, natural disasters or highway accidents. <img width="900" height="802" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517699c7e80680e02c275jpeg.jpg" alt=""/>Being afflicted with an NCDI (or chronic disease) is more fatal in Nepal than in developed countries because of affordability and restricted accessibility to adequate medical treatment. The poor are disproportionately vulnerable. The NCDI burden in Nepal is also different than in other parts of the world – there is a higher incidence of ischemic cardiac conditions, asthma, neurological disorders, cancers caused by untreated infections and injuries, for instance.For us, the report’s main finding, and most damning inference, is about how <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">treatment of NCDIs is driving Nepalis into indebetedness and penury</a>. The survey shows that half of all medical expenditure of families is out-of-pocket, and 60% of that is for treatment of NCDIs. This is because the government spends only 11% of its budget on health care, and only 6.4% of that is for treatment of non-communicable diseases.Despite the proven link between chronic ailments and poverty, donors still allocate only 1% of their development assistance for NCDIs.Treatment of injuries, gastro-intestinal infections, heart diseases, cancers, kidney and liver diseases are the most impoverishing NCDs for households. The report’s main conclusions are corroborated by our <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">field report</a> from Achham and Kavre this week  about how the lack of even basic surgical facilities in district hospitals and health posts is forcing Nepalis to undertake expensive and extended trips to private hospitals in the cities.Another recent study of 39 government hospitals commissioned by the Nick Simons Institute (NSI) showed a huge unmet need in remote areas for basic surgery like caesarians, orthopaedics, and abdominal operations. Nepal’s surgery rate is well below the Lancet Commission’s target of 5,000 operations per 100,000 population. Only one-third of patients currently can reach an orthopedic surgeon within two hours of travel. <img width="640" height="456" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365176b9c7e80680e02c276jpeg.jpg" alt="">The public-private partnership models that NSI and Possible are carrying out in remote government hospitals are ways to plug this gap: ensuring minimum staffing of a MDGP physician, anaesthesia assistant, staff nurse and biomedical technician in each hospital can offer basic treatment and surgery in remote areas, reduce the need for referrals, and save household income. At present Nepal’s density of hospitals with such staffing and equipment is at 0.4 per 100,000 population, as against the Lancet Commission’s recommendation of 20/100,000.The Nepal NCDI Poverty Commission report suggests additional measures: national health care delivery should respond to the increasing burden of NCDIs by decentralising.Impoverishment of households due to the high cost of treatment should be addressed through disease-specific policies for high-cost conditions and expansion of insurance coverage.It is often said that health is wealth, but in Nepal wealth is health. That can only be changed by making treatment of chronic conditions and injuries accessible, affordable, inclusive and equitable.Read also:<a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">State of the art rural hospital</a>, Marty logan <a href="http://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<a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">Communicating about non-communicable diseases</a>,  Elina Pradhan and Bigyan R Bista

Poor  health

On Tuesday, leader of the monarchist RPP once again gathered on Kathmandu’s streets to deliver fiery speeches, but this time there was no arson and looting and no need for riot police to fire live rounds or tear gas.
RPP leaders demanded the release of their members including vice-president Rabindra Mishra and MP Dhawal Shamsher Rana were arrested during the violent <a href="https://nepalitimes.com/news/republicans-and-royalists-on-nepal-s-streets">28 March protests at Tinkune </a>which left two dead. 
They denounced the current leadership of the main parties, demanding the <a href="https://nepalitimes.com/editorial/nepal-party-reincarnating-hindu-monarchy">restitution of Nepal as a Hindu kingdom</a>. They also said the government was responsible for the fatalities on 28 March because it provoked its rally with a tear gas attack even before it started.
It has now been revealed that the police fired at least 100 live rounds from high powered assault rifles at the crowd. Twenty-one of the 120 injured received bullet wounds, and most of them were bystanders and people trying to reach home. 
Tuesday protest on the Ring Road in Balkhu was much more subdued, and comparatively fewer RPP supporters showed up. The arson and vandalism in the previous protest appears to have cost some support for <a href="https://nepalitimes.com/news/the-ghost-of-monarchy-returns-to-haunt-nepal">former king Gyanendra </a>especially for the anointment of medical tycoon and bank defaulter <a href="https://nepalitimes.com/news/street-politics">Durga Prasai </a>as ‘commander’ of the Tinkune rally.
Some monarchists acknowledge Gyanendra’s mistakes when was king 2001-2008, but say he has had a lot of time to reflect on his shortcomings and seems more disciplined and committed. His supporters have tried to build on nostalgia among some Nepalis for<a href="https://nepalitimes.com/news/why-invest-in-nepal"> domestic stability </a>and international respect that <a href="https://nepalitimes.com/here-now/if-birendra-was-alive-nepal-could-still-be-a-monarchy">the monarchy</a> commanded. 
“Nepalis were promised better service delivery, opportunities for the underserved, as well as better, more honest use of state resources, but the <a href="https://archive.nepalitimes.com/news.php?id=16992">people in leadership </a>have not been able to deliver on their commitments,” says RPP leader Prakash Chandra Lohani. “The gap between their rhetoric and reality has widened, the people feel betrayed, and the respect Nepali people had previously had for them has changed to revulsion.” 
Indeed, many commentators have warned the three main parties and their <a href="https://nepalitimes.com/editorial/politics-as-usual">serial prime ministers</a> who have ruled Nepal for much of the past 30 years should address rising public anger with them, and see the writing on the wall.
‘<a href="https://nepalitimes.com/news/nepal-government-changes-again">The UML, NC and Maoists</a> must introspect about their conduct,” warns Gunaraj Luitel, editor of Nagarik, in an op-ed this week. ‘These leaders for life may save themselves from simmering public anger, but they will not be able to save the system. The monarchist wave can only be dispelled when citizens are assured of <a href="https://nepalitimes.com/here-now/nepal-s-local-election-gives-power-back-to-people">better governance</a> through <a href="https://nepalitimes.com/latest/real-world-training-for-youth-leaders">younger leaders</a>, and reforms.’ 
Rifts between radical royals who are gunning for a return to <a href="https://nepalitimes.com/here-now/mob-movement-and-mayhem">Panchayat-style absolutism </a>and moderate monarchists who favour a constitutional king have also weakened the movement somewhat. The split between the RPP and RPP-Nepal cost the royalists numbers in Parliament in 2022, and both parties denounced the violence last month, albeit shifting the blame on the government.
The irony is that the same royalists who want to scrap the republican Constitution had formed electoral alliances with the UML during the 2022 elections. RPP-Nepal chair Kamal Thapa contested the 2022 election with the UML. Thapa has not taken part in the last two rallies, saying he will only be a part of a movement under a national flag, and not a RPP party banner.
For his part, the RPP’s Rajendra Lingden is said to be hesitant to censure some of his party’s more radical royalists for fear of fissure within his ranks, despite his aversion to Durga Prasai’s role. 
Analysts have questioned why <a href="https://nepalitimes.com/news/old-is-still-gold-in-nepali-politics">supporters of the monarchy </a>have decided to reestablish an institution that would not ultimately have executive decision-making power. There are doubts about whether authoritarian-minded Gyanendra will be satisfied being a <a href="https://archive.nepalitimes.com/news.php?id=13957">ceremonial king</a>. 
Read also: <a href="https://nepalitimes.com/news/nepal-s-deja-vu-on-black-friday">Nepal’s déjà vu on Black Friday</a>, Sonia Awale
"The Nepali people will not accept <a href="https://nepalitimes.com/here-now/forgotten-woman-who-sheltered-communist-activists">an absolute monarchy </a>at this point of time, and both the public as well as <a href="https://archive.nepalitimes.com/news.php?id=8371">king Gyanendra</a> are fully aware that there is no other possibility beyond a constitutional monarchy," asserts the RPP’s Lohani. “The traditional monarchy’s institutional capacity might have been enough to meet the needs of feudal Nepal, but an absolute monarchy is impossible both in concept and practice in the context of <a href="https://archive.nepalitimes.com/regular-columns/Economic-Class/waiting-for-an-industrial-revolution,784">modern day Nepal</a>.”

New year revolutions

Besides multiple <a href="https://nepalitimes.com/news/republicans-and-royalists-on-nepal-s-streets">street demonstrations </a>that gridlocked Kathmandu’s traffic for the past weeks, public discourse in Nepal has also been dominated by dangerously <a href="https://nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking">high air pollution levels</a>. Caused mostly by hundreds of <a href="https://nepalitimes.com/news/wildfire-season-starts-early-in-nepal">forest fires </a>raging across the country, the smoke contains suspended soot particles that harms <a href="https://nepalitimes.com/opinion/playing-with-poison">human health</a>. Thursday’s rain have cleared the air somewhat, and many people will soon forget how bad the air quality was. But the time to address the roots of next summer’s fire season is now.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411060440_d1a119716a9031aadfdd611d299348d436842d376a03e664b8d773957a237524.jpg" data-media-id="editor_4" data-image-id="20250411060440_d1a119716a9031aadfdd611d299348d436842d376a03e664b8d773957a237524" data-rendition-name="original" width="502" height="540" loading="lazy" alt="Wildfires"> <figcaption>EXTINGUISHED: Forest fires raging all over Nepal in the week after 3 March (above) reduced air quality, creating a public health hazard in Kathmandu and across the country. Each red dot is a fire detected by infrared sensors on the NASA Fire Information for Resource Management System (FIRMS) satellite. But the rain on Thursday doused most of the fires (below) with more rain forecast over the weekend.</figcaption> </figure>  The reason everyone was talking about air pollution was because the<a href="https://nepalitimes.com/banner/nepal-is-going-up-in-smoke"> smoke from wildfires</a> was visible. But much more toxic are the invisible and odourless <a href="https://nepalitimes.com/news/nepal-doubles-its-carbon-footprint">gases from vehicular and industrial emissions </a>which have always been there. The theme of World Health Day on 7 April this week was ‘Healthy Beginnings, Hopeful Futures’ dedicated to <a href="https://nepalitimes.com/opinion/comment/saving-more-mothers-and-babies">preventing maternal and newborn deaths</a>. It is estimated that in Nepal, 30% of neonatal mortality can be blamed on air pollution. But that is only part of the story. Harmful as fine particulate matter is to human health, carbon monoxide, nitrogen dioxide, ground-level ozone and other gases in vehicular emissions are more hazardous to health. While the concentration of suspended particulate matter tinier than 1.5 microns (PM2.5) is closely monitored, these toxic gases are invisible, not measured much, and the public is not aware about the dangers they pose. Surface ozone is produced by the interaction of various gases found when <a href="https://nepalitimes.com/news/fossil-fuels-poison-air">burning fossil fuels</a>. Besides being poisonous, ground level ozone contributes up to 0.23°C to <a href="https://nepalitimes.com/here-now/nepal-s-mountains-are-melting">global warming</a> because it is also a greenhouse gas. A new policy brief by the Clean Air Fund titled The Case for Action on Tropospheric Ozone blames surface ozone for a half a million premature deaths every year, 54.8% of which are in South Asia. Ozone also stunts plant growth and reduces crop yields by 26% globally, and 11% loss in <a href="https://nepalitimes.com/news/economic-benefits-of-saving-the-ecology">forest productivity</a>, the report adds.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411060456_aa02a923f8b27544ae54d0220162678f5bbb5eeb8fc3c466173c22c49b3e9a85.jpg" data-media-id="editor_11" data-image-id="20250411060456_aa02a923f8b27544ae54d0220162678f5bbb5eeb8fc3c466173c22c49b3e9a85" data-rendition-name="original" width="998" height="724" loading="lazy" alt="Gas Chambers"> </figure>  Read also: <a href="https://nepalitimes.com/here-now/bad-air-and-polluted-politics">Bad air and polluted politics</a>, Sonia Awale Ground-level ozone is not emitted directly into the air like other gases, but is formed when oxides of nitrogen (NOx), carbon monoxide (CO) and volatile organic compounds (VOCs) released from automobile tailpipes or industry smokestacks react chemically with each other in the presence of sunlight. The main source of carbon monoxide in Kathmandu Valley are its 1.2 million two-wheelers. “Usually the concentration of carbon monoxide is 200-500 parts per billion (ppb), this has increased up to 3,000 in Kathmandu. Meanwhile, ground-level ozone has gone from 70-80 ppb to 150 ppb,” says Ravi Sahu, regional air quality specialist with the Kathmandu-based International Centre for Integrated Mountain Development (ICIMOD).&nbsp; Sahu says <a href="https://nepalitimes.com/news/no-smoke-without-fire-p7vb9dcj">rampant forest fires of the past weeks</a> have also added to carbon monoxide and ozone in the air, not just the fine particles that make up the visible smoke. He adds, “There isn’t much awareness about <a href="https://nepalitimes.com/banner/poisoning-the-air-we-breathe">ground-level ozone and carbon monoxide</a>, we need to urgently look into it.” A distinction must be made between good and bad ozone. Stratospheric ozone protects living beings from harmful ultraviolet (UV) radiation from the sun.&nbsp; Tropospheric ozone can again be separated into two types: ozone in the free atmosphere which is a greenhouse gas much more potent than carbon dioxide, and ground-level ozone which has adverse impacts on health and agriculture. ‘Cutting tropospheric ozone presents a unique challenge as it requires smart and fast action across multiple greenhouse gases and air pollutants, as well as multiple economic sectors,’ notes the Clean Air Fund's policy briefing. ‘It is a growing and neglected problem that needs an integrated approach on both a local and global level to tackle climate change and air pollution together.’ Dying young There was a time when Nepal made it to international news bulletins only if there were fatalities on Mt Everest. Now, Kathmandu’s bad air frequently makes headlines all over the world. This past week, the concentration of PM2.5 that harms human health was up to 40 times the WHO recommended guideline — adding to the poisonous gases already present from vehicle emissions. The Department of Environment says 40% of the pollution in the past weeks was from wildfires sparked by nearly 6 months without substantial rain over central Nepal. Most of the rest is from vehicular and industrial emissions from Kathmandu itself and across the southern border. NASA’s Fire Information and Resource Management System (FIRMS) which issues daily maps of fires, showed hundreds of blazes raging across Nepal on Wednesday, mainly in Chitwan, Parsa and along the East-West Highway.&nbsp; “If we look at the figures for the last few years, it is clear that wildfires have become the biggest source of air pollution, they are seasonal but have overtaken vehicular emissions,” says urban planner and environmentalist Bhushan Tuladhar. “Forest fires, stubble burning, and open burning of garbage are the bigger problems now. Nepal, India, Bangladesh, and Pakistan are at risk every year, we shouldn’t further delay in finding solutions,” warned air quality expert Bhupendra Das during an event on air pollution organised on 7 March by the Nepal Forum of Environmental Journalists (NEFEJ).&nbsp; Indeed, studies have shown that in winter 60% of the air pollution over Kathmandu is transboundary from the south, and in November it is compounded by smoke from crop residue burning by farmers in India and Pakistan blown in by prevailing winds. Forest fires are a regular pre-monsoon occurrence in Nepal, often intentionally set by farmers and herders to stimulate new grass growth for livestock. Winter rains have failed for eight of the past ten years, and this means the fires often spread out of control. The other reason for the increase in wildfires is the doubling of forest fires to 46% of the country’s area in the past 25 years. But this has happened simultaneously with outmigration, with some mountain districts losing 30% of their population between 2011-2021. With less pressure on forests for fodder and firewood, the undergrowth of community forests is loaded with dry fuel just waiting for a spark. The bowl-shaped topography of Kathmandu, Pokhara and other valleys further concentrates pollutants as they are trapped by surrounding mountains. But a year with a high number of wildfires is usually followed by a year or two with fewer incidents. For example: there were 6,537 fires in 2021 but the following year the number was down to 1,528. There were 5,216 fires last year, this year the number has already reached 1,800, and the trend is likely to be broken. Heavy rains forecast for the coming days are expected to douse some of the fires and clean up the air. But the damage has been done: Kathmandu residents of all age groups this week crowded clinics and hospitals with burning eyes, itchy throats, difficulty breathing, headaches, and dizziness. But in the longer term, soot particles that are tiny enough to jump the blood-air divide in lung capillaries do not just cause Chronic Obstructive Pulmonary Disease (COPD), asthma, but also cancers, heart attacks, strokes, birth defects and other chronic diseases. The latest Air Quality Life Index (AQLI) report by the University of Chicago shows that the annual concentration of PM2.5 in Kathmandu’s air rose from 17.87µg/m3 in 1998 to 31.33µg/m3 in 2022. Air pollution has got worse by 75% in Kathmandu in 25 years. During this time, air pollution has reduced the average life expectancy of Kathmandu’s residents by 3.5 years. According to the Health Effects Institute in Boston, dirty air is among the biggest public health concerns in Nepal killing over 42,100 a year. The adverse impact of high levels of air pollution is not limited to public health, it is seriously affecting tourism. Operators in Pokhara this week said that there were many negative online posts by visitors unable to see the famous panorama of Machapuchre and the Annapurnas even from Sarangkot. Aviation is also affected, as planes have to circle sometimes for hours burning a lot of fuel because of runway visibility being below minima at Kathmandu airport. The higher fuel cost is just passed down to customers, making air tickets in and out of Kathmandu some of the highest in the world. Kathmandu, with a population of four million, has not implemented a concrete policy to curb toxic air despite having formulated various action plans and repeated commitments by the government to protect the environment and control air pollution. The Department of Environment’s 2017 Air Quality Management Action Plan for Kathmandu put forward a policy to reduce air pollution caused by vehicles which was approved by the Cabinet, but has yet to be put to practice. The action included the immediate implementation of the Euro 5 emission standard to reduce pollution emitted by vehicles. However, Nepal has not even been able to implement Euro 4 standards so far. India, meanwhile, has already moved forward with the implementation of the Euro 6 standards. Says Ravi Sahu: “Air pollution in Nepal is not just about air pollution, it has ties to tourism, aviation, the economy so we must be prepared for annual conditions like forest fires, and this requires urgent interdisciplinary collaboration.” &nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411050452_821d09e283d8a590f1369bfb71b9b7fc6d950726e0651ea86c6488d04deb1742.jpg" data-media-id="editor_15" data-image-id="20250411050452_821d09e283d8a590f1369bfb71b9b7fc6d950726e0651ea86c6488d04deb1742" data-rendition-name="original" width="839" height="784" loading="lazy" alt="Silent Killers"> </figure>  &nbsp;

What is invisible is more dangerous

82 in २०८२

Here in the mountains of far-western Nepal, the biggest threat to life and limb is gravity. Women collecting fodder fall from trees, boys grazing goats fall off cliffs, heavily loaded tractors plunge from dirt roads carved out of steep slopes. There is nothing to be done about those who die on the spot. But for the severely wounded there is only one hospital: Bayalpata. And it is there that <a href="https://www.youtube.com/watch?v=CJzWlnYd0ZM&amp;t=8s" target="_blank">orthopaedic surgeon Mandeep Pathak</a> is the last hope for many wounded people. Pathak, 42, is too modest to tell us how many lives he has saved over the past 10 years he has worked at Bayalpata. But hospital records show he has performed more than 4,000 operations in the past decade, many of them so patients did not suffer permanent physical disabilities. Pathak also did 800 major life-saving surgeries in that time. “I treat patients with injuries, but I wish I could also treat poverty,” Pathak says, emerging from Bayalpata’s surgical theatre one recent afternoon. <div class="embed-block"><iframe width="700" height="415" src="https://www.youtube.com/embed/CJzWlnYd0ZM?si=s_rkbU4YDaw87gqH" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe></div> Sudurpaschim Province in Nepal’s far-west is far away from everything: from Kathmandu, from adequate medical care, from food security, and far from the reach of government services. It has suffered state neglect for centuries, its men mainly migrating to India for seasonal work to families who depend on subsistence agriculture. Pathak remembers the searing sadness he felt when a patient once told him, “Doctor, I sold the last of my rice to pay to come here, please give me a medicine that I can take on an empty stomach.” Pathak was born in Kathmandu, and after getting his MBBS from Kathmandu University, he got an MD from The Philippines. At a time when many Nepali doctors and staff nurses were emigrating, Pathak did not just return to Kathmandu but decided to go to one of the remotest districts in Nepal to serve those most in need. The hospital was established in 2009 in the village of Bayalpata, and has been managed by the non-profit <a href="https://www.nyayahealthnepal.org/" target="_blank">Nyaya Health Nepal (NHN)</a> as a public-private partnership treating 100,000 patients a year for no fees at all. NHN is now preparing to hand over the running of the hospital to the Sudurpaschim provincial government so its <a href="https://nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health" target="_blank">model of hospital management</a> can be replicated.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250414130456_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae.jpg" data-media-id="editor_4" data-image-id="20250414130456_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Bayalpata hospital"> <figcaption>Bayalpata hospital in Achham.</figcaption> </figure>  People from not just Achham but surrounding districts, and from as far away as Humla, bring patients to Bayalpata, sometimes walking for days. Some with complicated pregnancies are brought in stretchers, young children with broken arms walk into the emergency, and sometimes there are mass casualties when a tractor or bus falls off a road. And Pathak is always there with his team performing triage, and doing orthopaedic surgeries that would be difficult even in Kathmandu. Recently, his team did a hip replacement at <a href="https://nepalitimes.com/banner/state-of-the-art-rural-hospital" target="_blank">Bayalpata Hospital</a>. Mild mannered, modest, soft-spoken, hard-working, professional are the words families of patients who have been treated at <a href="https://nepalitimes.com/here-now/nepal-s-rural-lifeline" target="_blank">Bayalpata Hospital </a>use to describe Mandeep Pathak. But the surgeon is too busy to let all this get to this head.&nbsp; Asked why he does not emigrate like his peers or get a lucrative position at a private hospital in Kathmandu, Pathak answers simply, without a trace of self-importance, “I do not think I could get the satisfaction or sense of fulfilment anywhere else.” When travelling to attend medical congresses overseas or visit family in Kathmandu, Bayalpata has other doctors to take care of patients, but many wait patiently till Pathak returns for their consultation or surgery.&nbsp; When he returns from seminars abroad after learning the latest skills, Pathak’s suitcases are not full of clothes or presents, but titanium bone implants, external fixation rods, or intramedullary nails to be used in <a href="https://nepalitimes.com/news/altruistic-healthcare-models-in-nepal" target="_blank">surgeries at Bayalpata</a>.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025041414040_5356278472c1eb2b9e4af1d593d6234cc8dc5e5161a8c614197c01abefadbd80.jpg" data-media-id="editor_8" data-image-id="2025041414040_5356278472c1eb2b9e4af1d593d6234cc8dc5e5161a8c614197c01abefadbd80" data-rendition-name="original" width="2048" height="1368" loading="lazy" alt="surgery"> </figure>  Before Bayalpata Hospital was established, most people suffering broken bones had to travel down to Dhangadi or Nepalganj for treatment. No more. Although Pathak’s specialisation is orthopaedic oncology, he is mostly treating fractures and rejoining broken bones.&nbsp; Now as Bayalpata’s Hospital Director, Pathak also has administrative and fundraising duties. He has to take the 10-hour ride down to Dhangadi often to meet various Sudurpaschim ministries to release the hospital’s budget — that is sometimes more difficult than the most complicated surgery. Recently, he had to cancel an appointment with the Chief Minister to rush back to Bayalpata because there was a patient who needed emergency surgery. “I told myself, let me save this patient first, then I will try to save the hospital,” he recalls.&nbsp; Once, when he had to be away for a month on emergency surgery training in the US, the family of a 90-year-old woman who had dislocated her hip after falling from a staircase was waiting for him to return. Her son told Pathak: “Doctor, either put her out of her suffering, or cure her.” Pathak told him it was too dangerous to operate at her age, but the son said his mother was in so much pain it was worth the risk. The operation was touch-and-go, but it was successful. The woman who had been brought in on a stretcher, walked out of the hospital three days after the operation.&nbsp; A few months later, a 27-year-old woman was brought into the ER bleeding profusely from an arm mangled by a thresher machine. Even in that state, she was breastfeeding her baby. Pathak welled up seeing this display of selfless motherhood, as he wheeled her into surgery. She needed three operations, but now has full use of her hand. <div class="embed-block"><iframe width="700" height="415" src="https://www.youtube.com/embed/xJdxLD0hBqo?si=mOpM2R_DsYL88Lfg" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe></div> It is the sense of achievement from such recovery that keeps Mandeep Pathak here in this isolated village in the middle of nowhere. Bayalpata Hospital has not just saved lives, it also saves families from poverty because they do not have to take sick relatives to expensive city hospitals.&nbsp; In January, a woman was brought to Bayalpata with both hands broken. She said she had taken a fall, but Pathak did not believe her. When alone in the surgery, she finally admitted that her husband had beaten her.&nbsp; It was her husband who had brought her to hospital for treatment, but she refused to file a police report. Pathak quietly put both her arms in casts, thinking about the poverty, patriarchy and injustice in society that he is unable to treat.

cost-of-healthcare