A rapid assessment of the epicentre of the earthquake that hit just before midnight on 3 November shows that lack of accurate information about the status of survivors and their needs continues to be a challenge. Our trip to the hardest hit areas from Khalanga to Nalgad in this remote district in the mountains of western Nepal involved the rescue of a month-old infant whose mother was reported to have died from the cold.&nbsp; There has been inaccurate and sensationalised reporting in the media after people died from the cold. While it is true that winter has set in the mountains and the long term illnesses can be exacerbated by the cold, stress or unhygienic conditions, many of the deaths have been due to acute illnesses and existing preconditions. There have also been reports of relief items being stuck in bureaucratic bottlenecks and piling up in municipal offices instead of being distributed to those in need. While that may have happened in the early days of the earthquake, on this week’s trip that was not what we saw.&nbsp; In any natural disaster, it is important to recognise that the scenario for relief can rapidly change from day to day, thus making a rapid response and clear communication channels vitally important.&nbsp; We are concerned that inaccurate journalism based on hearsay without fact checking can foster an environment of cynicism and criticism, discouraging collaborative efforts. It can also affect the morale amongst first responders, spreading distrust.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20231201131252_0b36cd97d9d54136ebbc601ca2170c1402ec22944d1f8c5d837ba1e3dfc8ef13.png" data-media-id="editor_0" data-image-id="20231201131252_0b36cd97d9d54136ebbc601ca2170c1402ec22944d1f8c5d837ba1e3dfc8ef13" data-rendition-name="original" width="1368" height="1058" loading="lazy" alt="Jajarkot earthquake NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20231201131252_9f96af647fb9e343ef22159c2191e7aaac8574f6cce70891237a91d24747fcc2.png" data-media-id="editor_1" data-image-id="20231201131252_9f96af647fb9e343ef22159c2191e7aaac8574f6cce70891237a91d24747fcc2" data-rendition-name="original" width="748" height="1142" loading="lazy" alt="Jajarkot earthquake NT"> </figure>  Read also: <a href="https://nepalitimes.com/opinion/comment/learning-from-jajarkot-what-we-didnt-after-2015-695vpzle">Learning from Jajarkot what we didn't after 2015</a>, Sushil Gyewali Relief must be survivor-centred and not be sensationalised or politicised with fake news. A centralised database that can foster collaboration is being put up with accurate and up to date information on the <a href="https://jajarkot.himalayandisaster.org/">Jajarkot Earthquake Response website</a>. Partners on the ground can also fact-check and debunk false reports, and we urge reporters to seek out these primary sources instead of relying on sensationalised clickbait. Rubble and destruction&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_66e5ce77ae433644dabf10e3391e39021e92857248896af39bf19ad128e05e8b.jpg" data-media-id="editor_4" data-image-id="2023120112124_66e5ce77ae433644dabf10e3391e39021e92857248896af39bf19ad128e05e8b" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  As we approached the epicentre with three vehicles filled with jackets, sanitation kits, blankets, the destruction was shocking. Even in the relatively accessible areas like the district headquarter of Khalanga the houses are still in ruins. A month after the earthquake the rubble still has not been cleared. Things get worse the deeper we go into the mountains. On the way to Nalgad, there are rows upon rows of destroyed houses. Most people are living under tarp and bamboo tents, in one of them there were seven members of a family huddled inside. One man in Kalanga had broken his arm, and was sifting through the rubble of his home with his other hand. He was sheltering in a nearby school with many other neighbours.&nbsp; A school in Nalgad was still functioning, and students were attending classes in tents. Their school was damaged and there was fear of aftershocks.&nbsp; Multiple political groups and nonprofits are helping clear the rubble in places, but no active rebuilding has started yet.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/grief-stricken-survivors-are-cold-and-hungry">Grief-stricken survivors are cold and hungry</a>, Sagar Budathoki CGI-based temporary homes might be better than tents for this winter. But rapid, affordable, earthquake resistant and sustainable rebuilding must start as soon as possible using the experience and plans developed after the 2015 earthquake. Rural municipalities must be key partners in all rebuilding efforts. Relief organisations can divide up their efforts to avoid duplication. There are prototypes for <a href="https://www.dezeen.com/2015/07/11/prototype-bamboo-shelter-nepal-earthquake-victims-built-by-unskilledworkers-three-days/amp/">winterised temporary shelters</a> and <a href="https://habitatnepal.org/wp-content/uploads/2019/10/Bamboo-Temp-Shelter-Nepali-web.pdf">long term solutions</a> for reconstruction: Immediate Relief and Humanitarian Aid&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_fa55e5f5c7e0c08e34679ea94f7eee9d393899fe41c45d32ca0d8b3b52d00ee6.jpg" data-media-id="editor_8" data-image-id="2023120112124_fa55e5f5c7e0c08e34679ea94f7eee9d393899fe41c45d32ca0d8b3b52d00ee6" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Nepal has a one-door policy currently to manage aid coming into disaster zones. Each district’s disaster relief committee is led by the Chief District Officer (CDO), who is in charge of relief items coming to the region. Jajarkot district has received tons of relief material, and local distribution was initially the bottleneck. There are still reports of items not getting to those that live in remote and roadless areas.&nbsp; We saw this week that the distribution management appeared to have improved. Items lying in municipality offices and district offices were in the process of being delivered. The municipal system makes it easy to coordinate with local ward chairs to find the areas of acute need.&nbsp; Our trucks had to be registered with the CDO with an itemised list and approved for further transport deeper into the district. The process seemed seamless. In Nalgad municipality, where few relief organisations are present, the mayor’s office and the Nepal Army have coordinated with NGOs to distribute blankets, clothes to more remote regions.&nbsp; Read also:<a href="https://nepalitimes.com/news/earthquake-vacates-villages-in-nepal"> Earthquake vacates villages in Nepal</a>, Anita Bhetwal The municipalities are coordinating better, and working closely with relief aid partners. But there is still a need for logistics management and strategic distribution of relief material to difficult to reach villages. Special care must be given to villages at higher altitudes where it will soon start snowing. Relief organisations must respect the one-door policy, and not bypass this effort to coordinate relief and avoid waste and overlap. The Ward chairs have their feet on the ground and are the best source for exact need. They should be made partners in all aid distribution locally.&nbsp; Healthcare&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_b094ac6d0dfcdc924f571e1308307ebaa4b6b1d2b7d5c0ebcfe290466cd3abf0.jpg" data-media-id="editor_10" data-image-id="2023120112124_b094ac6d0dfcdc924f571e1308307ebaa4b6b1d2b7d5c0ebcfe290466cd3abf0" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Jajarkot has a well-equipped district hospital, and each municipality has a &nbsp;health centre. There are smaller health posts in wards within the municipality. The nearest high level facility with ICU capacity is in Surkhet.&nbsp; Jajarkot district hospital had a large number of traumas during the first weeks after the earthquake. The hospital has five medical officers, and one MDGP (consultant) physician, and can provide basic emergency care, maternal and child care including caesarean section and vaginal delivery, and has a robust pharmacy. The hospital’s patient census was not impressive during our visit.&nbsp; The Nalgad municipality health centre was busy with only one medical officer available. Large tents from UNICEF had been erected outside for additional inpatient ward and emergency space. There seems to be a gap from the district to support the local municipality's needs.&nbsp; We came across many groups coming to Jajarkot to conduct health camps. Though increased engagement has benefits, it is not so useful to have camps near the health centres or the district hospital as there are already facilities there. &nbsp;Doctors told us that they had extreme excess of certain supplies and not enough of others.&nbsp; Read also: <a href="https://nepalitimes.com/banner/in-a-disastrous-state">In a disastrous state</a>, Sonia Awale Groups organising health camps should focus on two areas: 1) bring specialist care that otherwise does not exist in this region, 2) reaching areas away from local health infrastructure. They must also coordinate with the district hospital and municipality health centre to assess their utility. Funds used for health camps could instead help strengthen local health facilities. The districts should divert some of their resources (doctors, nurses, etc) to some of these busy health centres in local municipalities like Nalgad. It does not make sense for one doctor to see a large number of patients in Nalgad, while the district hospital is not busy.&nbsp; Safeguarding Women and Children  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_2e48aaab35412bd26e577239a96e036781290ce1391da4a9b5d90d44410d9a63.jpg" data-media-id="editor_12" data-image-id="2023120112124_2e48aaab35412bd26e577239a96e036781290ce1391da4a9b5d90d44410d9a63" data-rendition-name="original" width="1800" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> <figcaption>Ramu Kharel (left) and Maggie Doyne with locals in Jajarkot. The infant whose mother died was brought down and is recovering in ICU in Surkhet.</figcaption> </figure>  There are a large number of pregnant and postpartum women in the most affected areas in Nalgad, Rukum and Kuse. Recent news items have used false narratives to gain viewership, but there is a real need for access to appropriate ante-natal and postnatal care, which was an issue that existed before the earthquake in underserved areas of western Nepal. Jajarkot hospital, the municipal health centres are both equipped to care for most of these women. Various groups are providing warm clothes for the most vulnerable and prioritising these women for safe winterised shelters is a must.&nbsp; There are child protection units and National Child Rights Council (NCRC) offices at each municipal office. When a child, adolescent, pregnant or postpartum woman is in potential or imminent danger, it is critically important that officers be notified immediately.&nbsp; The NCRC works directly with government bodies, police, licensed shelters, and relief agencies to ensure that the woman or child is taken out of danger. NCRC and Kopila Valley are able to work together directly to safeguard the children in distress. The involvement of NCRC also prevents child smuggling and safeguards against family separation, exploitation, and human trafficking. The use of trained trauma informed social workers and child protection officers is critically important when discerning information and keeps the child’s rights and protection at the centre.&nbsp; Available health centres must be equipped with in-facility and outreach programs to identify and care for the most vulnerable in the region. This disaster could be used as an opportunity to equip and build a system around the municipal health centre and district hospitals to create innovative models like <a href="https://www.nyayahealthnepal.org/">Nyaya Health Nepal’s</a> community health care model in Achham, where community health workers are trained and equipped to provide care at home. Read also: <a href="https://nepalitimes.com/opinion/rebuilding-resilience-7-years-later">Rebuilding resilience 7 years later</a>, Anil Pokharel When someone is really ill, taking the patient to Surkhet might be the only way but the road is long and hard. A streamlined approach to access government services like helicopter rescue must be available in this post-disaster setting.&nbsp; A robust ambulance and EMS service from either the municipal health centre and/or Jajarkot district hospital must be made.&nbsp; Water and Sanitation&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_186d4e99aa2c91f173de7e0e430b03a24c1099075fdbfeae8ead9b770cee9ca6.jpg" data-media-id="editor_15" data-image-id="2023120112124_186d4e99aa2c91f173de7e0e430b03a24c1099075fdbfeae8ead9b770cee9ca6" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Even before the earthquake, Jajarkot and surrounding districts were hit by a cholera epidemic in 2009 that killed over 300 people, many of them children. Running water and sanitation has always been a major concern and this danger has been exacerbated with the earthquake aftermath in the dry season.&nbsp; None of the temporary tents and shelters we saw had appropriate water access and hand washing stations. Donor agency temporary toilets were dirty with no hand washing. Water and hygiene must be a priority for development groups going forward. Relief groups must put WASH in their priority.&nbsp; After meeting survivors, relief workers and local elected officials we saw a resilience and a determination to bounce back. The items we took to Nalgad are being strategically distributed in coordination with municipality offices to reach those in most need.&nbsp; We were able to locate the one-month-old infant in Nalgad municipality’s Ward 8. The infant is now getting safe ICU level care now in Surkhet, and is doing better.&nbsp; Read also: <a href="https://nepalitimes.com/editorial/shaking-things-up">Shaking things up</a>, Editorial Resources for aid information and reporting can be found <a href="https://aidpulse.org/aidboard">here</a>. Important phone numbers:&nbsp; National Child Rights Council: 01-5550121&nbsp; Chief Minister Karnali: 985804444&nbsp; Chief District Officer Jajarkot: 9858047777&nbsp; Mayor Nalgad: 9842236335&nbsp; Mayor Kuse: 9858937755&nbsp; District Hospital Khalanga: 089-430188&nbsp; Ambulance: 102&nbsp; AIN (Federation for NGOs): 01-4468128&nbsp; Poison information center: 01-450-2011&nbsp; Suicide Hotline: 1166&nbsp; Police: 100 Ramu Kharel (ramu_kharel@brown.edu) is an emergency medicine physician with global health and public health expertise, and decade long experience in disaster response within Nepal. He is an assistant professor at Brown University, and is founder of <a href="http://www.hapsaglobe.org/">HAPSA Nepal</a>. Maggie Doyne is the co-founder of the <a href="https://blinknow.org/">BlinkNow Foundation</a> and, and has worked for 18 years in the Karnali region caring for at-risk children through community development efforts. She is a CNN Hero and author based in Surkhet.

original

674x448

610x380

500x500

400x266

400x240

400x203

301x200

1250x600

1084x550

Jajarkot: One month after the earthquake

As a nurse, Anju Chaudhary has to often test the limits of her skills when dealing with <a href="https://www.nepalitimes.com/here-now/another-babys-life-is-saved-in-rural-nepal">complicated pregnancies</a> that arrive at the government hospital here in Katari.&nbsp; She is also the leader of a team of nurses who are on duty for 24 hours a day, seven days a week, caring for patients. Chaudhary has helped deliver over 1,000 babies and <a href="https://www.nepalitimes.com/banner/saving-nepali-mothers-and-babies-district-by-district">prevented the deaths of many mothers and newborns</a>. But no case was as challenging as that of Sharmila Surkheti. One morning in March, the 30-year-old Dalit woman arrived at the hospital, weak and bleeding profusely.&nbsp; “We had never seen a mother in such a near-death situation, but we were prepared, and we got into action immediately to save her life,” recalls Chaudhary. Surkheti had already been pregnant 13 times in her young life. All six of her newborns were delivered at home, and she had undergone seven abortions. Barely a year ago, she had another baby who died at childbirth. Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepal-s-poor-new-mothers">Who will save Nepal's poor new mothers?</a>, Rojita Adhikari This year, she decided to try to risk her own life to try for another son but there was post partum haemorrhage after the baby was born. Her husband helped get her to Katari Hospital while leaving behind the newborn. It was a two hour walk from home. There was no General Physician at the hospital that day so it was up to Chaudhary and her nurse team to save her life. A quick decision had to be made. They used the bundle approach in postpartum haemorrhage (PPH) management to control the bleeding. As a chronic anaemic patient, the mother had a low haemoglobin of only 6.1, which was alarming. To save her life, the nurses planned to take Surkheti to a better-equipped hospital in Gaighat but the family could not even afford transportation. Read also: <a href="https://www.nepalitimes.com/here-now/nepal-s-rural-lifeline">Nepal's rural lifeline</a>, Sonia Awale Her blood pressure dropped alarmingly low, and the nurses immediately created an emergency fund to pay for the private ambulance to reach Gaighat. She also needed blood transfusion, but Surkheti’s husband was malnourished and there were concerns about his health. The nurses then found a male colleague at the hospital who agreed to donate his blood. They closely monitored the mother, and her haemoglobin improved to 8.8. The hospital’s Acting Medical Superintendent, Dr. Gaurab Shah, an MD Pathologist, also put a lot of effort into managing a blood donor.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230902040916_6d4eb5e618d116e1cbcc72776152080ad55f53e026f67be55044f350d2849c2e.png" data-media-id="editor_4" data-image-id="20230902040916_6d4eb5e618d116e1cbcc72776152080ad55f53e026f67be55044f350d2849c2e" data-rendition-name="original" width="2100" height="1500" loading="lazy" alt="Nurses in rural Nepal"> </figure>  The next day, the nurses gave her iron tablets, B complex, and vitamins and she was sent home. But during a post-natal home visit, the nurses were dismayed to see the utter poverty of the Surkheti’s family, including her husband and six children. 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 Given her anaemic state and being very weak, Surkheti was unable to produce milk and had been feeding biscuits to her baby which worried the nurses. The family had no money to buy formula milk.&nbsp; So the nurses started collecting cash from their own pockets and started a fundraiser through online requests and on the phone. But there was very little response, and the six nurses put in their own money to save the mother and baby.&nbsp; “The greatest gift for me was to hear the words of gratitude from the mother who survived the ordeal,” says Chaudhary modestly. Despite her training as a <a href="https://www.nepalitimes.com/multimedia/saving-nepali-mothers-on-mother-s-day">Skilled Birth Attendant</a> that she had done many years ago, Chaudhary had no knowledge of uterine balloon tamponade, which can help in the treatment of PPH.&nbsp; After graduating from her nursing education, she was transferred to Bir Hospital where she never got the chance to work with mothers and babies, as she was too busy handling injuries and accidents in the emergency department. It was only after she moved back to Katari Hospital in Udaypur that her career path changed with the help of the non-profit <a href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives">One Heart Worldwide</a> (OHW). She received an invitation from OHW to attend its Simulation-based Mentorship Program in 2017 which allowed her to learn new skills. “I feel fortunate that my team was there to help Surkheti, and today, both she and her baby are healthy,” she says.&nbsp; Indeed, at a time when many Nepali nurses aim to migrate abroad the nation should be thankful for the dedication and passion of nurses like Anju Chaudhary.&nbsp;

Saving one Nepali mother at a time

<div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe12359c7e80680e0da510jpeg.jpg" alt="" width="1400" height="933">Anandaban Hospital in Lalitpur that treats mainly leprosy patients. Photo: KUNDA DIXIT</div> No one would argue against Nepal needing to boost its budget for public health, but given the low allocation and poor management of government hospitals, the question arises: what do we do until politicians get their priorities right? Over the past few decades, health expenditure in Nepal has been consistently less than <a href="https://www.jointlearningnetwork.org/wp-content/uploads/2021/12/Nepal-JLN-General-Gov-Expenditures-23092021.pdf">one-tenth of the nation’s GDP</a>. If it was not for community level work by Female Community Health Volunteers and the effort of dozens of nonprofits medical care would be beyond the reach of most Nepalis. At present, <a href="https://www.jhas.org.np/jhas/index.php/jhas/article/view/267">70% of the medical expenditure</a> for people is met out-of-pocket. There are many instances where even middle-class households are pushed below the poverty line because they have to use all their savings, sell property or borrow money to meet hospital expenses of family members. When health financing relies heavily on such payments, people fall into the ‘medical poverty trap’, as their treatment costs are uninsured and expenses not reimbursed. In remoter parts of Nepal, families have had to sell property even to pay for fractures or simple operations for relatives who have to be taken to private city hospitals. Non-profits and international charities have stepped in to fill the gap left by the government’s incapacity to make quality healthcare more affordable and accessible. Stable healthcare infrastructure therefore relies on non-government funding and altruistic intervention. Subsidies by not-profits can be seen in virtually every sphere of healthcare in the country. From primary healthcare centres in the countryside to high-end hospitals in the cities, many would not be able to function without support from charitable organisations. The partnership is largely financial, and usually pay for services in underserved areas of the country for excluded communities. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe12399c7e80680e0da511jpeg.jpg" alt="" width="1500" height="1000"> </div> <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">Bayalpata Hospital</a>, in Accham district, for instance, is a model public-private partnership that can thrive when state-of-the-art medical interventions are melded with philanthropy. This government-owned hospital is managed by Nyaya Health Nepal (NHN) and provides absolutely free healthcare for 100,000 patients annually. In Kathmandu valley itself, the <a href="https://nepalcleftandburncenter.org/">Nepal Cleft and Burn Center</a> at Kirtipur Hospital is providing valuable service for cleft palate surgery and treatment of burns patients, and is run by a non-profit. It is Nepal's first teaching hospital specialising in deformity-correction reconstructive surgery. <a href="https://www.nepalitimes.com/banner/new-treatment-offers-hope-for-nepals-leprosy-patients/">Anandaban Hospital in Lalitpur </a>run by The Leprosy Mission, is one of South Asia’s finest facilities for leprosy treatment, and receives many referrals from in and out of Nepal every year. It uses a new technique called Leukocyte Platelet Rich Fibrin (LPRF) that helps cure lesions of leprosy patients much faster. United Mission to Nepal has been managing several hospitals across rural Nepal for the past 60 years, most notable being in Tansen and Okhaldhunga. These hospitals are testament to how healthcare facilities that place philanthropy front and centre in their operational modality can deliver quality treatment better than public hospitals across Nepal. While support from foreign non-profits has become part and parcel of a well-managed hospital in Nepal, foreign grants alone cannot transform healthcare in every corner of the country. After all, they are just temporarily doing the government’s job. Nepal’s Constitution guarantees free basic health care for every citizen, but that has only remained a lofty unfilled goal in many parts of Nepal. The only alternative is to build a self-sustained funding system to run medical facilities, and the easiest way to achieve this while a universal national insurance scheme comes to fruition, is to rely on domestic and international volunteerism and philanthropy. Philanthropy is in fact deep-rooted in Nepal’s sociocultural structure and the country in fact stood <a href="https://www.cafonline.org/docs/default-source/about-us-research/caf_world_giving_index_2022_210922-final.pdf">56th in the World Giving Index, 2022.</a> This means that Nepalis are, on average, more likely to donate to charity than people in more than half of the world’s countries. The only problem is that they do not have much money to spare, and whatever they give is not enough to take care of the enormous burden of need. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe123d9c7e80680e0da512jpeg.jpg" alt="" width="1400" height="1050"> </div> Channeling locally raised funds into innovative healthcare projects through philanthropic organisations is one way to go about encouraging local giving. The problem lies in that local donors, because they do not trust Nepali &nbsp;charities resist donating institutionally. Corporates that would like to donate are also held back because there is no provision for tax deductible donations to charity – possibly because the government does not have a transparent way to ensure that it will not be misused. This has propelled hospitals and health projects in Nepal to turn to external, international sources of funding. One example is the <a href="http://archive.nepalitimes.com/news.php?id=11436">Nick Simons Institute</a> (NSI) that backstops 44 hospitals and health care centres across Nepal because its founder had a special personal attachment to Nepal. Outside funding also inhibits Nepali donors who think there is plentiful foreign funds. To change this dynamic, Nepal needs to alter the culture of giving. This change starts by building local trust. If local donations are to be pooled effectively, their givers need to trust healthcare projects and believe in the value they will create. This comes along with the need for the state to strengthen tax incentives to encourage philanthropic giving. But aside from local individuals and communities, for-profit companies also have a major role to play. In 2017, when <a href="https://kathmandupost.com/money/2017/01/28/bfis-told-to-spend-1-percent-of-profit-on-csr-activities">Nepal Rastra Bank mandated banks and financial institutions </a>to use at least 1% of their net profits for philanthropic activities, it was a major step to encourage corporate altruism. A 2021 <a href="https://www.nrb.org.np/contents/uploads/2021/08/CORPORATE-SOCIAL-RESPONSIBILITY-IN-NEPALESE-BANKING-INDUSTRY.pdf">survey</a> conducted by the Nepal Rastra Bank found that 41% of banks and financial institutions in a sample expressed commitment to support various deprived sectors, with health being the second most popular choice after education. However, these companies need to find more ways to engage in Corporate Social Responsibility activities focussed on healthcare. This may include incentivising doctors to serve in remote locations where urgent medical attention is most needed, investing to upgrade teaching methodologies and improve access to medical literature, supporting non-mainstream illnesses such as autism and dementia, and subsidising follow-up health checks instead of one-time health camps aimed purely for image building. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150240/63fe12419c7e80680e0da513jpeg.jpg" alt="" width="1400" height="650"> </div> Healthcare innovation is another area where funds are needed since the government is not fulfilling its mandate. As digitisation dominates healthcare, there is a need for modern healthcare infrastructure, including research and innovation centers to innovate. But more pressing is that access to even basic health facilities remains a formidable challenge in rural Nepal. Local philanthropy, from individuals, communities, and companies allows local context and culture to shape health projects, increasing community ownership. It leverages the collective interests of local donors, making them feel directly involved in development. Local funding has the added benefit of kindling trust among rural people in the healthcare infrastructure they invest in. Transparent philanthropy can encourage rural communities to seek services from these establishments. This may further discourage informal at-home diagnosis and witch-doctor consultations, which a recent study in Humla found <a href="http://www.journaldmims.com/temp/JDattaMegheInstMedSciUniv173616-3680661_101326.pdf">was the case for 50% of patients</a> in the district. To be sure, it is not that the government has not made efforts. In public hospitals, primary healthcare is free of cost. But it only covers very basic services. Most hospitals are overcrowded, and lack minimum service standards. Private hospitals are state-of-the-art and provide international standard medical care, but are so expensive that they are out of reach of most Nepalis. Local altruism, could bridge the gap between these two extremes. It can fill the healthcare need, but also nudge the government and private sector to prioritise quality care over all else. Yugottam Koirala and Yugeshwor Koirala are twins, and are from the Punyaarjan Foundation. <a href="https://www.punyaarjanfoundation.org.np/">punyaarjanfoundation.org.np</a>

Altruistic healthcare models in Nepal

<img width="800" height="438" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe119b9c7e80680e0da4eajpeg.jpg" alt=""/>Nurse Sabita Gyawali goes to school bright and early as the first rays of the sun hit Mt Dhaulagiri to the north, and she gets to work right away. Shen the students start arriving, she checks that they follow cleanliness routines, and teaches them how to wash hands properly. She provides first-aid to those who need it, and is responsible for the students’ physical and mental health. But her main priority is to make sure that no student has brought junk food for lunch. In fact, she has prohibited packaged chips and noodles from the school grounds.   Gyawali has been a nurse for nine years, much of it at Kathmandu’s Sahid Gangalal National Heart Center. In 2019, she came to Baglung to work at Bidya Mandir Secondary school under the Health Ministry’s new 'One School, One Nurse' program.  Once there, Gywali designed the school’s lunch menu and already there has been a positive change in the eating habits of students – even teachers.  “Initially, students from elementary to high school would eat packaged store-bought lunch, she explains. “It was very difficult to wean the children off their junk food habit, but it is now under control.”The World Food Programme (WFP) has been managing school meals across Nepal for 45 years, and the government has been gradually assuming responsibility and expanding the project. Now, thanks to the initiative, students don’t go home for lunch anymore and attendance rates have increased, resulting in fewer dropouts.However, there are challenges. The Rs15 per student charge for lunch is beyond the means of some students who have working parents, or are in single parent households, and there is not enough time to bring a tiffin box.  For some students, this means coming to school on empty stomachs. For others, it was cheaper and more convenient to buy quick-and-easy junk food.  <img width="1350" height="2400" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe119e9c7e80680e0da4ebjpeg.jpg" alt="">“The budget provided by the government was low enough that only little snacks or small meals used to be served," notes Gyawali, who then came up with a lunch menu that would fit the budget.And while the school lunch menus made by the government might be applicable to rural schools, they do not work for public schools in urban areas with the same budget.The other problem is not having enough nurses. There are 82 public schools within Baglung Municipality, out of which only five secondary schools have nurses. <img width="1232" height="693" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe11a19c7e80680e0da4ecjpeg.jpg" alt="">Ram Prasad Khanal, the head of the municipality's health department, says that the municipality has asked the state government to appoint nurses to all the schools. “Every school that has a nurse has shown positive growth,” notes Khanal.At Bageshwari Secondary School in Bhaktapur’s Chyamasing, students have stopped consuming junk food for lunch due to the efforts of nurse Sajina Manandhar. “It is very difficult to take students off instant noodles, but we have managed to do it.”The ‘One School, One Nurse’ program is run by the Nursing and Social Security Division under Nepal’s Department of Health Services (DoHS) and aims to  encourage children to have a balanced diet and improved hygiene. The program also supports adolescent sexual and reproductive health, as well as mental health.“The school nurse program has brought about a noticeable improvement in nutrition-related problems, mental health, menstrual health, and even school dropout issues,” says Bala Rai, a senior hospital nursing administrator at the Nursing and Social Security Division.But there is a long way to go. So far, only about 1,000 schools out of 10,644 public secondary schools nationwide have appointed school nurses.The DoHS measures nutrition impact through 'anthropometry' — measuring the heights and weights of children to determine whether or not they are malnourished. A recent Demographic Health Survey (DHS) revealed that 25% of children under five have stunted growth while 8% are underweight as compared to 36% and 10% respectively in 2016.There is improvement, but more can be done, and the government has set a target to reduce the growth stunt down to 15% by 2030.   <img width="800" height="450" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe11a59c7e80680e0da4edjpeg.jpg" alt="">The survey also revealed the program, which involves nurses also making home visits, has been instrumental in identifying children who have learning disorders, mental health issues, or those who have been victims of domestic violence. Illnesses have been identified and reported to hospitals, and it has also become easier to educate adolescents about sexual and reproductive health."We have appointed health-in-charges to each class so that students feel comfortable speaking to and about themselves,” explains Sajina Manandhar. “We continuously meet with those in charge, and provide them information related to reproductive health and family planning.”Nurse Anamika Sharma says that the number of girls who miss school while having their period has gone down by 90% since she began working as a school nurse, largely because it is easier for female students to ask for pads at school. Menstrual health counseling is also more readily available.Binu Kakshapati is the School Nurse Focal Person of Bagmati Province, and says the attendance of female students has gone up since the province began distributing pads in public schools. “Students have started to become more open to using pads since the government started distributing them in Bagmati,” she adds.In some schools, nurses even fill in when a math or science teacher is absent. Bala Rai says she had to send a circular to the local units to ask them to stop forcing nurses to do jobs that they are not there to do.Translated from the Himal Khabar <a href="https://www.himalkhabar.com/news/133436" data-saferedirecturl="https://www.google.com/url?q=https://www.himalkhabar.com/news/133436&amp;source=gmail&amp;ust=1676366852671000&amp;usg=AOvVaw2z3rWSO2Xmif-YMO_MB9wL">original</a> by Shristi Karki.

Nurses ensure nutrition for Nepal’s children

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111414114/63723d469c7e80680e0c9667jpeg.jpg" alt="" width="1882" height="1248"/>Nepal’s agreement in August to supply an initial 100 nurses to Britain with an option for several thousand more in future was followed by <a href="https://www.theguardian.com/politics/2022/sep/25/plan-to-recruit-nepal-nurses-for-nhs-puts-them-at-risk-of-exploitation" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.theguardian.com/politics/2022/sep/25/plan-to-recruit-nepal-nurses-for-nhs-puts-them-at-risk-of-exploitation&amp;source=gmail&amp;ust=1667191551913000&amp;usg=AOvVaw0jEsiELAF23WOoR1iMe-Q0">debate in both countries</a> about the pros and cons of the deal.Nursing workforce managers and researchers in Nepal, Britain and in international agencies have drawn attention to the fact that the nurses are being diverted from greater need back home to fulfil the UK's shortfall. But there is support for Britain's international recruitment of healthcare professionals from nursing colleges in Nepal and the <a href="https://www.nepalitimes.com/here-now/new-uk-options-for-nepali-chefs-and-nurses/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/new-uk-options-for-nepali-chefs-and-nurses/&amp;source=gmail&amp;ust=1667191551913000&amp;usg=AOvVaw00lunMQfm5PaWjBAuKTKwL">global aspirations of nurses themselves</a>.Presently, the UK faces a considerable shortfall in the hiring and retention of student nurses. Scotland has <a href="https://www.bbc.com/news/uk-scotland-62985343" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.bbc.com/news/uk-scotland-62985343&amp;source=gmail&amp;ust=1667191551913000&amp;usg=AOvVaw2uoO5Ht7E0kSxSASuPVAS7">not been able to meet its student nurse recruitment targets</a>, with a gap this year of over 700 student candidates. This means Scotland alone will be short of 700 nurses in three years’ time, when the current intake of students graduates. Furthermore, the student dropout rate is currently around 25%.Across Britain, by the time the current cohort graduates there will already not be enough nurses in the UK labour market even without the previous shortfall. And there are said to be vacancies for up to 50,000 health professionals in the NHS with the post-Brexit departure of East European staffers.Britain therefore has very little choice but to recruit nurses from other countries. In the past nurses have been hired from English-speaking countries with weaker economies like the Philippines or India (see graph).<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111414114/63723d499c7e80680e0c9668jpeg.jpg" alt="" width="2044" height="1310">British nurse recruitment policy now displays little concern for source countries’ workforce situations, and of World Health Organization’s ethical recruitment guidelines which bars hiring medical workforce from ‘red list’ countries that do not have sufficient nurses and doctors for their own populations. But the staffing gap is so serious that countries like the UK, Japan, the <a href="https://www.nepalitimes.com/here-now/overseas-nepalis-on-the-covid-19-frontlines/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/overseas-nepalis-on-the-covid-19-frontlines/&amp;source=gmail&amp;ust=1667191551913000&amp;usg=AOvVaw1BVT7aW5dfuYKp8X5LHeH_">United States,</a> Canada, <a href="https://www.nepalitimes.com/here-now/demand-grows-for-nepali-caregivers-in-israel/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/demand-grows-for-nepali-caregivers-in-israel/&amp;source=gmail&amp;ust=1667191551913000&amp;usg=AOvVaw2OzwZhw_Mum2Z_ml8roKHV">Israel</a> and other European countries are competing to attract health professionals, disregarding the WHO guideline.For Nepal, the situation is just the opposite. There is no shortage of nursing students considering a professional education. And as a result of increased nursing education capacity, there are more students successfully graduating than Nepal’s hospitals can employ. Unlike the UK, there is no major concern about student dropout rates in Nepal, and most nursing students complete their education and graduate.Then there is also the push-factor of low starting salaries back home that makes overseas work attractive. Many nursing graduates struggle to find suitable employment within Nepal. For them international jobs are the best option. In fact, a majority of nursing students in Nepal are pursuing their studies with the sole focus on emigration.Given the lack of a clear and appropriate migration pathways to the international labour market, Nepali nurses are going abroad as students to further their education. The number of nurses taking this route is much higher than those going abroad directly as employees.Because of the lack of safe and effective avenues for Nepali nurses to get jobs abroad, including in the UK, recruitment agencies in Kathmandu have found this a lucrative option. They are known to collude with international nurse recruiters to exploit nurses whose desperation to earn more makes them vulnerable.The laws of supply and demand mean that this happens not only in Nepal and the UK, but globally. Migrant nurses seeking employment, or further education abroad, often fall victim to recruiters who charge exorbitant fees from nurses yearning to leave their home country.To break this vicious cycle, there is an urgent need to create transparent and fair employment options for Nepali nurses for the UK's NHS.The UK for its part should improve the working terms and conditions for all of its nurses, including retention of its own nursing students.Nepal must also have a proper workforce plan in place, and create gainful employment for its own graduate nurses at home.  Indeed, improving the recruitment and retention of nursing workforces should be a top priority for all developing countries supplying health professionals to well-off ones.Countries like Nepal need to improve  investment in the health sector if they are to provide Universal Health Coverage by 2030, which is a Sustainable Development Goal of the United Nations of which Nepal is a signatory.Radha Adhikari is a Lecturer in School of Health and Life Sciences, at the University of the West of Scotland, and has published extensively on international nurse migration and global health workforce challenges. Her latest research monograph, Migrant health professionals and the global labour market: the dreams and traps of Nepali nurses, was published in 2019, by <a href="https://www.taylorfrancis.com/books/9780429325731">Routledge</a>.Read more: <a href="https://nepalitimes.com/here-now/new-uk-options-for-nepali-chefs-and-nurses/">New UK job options for Nepalis</a>,  Upasana Khadka

Radha Adhikari

Nepali nurses now Britain-bound

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413118/6372307e9c7e80680e0c256cjpeg.jpg" alt="" width="1641" height="1000"/><figcaption>Photo: NYAYA HEALTH NEPAL</figcaption></figure>Viral hepatitis is a disease of the liver that is preventable, treatable and curable in most cases. It is a disease where elimination can and must be achieved.On this World Hepatitis Day, the World Health Organisation is highlighting the need to bring hepatitis care closer to the people. This means making hepatitis care available, affordable and accessible to one and all who need it without discrimination.This is a crucial component in the quest towards elimination of viral hepatitis as a public health threat by 2030. Elimination would translate to 90% reduction in incidence and 65% reduction in mortality by 2030, compared with the corresponding figures of 2015.The action against hepatitis cannot wait any longer. Firstly, it is the only communicable disease where mortality is showing an increasing trend. Globally, approximately 354 million people are suffering from hepatitis B and C and one person is dying every 30 seconds due to its complications.South-East Asia has 20% of the global morbidity burden of hepatitis. An estimated 218,000 people died due to hepatitis in the Region in 2019. About 95% of all hepatitis-related deaths are due to cirrhosis and liver cancers caused by the hepatitis B and C virus.Second, viral hepatis is a disease that is completely preventable. Clean food and good personal hygiene, along with access to safe water and sanitation, can protect us from hepatitis A and E. Measures to prevent hepatitis B and C need to focus on full coverage with hepatitis B immunisation including a birth dose, as well as access to safe blood, safe sex and safe needle usage.Third, a world free of hepatitis is practical and feasible, and it is one of the few infectious diseases the elimination of which is tangible. We do have the tools to diagnose, treat and prevent chronic viral hepatitis, and thereby eliminate viral hepatitis.Safe and effective vaccines exist to prevent hepatitis B, alongside new and powerful antiviral drugs that can manage chronic hepatitis B and cure most cases of hepatitis C. These interventions together with early diagnosis and awareness campaigns have the potential to prevent 4.5 million premature deaths in low- and middle-income countries by 2030.However, access to these services is often out of reach of communities as they are usually available at centralised/specialised hospitals at a cost which cannot be afforded by all. People continue to die because of late diagnosis or lack of appropriate treatment, if they are being diagnosed or treated at all. Early diagnosis is the gateway for both prevention and successful treatment.Modest testing and treatment coverage is the most important gap to be addressed for an effective response to the hepatitis epidemic. If we look at the treatment cascade of the South-East Asia Region, only about 10% of people with hepatitis know their status. And of those who know their status, only 5% are on treatment. Of the estimated 10.5 million people with hepatitis C, just 7% know their status, of which around 1 in 5 are on treatment.This gap, primarily attributable to general lack of awareness, needs to be patched up. This is what this year’s World Hepatitis Day campaign on 28 July is all about. It highlights the need to accelerate the fight against viral hepatitis by testing and treating the real people who need it, i.e. closing the equity gap by “leaving no one behind”.Even before Covid-19, very few countries were on track to reach the 2030 elimination goals set by WHO. The pandemic has put elimination efforts further behind. Rather, it has potentially jeopardised national elimination programs. Fear of Covid-19 has been a substantial barrier to hepatitis testing and treatment throughout the crisis.Amid all the challenges, the Region has continued to implement key interventions to prevent, detect and treat hepatitis, and to engage and empower at-risk populations. Since 2016, when the Region launched its Action Plan for Viral Hepatitis 2016–2021, nine countries have achieved more than 90% coverage of the third dose of hepatitis B vaccine. Four countries have achieved the hepatitis B control target of less than 1% seroprevalence among children over 5 years of age.En route to the 2030 target of eliminating hepatitis, there are some transitional targets to be achieved. By 2025, together we must reduce new infections of hepatitis B and C by half, reduce deaths from liver cancer by 40%, and ensure that 60% of people living with hepatitis B and C are diagnosed and that half of those eligible receive appropriate treatment. This can only be achieved if hepatitis care reaches to the community. In order to do so, several priorities must be addressed, and these include the need to:<ul><li style="font-weight: 400;" aria-level="1">Enhance political commitment across all countries of the Region and ensure sustained domestic funding for hepatitis.</li> 	<li style="font-weight: 400;" aria-level="1">Improve access to drugs and diagnostics by further reducing prices, including integrating costs in national health and domestic financing.</li> 	<li style="font-weight: 400;" aria-level="1">Develop communication strategies to increase awareness as the vast majority of the people do not know that they are infected, especially among subpopulations that are at higher risk of hepatitis B and C.</li> 	<li style="font-weight: 400;" aria-level="1">Innovate service delivery to maximise the use of differentiated and people-centred service delivery options across HIV, viral hepatitis and STIs to tailor and deliver services according to people’s needs and preferences in line with the primary health care approach. Decentralising hepatitis care to peripheral health facilities, community-based venues and locations beyond hospital sites brings care nearer to patients’ homes. Bringing care closer to the community will also need innovations to strengthen community engagement, community-based service delivery and community-led monitoring.</li></ul>For the first time, an integrated Regional Action Plan for viral hepatitis, HIV and STIs 2022–2026 is being developed by WHO. This integrated regional plan will ensure effective and efficient utilisation of limited resources available for the Region and will guide countries to adopt a person-centred approach rather than a disease-specific one.All countries of South-East Asia must accelerate the coverage of testing and treatment services, including through large scale adoption of innovative technologies, simplified approaches at the primary health care level, and community participation. WHO remains committed to make South-East Asia free from viral hepatitis by 2030.As we observe World Hepatitis Day, we must look forward and act together with communities and all stakeholders for a future free of hepatitis. This will lay a firm foundation for a healthier, more equitable and more prosperous Region and the world.Poonam Khetrapal Singh is the WHO Regional Director for South-East Asia.

Poonam Khetrapal Singh

Bringing hepatitis care closer to you

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ec9c7e80680e0c0322jpeg.jpg" alt="" width="269" height="642"/><ul><li style="font-weight: 400;" aria-level="1">Belamati Nepali of West Rukum was diagnosed with intestinal cancer and underwent surgery in Lalitpur. Her husband Khadke sold the family livestock to pay for his wife’s chemotherapy. He mortgaged his house to a local lender for Rs500,000, which he will lose if he doesn’t pay it back by October. But the money has run out. He says, "I am worried about losing my home, but I am now even more afraid of losing my wife.”</li> <li style="font-weight: 400;" aria-level="1">Aman Dhamala’s 23-year-old son was seriously injured in a landslide last year in Kalikot. A local hospital could not treat him, and he borrowed Rs250,000 to hire a helicopter which came seven hours later. His son died in the helicopter before reaching Kathmandu. "If we had a better equipped hospital in Kalikot, my son would be alive today. Now I am left with nothing but a huge debt.”</li> <li style="font-weight: 400;" aria-level="1">Suman Lamichhane broke his right leg in a fall 12 years ago in Gorkha, but because of improper treatment there, the National Trauma Centre in Kathmandu had to amputate it. Suman does not have a family. He had to sell everything he owned for treatment, but could not save his leg.</li> <li style="font-weight: 400;" aria-level="1">Punsiram Tharu’s son was diagnosed with retinoblastoma at Kanti Children’s Hospital this month. Treatment would have cost Rs300,000, and there was a 95% chance of recovery. But the Rs100,000 the government provides for cancer treatment was not enough, Punisram does not own any property, and no one back home will lend him money. The daily wage earner cannot afford his son’s treatment.</li></ul><ul><li>Six-year-old Roshan Tamang was taken home to Kavre by his parents midway through his cancer treatment in February because they could no longer afford his treatment. “I had to sell all my property for my son’s chemotherapy, but we were not sure he would get better, and we ran out of money. It broke my heart to take him back home,” Roshan’s father said. Roshan died at home three months ago.</li></ul>Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, EditorialNepalis are losing their lives and homes paying for expensive medical care. Others are living with life-long disabilities because they cannot afford treatment.Every year, the WHO estimates that 500,000 people across the country are pushed below the poverty line, and another three million face financial burden because of expensive medical care, and lack of insurance. That is over 10% of Nepal’s entire population.The cities have modern private hospitals which have made it possible for many Nepalis not to have to go abroad anymore for treatment. But these hospitals are out of reach of most Nepalis. The WHO recommends more than 10% of a nation’s total budget to be invested in health. This year’s budget allocates only 6.87%, which is even lower than other developing nations.Most of that money is allocated for construction and unnecessary equipment, there is not enough to train new doctors and nurses or retain them in rural hospitals.There was some hope with the introduction of the national health insurance policy, but the benefit amount of Rs100,000 per household is not enough for critical care.Instead of streamlining a national insurance scheme so healthcare is more equitable, the finance minister announced plans in his budget speech last month to privatise it.Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health/">Taking wealth out of health</a>, Anita Bhetwal<h2>Fix what is broken in Nepal's health system</h2><h2>Decentralised healthcare and a national insurance program can achieve equitable medical treatment for all Nepalis</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ee9c7e80680e0c0323jpeg.jpg" alt="" width="1024" height="683"><figcaption> </figcaption></figure>Ujjwal Thapa, the founding chair of Bibeksheel Sajha Party, died on 1 June last year due to complications from Covid-19.Thapa’s treatment, which cost Rs2.5 million, was crowdsourced after he was unable to put together enough money to pay mounting hospital bills. His family raised Rs6.8 million for the treatment of a young politician known for his integrity and vision for the country.Thapa needed financial support despite belonging to an upper middle class family with a house and business in Kathmandu.Covid-19 exposed the pre-existing failure of Nepal’s public health system and high cost of treatment at private facilities have forced many families into a vicious cycle of poverty, as well as countless preventable and premature deaths.Nepal’s healthcare mechanism is at odds with the constitutionally guaranteed fundamental rights of Nepalis, and needs a complete overhaul. Government hospitals cost less, but treatment is sub-standard and private care is too expensive.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 KoiralaNepalis have had to sell property and livestock to pay hospital bills, and fall prey to loan sharks. Others have had to abandon treatment midway or entirely knowing that doing so would mean certain death.The government subsidises treatment for diseases including cancer, Alzheimer's and kidney failure, as well as for families of those who were killed or injured during the conflict. However, the amount does not even cover transportation for treatment in most cases. Bureaucratic red tape means not all patients receive the benefits.Arun Shahi, an oncologist at Patan Hospital says that cancer treatments might take up to five years, and cost as much as Rs20 million: “How much is the Rs100,000 government subsidy going to cover?”Particularly tragic are the stories of children whose parents have had to discontinue treatment for lack of money. Doctors at Kanti Children’s Hospital say they have seen at least five such cases from Achham, Sindhuli and Sarlahi districts in the last six months.“It is heart-breaking to be forced to send young children home, and we are very much aware that the lack of treatment will mean they will not live,” says Bishnurath Giri, a paediatric oncologist at Kanti.Read more: <a style="font-weight: 600;" href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudhathokiIn Nepal, medicine for chronic diseases like diabetes and high blood pressure cost about Rs1,000 per month. Kidney dialysis, required to be done thrice weekly, costs Rs2,500 per session. Cancer treatment cost a minimum of Rs300,000, while bone marrow transplants at private facilities cost up to Rs3 million. A brain surgery, which is not available at government hospitals, costs around Rs2 million at the Neuro Hospital in Bansbari.Meanwhile, the overall costs of a liver transplant could be as high as Rs3 million. Sagar Poudel, who sees up to 30 patients with liver disease at the Chitwan Medical College every day, says that at least five of those patients require liver transplants, but cannot afford it.For families in remote areas, even a fall from a tree or injury in a highway accident can sink them deeper into poverty. Many of Nepal’s migrant workers admit they seek overseas employment to pay debts incurred for medical treatment of family members.The average cost of treatment for an accident and surgery in private hospitals is Rs200,000. Just an ICU bed in a private institution in Kathmandu costs Rs20,000 per day, while the daily cost for patients needing ventilators is Rs100,000. Critical care at government hospitals is only about Rs15,000 cheaper.Additionally, the absence of a medical audit for treatment in Nepal, unlike in foreign countries, has led Nepali service providers to charge money arbitrarily by directing patients into unnecessary tests and treatments.Read also: <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">Health insurance must be an election agenda</a>, Gaj B GurungAnd since patients do not have technical knowledge of medical treatment, it is difficult for them to decide on the choice of service. "It is up to the patient to decide, but healthcare providers have taken the decision out of their hands," says Poudel, the liver transplant surgeon.And when families cannot afford treatment fees, hospitals are known to hold new mothers and babies, mentally ill patients, as well as bodies of deceased family members hostage.The over-saturation of private health institutions in Kathmandu has also led to unhealthy competition between private hospitals which have been known to pay ambulance drivers commissions for bringing patients to them. Tests performed in one hospital are not recognised by another, and a patient needs to take them all over again.Patients were already bearing the brunt of expensive medicines and over-prescription of unnecessary medications. Big pharma pays commissions to hospitals and doctors for prescribing drugs. Indeed, up to 75% of the total expenditure or medical treatment is spent on pharmaceuticals."While there is a big managerial weakness in the government health institutions, the private sector is engaged in unethical profiteering, and ordinary Nepalis are squeezed between those two problems,” explains physician Kiran Raj Pandey, author of Up is the Curve: A Genealogy of Healthcare in the Developing World.Read more: <a style="font-weight: 600; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeAccording to the National Health Accounts Report 2018, Nepalis spend 80% of their out-of-pocket expenses on private medical treatment. Nepal’s healthcare mechanism is not only causing people to spend a significant portion of their income on treatment, but also increasing indebtedness.Experts have time and again called for the elimination of out-of-pocket healthcare payments due to continued investment into an unregulated private medical sector.“The state has let hospitals and clinics charging arbitrary fees off the hook, this needs urgent fixing,” says public health expert Kedar Baral.The answer is a citizen-centric national health insurance program to reduce the burden of medical costs. Public health expert Sharad Onta says: “Healthcare cannot be a commodity, and patients are not customers."Meanwhile, Baburam Marasini, former director at the Epidemiology and Disease Control Division says that the treatment cost of 90% of patients will be reduced if health services are decentralised to primary health centres as well as local and provincial hospitals.Introducing a national health insurance scheme would then also mean sustainability for district hospitals and local primary health care centres.Read more: <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

Sick of it

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222d29c7e80680e0c0318jpeg.jpg" alt="" width="1400" height="905"/><figcaption>Photo: NEPALI TIMES ARCHIVE</figcaption></figure>Every year, half a million Nepalis fall below the poverty line paying for expensive medical care. Another three million face financial burden, unable to pay hospital bills even after selling their assets. This is over 10% of Nepal’s population.Nepal might have taken dramatic strides in reducing maternal mortality and childhood malnutrition in the last decades, but it is lagging behind in assuring accessible and affordable healthcare for its people.This is a crime, it goes against the Constitution which guarantees basic health care for all Nepalis. Like other social sectors including education, healthcare is either over-commercialised or offers substandard service.Public health is just not the priority of the government, especially when it comes to the poorest and most neglected sections of society. The state’s investment in healthcare is inadequate, and the budget allocation for the health sector is considerably lower than the global average of 10% of GDP, and is less than most developing countries.Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudhathokiEven the budget that is set aside for healthcare is mostly spent on shoddy infrastructure, or procuring unnecessary and expensive equipment that is never used. There is little left for trained medical personnel and retaining them in remote area hospitals.Nepalis are sick because they are poor, and they are getting poorer because they are sicker. Most families that cannot afford treatment in private institutions have to sell property or borrow from loan sharks to pay medical bills.Private hospitals and clinics operate on free market principles, and need a return on investment. The most lucrative business in Nepal today is medical education, and the sky high fees in those colleges perpetuate the cycle of over-priced medical treatment.Read more: <a href="https://archive.nepalitimes.com/news.php?id=18362#.YrLw3-xBzDI">Do hospitals have to be so expensive?</a> Elipha PradhanangaHealthcare should not be guided by the free market, and as long as the state does not take responsibility for the wellbeing of its citizens we will never achieve equity.Medical care cannot be a commodity, patients are not customers.Primary health care (PCH) is free in government hospitals in Nepal, and is paid for through taxes. Specialised medical care is best covered by insurance so the cost is not passed on to patients and their families. But in Nepal, primary health care is too basic, government hospitals are crowded and understaffed, and private hospitals are out of reach of most.A welfare state with a social safety net pays for free healthcare through taxes, or insurance. Tax revenue goes for other sectors besides health, but medical insurance is targeted for specifically for health.Countries like Bhutan, Cuba and Sri Lanka show that it is indeed possible to achieve free universal healthcare. Nepal itself has public-private partnership models like Bayalpata Hospital. Replicating these examples requires political will, and a national vision.Read more: <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 BhattaraiOur salvation may lie in national health insurance that is mandatory and where the premium is based on a family’s capacity to pay. Nepal introduced its national insurance scheme in 2017, and the premium is now Rs3,500 per year per family for a benefit package of Rs100,000. But this does not even pay for an ambulance to a city hospital.Late reimbursement to care providers is chronic, and hospitals now want to pull out from the national insurance program. Patients are cannot access timely treatment, and  are dropping out.To correct this mistake, the government is making another blunder: hand over management of health insurance programs to the private sector.The state is giving up on health insurance without even trying, abandoning citizens and leaving them at the mercy of profiteers.Letting the private sector manage health insurance defeats its very purpose: providing equitable and affordable medical care for those most in need and to prevent them from falling into the poverty trap.A better alternative is to work within the existing health insurance program by upgrading its features including the revaluation of the premium and benefits, bringing in private institutions for research and technical know-how, and digitisation of reimbursement for care providers.There are ways the Nepali state can fulfil its constitutional obligation to ensure healthcare for all, and deliver on promises not kept. It just has not tried hard enough.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 KalauneeSonia Awale

Sonia Awale

In a healthy state

<img width="3724" height="2151" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c729c7e80680e0bd491jpeg.jpg" alt=""/><a href="https://archive.nepalitimes.com/news.php?id=12452#.YlFKe9NBxH0">Goitre</a> was once so <a href="https://www.nepalitimes.com/latest/from-pandemic-to-epidemic-to-endemic/">endemic</a> in Nepal that it was considered a sign of beauty. Entire villages across northern Nepal that relied on <a href="https://www.nepalitimes.com/banner/the-salt-of-the-earth/">Tibetan rock salt</a> suffered from iodine deficiency, and cretinism was widespread.Read also: <a href="https://www.nepalitimes.com/banner/the-salt-of-the-earth/">The salt of the earth</a>, Jag Bahadur BudhaUnlike sea salt which contains adequate iodine, the micronutrient mostly evaporates from rock salt, and people who used it were affected by <a href="http://archive.nepalitimes.com/news.php?id=9144#.YlFK49NBxH0">iodine deficiency</a>. Those suffering from it had throats disfigured with large growths.A successful public-private partnership between the government, Salt Trading Corporation and aid agencies <a href="http://archive.nepalitimes.com/news.php?id=9144#.YlFK49NBxH0">iodised salt</a> under the brand आयो नुन and this all but eradicated visible goitre — it went down from 55% in 1965 to only 0.4% in 2007. This is one of Nepal’s public health success stories.However, in solving one problem, we may have created another. The country is now facing thyroid disorders caused in part by excess iodine intake. Recent studies show an increasing prevalence of thyroid disorders, even among younger Nepalis.A 2019 community-level survey in five districts found the prevalence of thyroid disorders at 4.32%. Nearly three-fourths of those were subclinical hypothyroidism, 13.7% primary hypothyroidism and another 13.7% were hyperthyroidism.Hypothyroidism is when the thyroid gland does not produce enough hormones. In hyperthyroidism, on the other hand, the gland is overactive and produces too much hormones. Subclinical conditions do not need immediate treatment.The figures for hospital-based surveys are much higher. In a paper published in 2015 based on 5,230 cases from Teaching Hospital in Kathmandu, 29% were diagnosed with thyroid disorders. Higher prevalence was found in the 31-45 age group.However, experts are cautious about pinpointing excess iodine in the diet as the only cause for thyroid disorders.“The prevalence of thyroid disorders has indeed increased in the last 10-15 years, but this could also be a result of better diagnosis even in rural areas,” says endocrinologist Ansumali Joshi.The recommended daily intake of iodine is 150 micrograms, but is higher for <a href="https://www.nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time/">pregnant and lactating women</a>. <img width="477" height="544" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c759c7e80680e0bd492jpeg.jpg" alt="">A 2016 survey showed that 67.5% of households in Nepal have excessive iodine intake in food. School-age children were classified in the ‘excessive’ range, pregnant women in ‘adequate’ and women of childbearing age in ‘more than adequate’. Iodine intake was higher in the central and western parts of the country and the Tarai.“Iodised salt has reached every corner of Nepal and because there is excessive use of salt in food items, logically people are overdosing on iodine,” says cardiologist Prakash Regmi. “Excessive salt intake is already a leading cause of <a href="https://archive.nepalitimes.com/news.php?id=18115#.YlFMNtNBxH0">heart</a> and <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639">kidney diseases</a>. And excess iodine is now adding thyroid dysfunction which can affect the brain and the nerves.”After the 2016 assessment, the government reduced iodine content in salt from 50PPM (parts per million) to 30PPM. Experts say it might be time to reduce it further, or even add the micronutrient in some other food item.Misinterpretation of iodine ‘overdosing’ could also send out the wrong message, they warn, leading to the public avoiding iodised salt, and thus reverse Nepal’s successful eradication of iodine deficiency.Other factors affecting thyroid glands include viral infections and endocrine disrupters like <a href="https://www.nepalitimes.com/latest/biodegradable-plastic-launched-in-nepal/">plastics</a> and certain chemicals. Thyroid disorders can also be hereditary. Covid-19 has also been associated with thyroid inflammation, resulting in hyperthyroidism or thyroiditis.Untreated hyperthyroidism can lead to ‘thyroid storm’, a very rare but life-threatening condition in patients often referred to Kathmandu hospitals due to <a href="http://archive.nepalitimes.com/news.php?id=4980#.YlFMxNNBxH0">lack of treatment facilities</a> elsewhere.“We know either too much or too little about thyroid disorders. But there is a general lack of clear understanding, I have a lot of patients who visit me all panicking about their thyroid test results,” says endocrinologist Jyoti Bhattarai. “But there is a spectrum to thyroid diseases, and many do not need treatment. Subclinical hypothyroidism is one example.”Read also: <a href="http://archive.nepalitimes.com/news.php?id=18379#.YlFJb9NBxH0">Diabetic dilemma</a>, Buddha Basnyat There are groups more at risk: pregnant women and those planning to conceive who should take thyroid function tests to prevent possible premature birth, miscarriage and even stillbirth. Women unable to conceive should also be screened.And ideally, all newborns should also take a test because early diagnosis of a congenital hypothyroidism can almost entirely prevent mental disability. Another risk factor is obesity.“Growing up in the mountains I had several family members afflicted with goitre. We have made much progress since then, but it is time to change our focus and study the prevalence of thyroid disorders today,” says Pokhara-based physician Bikash Gauchan. “It affects multiple systems and patients experience a wide range of symptoms with implications on both <a href="https://www.nepalitimes.com/latest/the-other-pandemic-mental-health/">mental</a> and <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">physical health.</a>”Endocrinology and the study of hormones used to concern only the well-to-do. Public health in Nepal was all about preventing infectious diseases which afflicted the poor. Today, the lines are blurred, and Nepal needs treatment for chronic diseases of the vital organs like the lungs, heart, kidney and stomach for all sections of society.Says Jyoti Bhattarai: “The field of endocrinology in Nepal needs much more commitment and investment. While hormonal dysfunctions including thyroid disorders are often not immediately fatal, they can significantly affect one’s quality of life.” Read more: <a href="https://www.nepalitimes.com/latest/why-do-so-many-nepalis-have-high-blood-pressure/">Why do so many Nepalis have high blood pressure?</a> Sonia Awale

Either too little, or too much iodine

<figure><img width="1198" height="679" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c059c7e80680e0bd46djpeg.jpg" alt=""/><figcaption> Locals from Budhinanda in Bajura transporting a woman in labour to a hospital in district headquarters. All photos: PRAKASH SINGH</figcaption></figure><img width="1456" height="589" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c079c7e80680e0bd46ejpeg.jpg" alt="">Nothing could be more symbolic of the misplaced priorities of all three tiers of government in Nepal than the sight of women giving birth by the wayside at a time when politicians are <a href="https://www.nepalitimes.com/latest/nepals-shortsighted-view-tower-craze/">inaugurating yet another view-tower</a> in a lavish function.As a reporter based in Bajura district in Nepal’s rugged northwestern mountains, I have see many mothers with complicated pregnancies being carried on stretchers to hospitals. Usually, they are women who have been in prolonged and agonising labour. Many do not make it, and die along the way. I was working on a story on maternal mortality when I came across a photograph from four years ago of a woman giving birth along a trail. I tweeted it on 26 March, and the image immediately went viral because it coincided with the inauguration by Pushpa Kamal Dahal of a nine-storey view-tower in Rolpa district.<blockquote>बाटोमा यसरी बच्चा जन्माउछन्, दुर्गमका महिला <a href="https://t.co/sZfmFmzv3F">pic.twitter.com/sZfmFmzv3F</a>— Prakash Singh (@prakashbajura) <a href="https://twitter.com/prakashbajura/status/1507590311073230853?ref_src=twsrc%5Etfw">March 26, 2022</a></blockquote> Even though that photograph was from some years ago, the situation with maternal and infant deaths in Bajura has not improved. For Nepal’s netizens, that symbol of neglect was in stark contrast with the view-tower building spree across the country. In fact Bajura has one of the worst socio-economic and health indicators in Nepal. Just in the past three years, eight women with difficult pregnancies have died while being transported to the district’s only hospital in Martadi. These were just ones that were officially recorded, there are surely many more mothers in far-flung villages of this district who did not make it.Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar BudathokiThe mother and baby in my photograph that went viral in social media were the lucky ones. The mother’s name was Tara Luhar from Budiganga Municipality, and after running into them on a village trail, I took the photo after taking their consent.   Although heavily pregnant, Tara had been doing all household chores herself, including raising her other children and taking care of the livestock and farm. No female community health volunteer had visited her home and she did not know that she needed pre-natal checkups, and the need to deliver in a health post or hospital. Most women in Bajura’s traditional families are <a href="https://www.nepalitimes.com/here-now/the-curse-of-being-new-mothers/">banished to cowsheds during childbirth</a>. It was only when her labour dragged on for four days that neighbours and relatives decided to carry Tara to the health post in a stretcher. During the journey lasting several hours, the baby came out and into the dusty trail. Tara simply carried her baby, and walked back home.  This week, after the photograph made her famous, I called Tara Luhar. She said the baby was now four years old and they were both were healthy. Her husband, who was working in India, had died at about the time her son was born. As single mother, she now struggles to make ends meet.“Most of our births in Bajura are at home, there are very few institutional deliveries,” explains Bimala Pandey of the Bichchyan Health Post in Bajura. “There are many cases of women giving birth while on their way. We have to refer the complicated cases to Achham.”  Nepal has taken dramatic strides in reducing its maternal mortality ratio (MMR). It has come down from 880 per 100,000 live births in 1980 to less than 200 in 2019. But maternal deaths have gone up again in the past two years because of the drop in institutional <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/">deliveries during the pandemic.</a> Bajura’s maternal mortality ratio in 2014 was much higher than the national average: 380. The district ranks at the bottom among Nepal’s districts in the Human Development Index (HDI), with just 0.364 against a national average of 0.602 in 2019. The infant mortality ratio has improved, but is still at 27 deaths per 1,000, mainly babies who die within a month of being born.Although the photograph of the mother giving birth by the side of the road sparked outrage on Nepal’s cybersphere, for Bajura it was just another tragic reminder of its poor state of healthcare. Three <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/">mothers die at childbirth every day</a> in Nepal, and in Bajura there is not a month that goes by without news of yet another mother who does not make it while giving birth by the roadside. <figure><img width="1200" height="681" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c0b9c7e80680e0bd46fjpeg.jpg" alt=""><figcaption>Bajura's Nitikhola resident Parvati Budha, 23, delivering a baby on the way.</figcaption></figure>The <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/">high cost of ambulance</a> and lack of political connections to get medical evacuation by helicopter under the <a href="https://www.nepalitimes.com/here-now/nepals-air-ambulance-saves-mothers/">President’s Program for Women’s Upliftment</a>, most families have to physically carry pregnant women with complicated pregnancies. Last month, 23-year-old Parbati Buda of Himal Rural Municpality had her baby while being carried for over six hours to the local health post. Buda was lucky to survive. In the past year two women died while being carried to Achham – the travel by stretcher and jeep took too long, and the family had waited till it was too late to save them.Because local health posts are not properly equipped to deal with births in which a caesaerian section may be required, many families try to take them to <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Bayalpata Hosptial in adjoining Achham district</a>, which has a dedicated maternity ward and surgery.Read more: <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 BhattaraiPrakash Singh is editor in chief of Badimalika Khabar in Bajura.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c0e9c7e80680e0bd470jpeg.jpg" alt="" width="120" height="150">

healthcare