<img width="6016" height="4016" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131128/637234649c7e80680e0c492ejpeg.jpg" alt=""/>Nepal’s first-ever Human Milk Bank has been established in Kathmandu, with President Bidya Devi Bhandari inaugurating it at the Paropakar Maternity and Women’s Hospital on Friday. The milk bank ensures a baby-friendly health system and gives premature, low birthweight and other at-risk infants access to the benefits of breastmilk and a healthy start to life.An estimated 81,000 babies are born pre-term in Nepal every year, and low birthweight babies face a higher risk of dying in the first month. Nepal’s neonatal mortality rate is 16 per 1,000 live births during first 28 days of life, and 25 out of 1,000 babies die before their first birthday. Although Nepal’s infant mortality rate has been reduced dramatically in the  past 20 years, neonatal mortality is still high.Read also: <a href="https://www.nepalitimes.com/banner/back-to-the-nipple-in-nepal/">Back to the nipple in Nepal</a>, Sonia Awale“Human breast milk contains the best source of nutrition and ensures survival and healthy growth of babies. It bolsters brain development and has lifelong benefits for the baby and the mother,” says Bibek Kumar Lal of the Family Welfare Division at the Ministry of Health and Population. “It contains antibodies which offer a powerful line of defence against infection and malnutrition and helps towards preventing deaths of infants and young children,” Lal adds.  Exclusive breastfeeding has the potential to prevent 13% of under-five deaths globally each year. In Nepal, only 42% of children under 2 years of age are breastfed within one hour of birth, and 62% of children under six months are exclusively breastfed, according to a 2019 survey.  <img width="750" height="401" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114131128/637234689c7e80680e0c492fjpeg.jpg" alt="">“Premature, low birthweight and small for gestational age babies usually have feeding problems and direct breastfeeding is often not possible. So, the next best alternative is breast milk, preferably from their biological mother,” says Amir Babu Shrestha of Paropakar Maternity and Women’s Hospital.Such newborns are usually given infant formula milk, which exposes them to risk of infection. Donor human milk is therefore preferred.Read also: <a href="https://www.nepalitimes.com/opinion/we-are-what-we-eat/">We are what we eat</a>, Aruna UpretyThe new Human Milk Bank called Amrit Kosh at the Paropakar Maternity and Women’s Hospital has the facilities to collect, pasteurise, test and store safe donor human milk from lactating mothers and then provide it to infants in need. The centre has been established in partnership with the European Union and UNICEF.Says EU Ambassador to Nepal Nona Deprez: “We are proud that this tripartite partnership has led to the establishment of Amrit Kosh, we hope that more and more newborns unable to receive their mother’s milk can benefit from breastmilk in protecting their health and supporting their development.”Nepal’s Multi-Sector Nutrition Plan (MSNP) seeks to improve maternal, adolescent, and child nutrition throughout Nepal by promoting healthy, nutritious, and diversified diets for adolescents, pregnant women, breastfeeding mothers, infants, and young children. Since 2013, UNICEF has been supporting the Government of Nepal in implementing MSNP, with funding support from the European Union.“The Human Milk Bank initiative is critical to advancing our joint efforts under Nepal’s Multi-Sector Nutrition Plan to improve child nutrition and particularly to address acute malnutrition of children in Nepal,” says Elke Wisch, UNICEF Representative to Nepal.Read also: <a href="https://www.nepalitimes.com/here-now/nepals-air-ambulance-saves-mothers/">Nepal’s air ambulance saves mothers</a>, Nepali Times

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Nepal’s first Human Milk Bank

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f29c7e80680e0b288djpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photos: UNICEF NEPAL</figcaption></figure>Despite periods of political and economic instability, Nepal achieved dramatic progress in maternal and child health in the early 2000s becoming an international model.It took great strides in reducing childhood malnutrition, in particular, reducing stunting from 57% in 1996 to 33% in 2016. Maternal and Infant mortality rates also similarly declined, only for much of these successes <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">to stall in the recent years</a>. And this trend has been made worse by the Covid-19 pandemic, states a new UNICEF report.Titled “<a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">Nutrition in Nepal: Three decades of progress for children and women</a>”, the report brings together a set of nine original articles that examine the drivers of success and identify where greater policy and programmatic action is needed to achieve the Sustainable Development Goal (SDG) nutrition targets.“Optimal maternal and child nutrition is the basis for developing a resilient society,” says EU Ambassador to Nepal, H.E. Nona Deprez. “The decline in the number of malnourished children, improvements in health facilities and services, and the multisectoral approach used in Nepal over the past three decades are a testament to the Government of Nepal’s commitment to reducing all forms of malnutrition.”A <a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">special supplement of the Maternal and Child Nutrition Journal</a> published on Thursday lists some of Nepal’s biggest nutritional achievements. Between 1996-2016, the early initiation of breastfeeding saw an increase from 18% to 56%, and complementary feeding increased from 54% to 77%.During the same period, women taking sufficient iron and folic acid supplements during their pregnancy rose from 6% to 71%. This was combined with earlier and more frequent antenatal care visits.Consistent administering of Vitamin A has saved the lives of an estimated 45,000 Nepali children under the age of five, between 2002 and 2015. Similarly, households using adequately iodised salt doubled from 35% to 77% from 1998 to 2016.Much of this progress can be credited to improvements in household wealth, parental education, and <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">sanitation</a>. But equally important was increased coverage of health and nutrition services undertaken by successive governments.Nepal Government utilised ground-breaking research to test interventions and overcome challenges, it is also committed to enforcing mandatory legislation such as salt iodisation, writes the journal supplement.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f69c7e80680e0b288ejpeg.jpg" alt="" width="1500" height="1001"><figcaption></figcaption></figure>Mobilisation of <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">Female Community Health Volunteers</a> (FCHVs) across Nepal villages and towns have improved the health of mother and children, so has an investment in sectoral programs including education and sanitation.But there are now new challenges to achieving national and global targets on nutrition, which also threatens to undermine past gains.“The learning from the past 25 years that are incorporated in the supplement will inform and contribute to future improvements. However, we must act now, given the impact that the pandemic has had on the nutritional health of mothers and their children,” says Elke Wisch, UNICEF Representative to Nepal.During the pandemic, most households experienced job losses or reduced income. With the <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">Omicron-led third wave</a> spreading across Nepal, the pandemic’s ensuing socioeconomic crisis is long from over.This means reduced dietary intake among children and mothers. School closures will deprive many children of getting one decent meal a day. All this will add to <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/" target="_blank" rel="noopener noreferrer">childhood malnutrition</a> which continues to be a major cause of death and retarded mental and physical development among younger populationsAs such, UNICEF has recommended the government to improve the general public’s access to nutritious, safe, affordable, and sustainable diets. It also suggests integrating essential nutrition services into the existing service delivery platforms like family planning, antenatal, delivery and post-natal care and well-child and sick-child care and continuing to mobilise FCHVs to reach more women and children.To disseminate factual information, advice and counselling on infant and young child feeding, <a href="https://www.nepalitimes.com/here-now/3rd-covid-wave-infects-nepals-frontliners/" target="_blank" rel="noopener noreferrer">healthcare workers</a> can also use multiple communication channels such as radio, TV or social media.But perhaps equally if not more important is strengthening local levels so that they can plan, implement and monitor nutrition programs and services, and maintain Nepal's commitment to generating data, information, and evidence to assess progress and inform decisions.

Covid undermines Nepal's mother-child gains

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107121148/6368f1049c7e80680e035a06jpeg.jpg" alt="" width="800" height="1199"/><figcaption>Pics: NSI</figcaption></figure>Avinashi Poudel, 30, is a mother of two, including a 10-week baby boy. She only breastfeeds her baby, and has supportive in-laws and a mother friendly environment at her workplace. But seven years ago when she was a first time mother, she was not aware of the benefits of exclusive breastfeeding and her first baby did not get enough of her milk.Rama Thapa, 23, moved to Kathmandu from Tanahu after she got married. She now has a six-month baby boy, and feeds him food supplements because she says her own milk is not enough. Her family and friends told her the baby needs the formula to grow up strong and healthy.Nearly seven out of every ten Nepali mothers still exclusively breastfeed their babies, but some families are turning to supplements because of inroads by baby food manufacturers. Ironically, mothers in western countries where those baby food alternatives were first introduced, have returned to exclusive breastfeeding.Nepal is among the countries that are already above the World Health Organisation (WHO) target to increase the rate of exclusive breastfeeding in babies' first six months to at least 50%, by 2025. However, because of aggressive marketing by baby formula brands, Nepal has set its own national target to increase exclusive breastfeeding to 80%.“Nepal has set a good standard in breastfeeding but we need to sustain it and make further progress, this requires policy implementation and monitoring,” says Pradiumna Dahal, nutrition expert at UNICEF Nepal, who is worried that not all health workers are aware of the benefits of breastfeeding.The use of breast milk substitutes is so widespread that health professionals in the Far-West are prescribing bottled milk in hospitals. Baby food is a burgeoning industry, and salesmen often target hospitals, doctors and nurses with inducements to prescribe babies substitutes for breast milk.After a huge international outcry against Nestle and other baby food supplement manufacturers, the WHO adopted the <a href="http://www.who.int/nutrition/publications/code_english.pdf" target="_blank" rel="noopener noreferrer">International Code of Marketing of Breast-milk Substitutes</a> to promote breastfeeding. Nepal passed the <a href="http://www.nnfsp.gov.np/PublicationFiles/2574d2af-7992-469b-befa-ad939ac96497.pdf" target="_blank" rel="noopener noreferrer">Substitute of Breast Milk Act</a> in 1992 to control the sale and distribution of breast milk substitutes. It penalises health professionals pushing and manufacturers promoting baby food formulas.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107121148/6368f1079c7e80680e035a07jpeg.jpg" alt="" width="500" height="234">But while the $70 billion global baby food industry has seen sales plummet in Western countries, as more mothers embrace breastfeeding, modern lifestyles and higher purchasing power has pushed families in developing countries to use infant formulas.Recently, the <a href="https://www.theguardian.com/us-news/2018/jul/08/trump-administration-opposes-breastfeeding-resolution-report" target="_blank" rel="noopener noreferrer">Trump administration exerted pressure to dilute</a> the clause in a resolution to promote and support breastfeeding at the World Health Assembly in Geneva in order to promote the interests of infant formula manufacturers. The US delegation even threatened Ecuador that it would terminate military aid if it voted for the resolution. Washington could also cut funding for WHO, the UN Population Fund and other agencies involved in promoting breastfeeding, reproductive health, contraceptives, abortion and even vaccination programs in developing countries, including Nepal.Allowing infant formula manufacturers unrestricted access to the domestic market threatens to undo decades of effort in Nepal to reduce the infant mortality rate and promote <a href="http://archive.nepalitimes.com/article/nation/people-politics-placentas-child-delivery-complications,3922" target="_blank" rel="noopener noreferrer">maternal health</a>.“We have been working to promote breast milk and convinced a large proportion of mothers in Nepal to exclusively breastfeed. However, we have not been able to regulate the activities of the manufacturers of breast milk substitutes,” says Bikash Lamichhane at the Department of Health Services.Nutritionist Aruna Uprety says that despite the government’s claim that the rate of exclusive <a href="https://katherinerosman.com/extended-breastfeeding/" target="_blank" rel="noopener noreferrer">breastfeeding</a> has increased, breast milk substitutes are used widely, even in government hospitals. Manufacturers are known to reward clinics and doctors promoting and prescribing their infant formulas.“Breastfeeding is engrained in our culture, we don’t need foreign experts to teach us its significance. We just need to create awareness and provide an enabling environment for women to be able to breastfeed,” Uprety told Nepali Times.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107121148/6368f1089c7e80680e035a08jpeg.jpg" alt="" width="800" height="1199">Indeed, health officials say any future cuts in American funding for maternal and child health should not make a big dent on efforts to promote exclusive breastfeeding in Nepal.In 2016, the government set up a system to monitor the use of breast milk substitutes in each district. But with new federal and provincial structures in place, and confusion about the role of district health offices, experts are worried that the monitoring system will not be effective.A <a href="http://www.nphss.org.np/archive_2012/52-54.pdf" target="_blank" rel="noopener noreferrer">survey in 2011 by the Institute of Medicine</a> showed that despite the Baby Friendly Hospital Initiative, there had been no action to control and regulate breast milk substitutes and producers and the distributors were found to be violating the Breast Milk Substitute Act. The study also noted that the promotion of breastfeeding was not prioritised and awareness was limited to token functions during World Breastfeeding Week.Studies have shown that counselling, awareness and legislating paid maternity leave increased the rate of exclusive breastfeeding, and had an immediate impact on maternal and infant health as well as the overall economy.Says UNICEF’s Dahal: “We need to encourage more women to breastfeed. That means adding breastfeeding corners in our work places and providing maternal security in the form of sufficient leave.”The Department of Health Services is planning to inaugurate a breastfeeding corner at its own office in Teku to mark World Breastfeeding Week (1-7 August). UNICEF is supporting the government to set up 30 baby friendly hospitals, and train counsellors and other personnel. The Ministry of Health is also preparing to extend the duration of paid maternity leave from two months to six, to improve maternal and child health.<h4>The Trump tremor</h4><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107121148/6368f10b9c7e80680e035a09jpeg.jpg" alt="" width="640" height="354">Nepal has scored dramatic success in reducing maternal and infant mortality rates over the few decades, and USAID has been one of the biggest bilateral backers for family planning, reproductive health, maternal and child health projects.However, funding for these programs has often been affected by successive Republican administrations because of a strong conservative lobby for the <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841" target="_blank" rel="noopener noreferrer">Global Gag Rule</a>, which seeks to end American aid for contraceptive promotion and abortion.The <a href="https://pai.org/wp-content/uploads/2016/12/Access-Denied-The-Impact-of-the-Global-Gag-Rule-in-Nepal.pdf" target="_blank" rel="noopener noreferrer">last time it was in effect, during the Bush Administration</a>, mobile clinics providing reproductive services to rural Nepal were discontinued. The Family Planning Association of Nepal (FPAN) lost $400,000 in USAID-funded contraceptives, which represented two-thirds of its total stock, and a further loss of $100,000 per year that supported reproductive health clinics.President Donald Trump has renamed the Gag Rule as ‘Protecting Life in Global Health Assistance’ after restoring it in March 2017. Despite its new name, it is actually stricter, even targeting breastfeeding and vaccines.“The Global Gag Rule is not new, what is new is that it has come back with added force under Trump and can have devastating consequences on Nepal,” explains public health expert Aruna Uprety. “By pulling money out of abortion, they are going to increase unsafe abortions and end up killing more women. It is against human rights.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107121148/6368f10d9c7e80680e035a0ajpeg.jpg" alt="" width="600" height="558">Just a month before the 2015 earthquake, the Nepal Government made a commitment to increase the family planning budget allocation by 7% annually. It partnered with international and private organisations to meet the target, but most of these partners are likely to lose a chunk of their funding.“Our government already lacks resource to meet the commitment. With the US pulling out, the gap is only going to widen,” says an official working in family planning.A US Embassy spokesperson said the United States remained committed to helping the welfare of women and children in developing countries: “The Protecting Life in Global Assistance policy has not reduced funding for women and children’s health by one dollar. USAID works together with the Government of Nepal and other external development partners, including multilateral partners, to coordinate interventions, synergise, and reduce gaps. USAID has strong working relationships with both UNFPA and WHO in Nepal.”Although <a href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/" target="_blank" rel="noopener noreferrer">family planning</a> is a small component of the aid budget for maternal health, the cuts are biting. The EU and Nordic countries have stepped in, but their contribution does not meet the shortfall.At the recent World Health Assembly in Geneva, the United States wanted to dilute a routine agreement on breastfeeding, amidst a global outcry.The United States delegation wanted to water down the resolution by removing a call on governments to ‘protect, promote and support breast-feeding’ and another clause calling for restrictions on the promotion of baby foods.“What happened was tantamount to blackmail, with the US holding the world hostage and trying to overturn nearly 40 years of consensus on the best way to protect infant and young child health,” Patti Rundall of the British advocacy group Baby Milk Action was <a href="https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html" target="_blank" rel="noopener noreferrer">quoted by the New York Times </a>as saying.The uproar set off alarm bells in Nepal, where donor support has been critical in trying to meet the target of getting 80% of mothers to breastfeed by 2022.The US Embassy clarified that improving nutrition among mothers, infants, and young children was still an important public health priority for the United States, and it remained committed to working with WHO and other stakeholders to improve health and nutrition through “cost-effective and evidence-based” measures.But, the spokesperson added: “While the United States recognises that breastfeeding and provision of breast milk is best for all babies, we recognise not all women are able to breastfeed for a variety of reasons. These women should have access to full and accurate information about breastfeeding, the benefits of breastfeeding, and safe alternatives when breastfeeding is not possible.”Some experts contend that cuts in funding would not affect the breastfeeding campaign, and Nepal did not need to be dependent on donors anymore.“Even if the US cuts funding, Nepal is capable of going ahead on its own. Awareness here about breast milk far exceeds any opposition from outside, it’s just that the government has to own it,” says former WHO public health expert Rita Thapa.Aruna Uprety agrees, but adds that the Americans have played cleverly on a woman’s choice not to breastfeed: “This distracts from the fact that mother’s milk is the healthiest for babies.”The conclusion is that Nepal is perfectly capable of maintaining its momentum not just on breastfeeding, but also on protecting maternal and infant health with or without outside help.<h4>Breast is best</h4>Awareness and education can double exclusive breast-feeding rates in societies. Paid maternity leave can increase breastfeeding rates by 50%. This directly helps the national economy, and the health of mothers and babies. Breastfeeding:<ul><li>Prevents breast cancer deaths</li> <li>Reduces infant diarrhoea by half and respiratory infections by one-third</li> <li>Decreases hospital admissions by 57-72%</li> <li>Children's IQ increases by average of 3 points</li> <li>Investing $1 to promote breastfeeding yields $35 in economic returns</li></ul>https://www.youtube.com/watch?v=-PSs2cPsciw

Sonia Awale

Back to the nipple in Nepal

It was pure drama: the political transition in Madhes unfolded by the dawn’s early light. At around 4AM on Monday, Province Head Sumitra Subedi Bhandari quietly departed Janakpur saying she was headed to Kathmandu for health reasons.&nbsp;
Outgoing Chief Minister Jitendra Sonal, whose coalition had begun to unravel, even saw her off, asking supporters to clear the road for her motorcade.
But an hour later, instead of continuing on to the capital, Bhandari stopped in Bardibas on the East-West Highway. There, as the sun started rising over the misty plains, she administered the oath of office to Saroj Kumar Yadav of the CPN-UML, invoking Article 168(3) of the Constitution.&nbsp;
Bhandari is also a member of the CPN-UML. The provision she invoked is typically used only after coalitions fail under Article 168(2), and the timing and location of the swearing-in have since drawn scrutiny.
Bhandari was subsequently relieved of her duties, and former National Planning Commission member Surendra Labh Karna was sworn in as the new Madhes province head on Tuesday.
Sonal had formed his government barely a month ago, with the backing of 56 provincial lawmakers but it became evident he would not secure the 54 votes needed to survive a confidence motion.&nbsp;
Several lawmakers in his coalition publicly signalled they would abstain. Still, the seven-party alliance that opposed Yadav’s appointment argues that the Province Head, who is the highest constitutional rank in the provincial structure, acted prematurely and under pressure from central UML party command.&nbsp;
A coalition of seven parties, including the Nepali Congress (NC), had been urging the Province Head to invite them to form a new government under Article 168(2). At the same time, the UML, which had been holding demonstrations outside the Province Head’s office in Janakpur, was calling for the formation of a minority government under Article 168(3).
The alliance of the seven parties that included the NC and Maoist Centre took to the streets. By mid-morning, protests had escalated outside Madhes Bhawan with cadre vandalising both the Chief Minister’s office and the Province Head’s office.
This was the third government in Madhes to fall since the 2022 provincial elections, and it follows a similar pattern. The previous Chief Minister Satish Kumar Singh of the Janamat Party, resigned before a scheduled confidence vote after losing the support of his own party and others including NC and LSP.&nbsp;
His resignation unfolded amid nationwide GenZ protests against corruption, demanding accountability and reform. The recurring instability points to a structural tension in Nepal’s federalism.&nbsp;
Provincial politics remain closely tied to alliances shaped in Kathmandu. The withdrawal of support by parties like the NC and Maoist Centre in provinces often reflects national-level calculations rather than provincial priorities.
As a result, the Provincial Assembly is repeatedly consumed by survival of the coalition instead of governance. Development work stalls. Budget execution slows. Public frustration grows. In a province that was at the forefront of the movement for federalism to counter what is seen as neglect, apathy and discrimination by Kathmandu, the sense that the system may not delivering on its promise is becoming increasingly pronounced.
If federalism is to be strengthened, provincial governments must be able to function with a degree of autonomy that currently exists more in principle than in practice. Otherwise, the perception that federalism is costly, unstable, and ineffective will continue to expand, providing fertile ground for anti-federal sentiment that is already gaining traction.
Earlier examples such as the NC General Secretary Bishwo Prakash Sharma in January calling for a new government in Madhes led by his party demonstrates how the central party leadership deliberately intervenes in provincial affairs. His remarks came during campaigns for bi-elections in Madhes when former CM Singh had been in office for six months only.&nbsp;
Likewise, in early June 2024, the federal coalition in Kathmandu shifted from a Maoist Centre and NC to form a new alliance between the NC &nbsp;and the UML. Within a day, coalition negotiations in Madhes changed to mirror this.
UML leaders publicly stated: “The issues at the federal and provincial levels will be resolved together.” This indicated that the realignment in Madhes followed national party decisions rather than provincial deliberation.
The events that unfolded in Madhes are a reminder that federalism in Nepal is still in transition, and that its success depends on political actors honouring the constitutional framework.

Chronic instability in the Madhes

This is the 73rd episode of Diaspora Diaries, a Nepali Times series in collaboration with Migration Lab providing a platform to share experiences of living, working and studying abroad. I don’t remember playing with dolls as a little girl. There is not much to remember from my childhood.&nbsp; My responsibilities began at a very young age, as I had two younger brothers to take care of. I was born in Sarlahi, but we moved around quite a bit as my father was in the government and got transferred frequently.&nbsp; From Rasuwa to Dang, from Nepalgunj to Kathmandu. I struggled to adjust in Kathmandu because I joined Grade 9 in the middle of the term. The education was different and fellow students also did not support me initially. But over time, I adjusted and made friends. I did not dream of becoming a nurse. It was by accident. I wanted to pursue medicine, but failed the entrance exam by a few marks. I did not want to lose a year, so decided to take up microbiology instead.&nbsp; I got married after my undergraduate, and my husband encouraged me to take up something more technical like nursing or engineering instead of Masters in Microbiology. As my quantitative background was weak, I chose nursing. I felt like I was born to be a nurse. Juggling my married life and studies was difficult. My teachers would often ask me why I am falling behind. It was not easy, but I managed and took up a full-time job as a nurse. There are challenges being a nurse in Nepal. You are overworked, underpaid, there is lack of appreciation. Superiors can be overbearing. These problems persist. But the bright spot is that you get to serve fellow Nepalis, and be close to your family.&nbsp; Just like I had no intention initially of becoming a nurse, I had no intention of migrating overseas. But life had different plans for me. After my baby boy was born, I noticed that something was off. Even at nine months he had not started crawling or sitting. As a nurse I knew something was wrong, and I took him for check-ups. He tested negative for down syndrome, but he had a heart defect.&nbsp; The cardiologist recommended that I take him to India where he was diagnosed with Williams Syndrome, a rare genetic condition that affects 1 in 10,000 people. It delayed his development. I looked for therapy. It was either not effective, or too expensive. Some schools also refused to admit him, and it drove me to tears.&nbsp; My family members overseas in the UK, US told me to emigrate as there were better facilities for differently abled children. So I decided to apply to the UK. Luckily just then there were calls for candidates under the Nepal-UK government-to-government pilot scheme for 100 nurses. Only 40 met the criteria, and I was one of them.&nbsp; I still remember the day I received the news on the day of my puja. There were people around me, and they told me that it was the result of my fasting and devotion on that auspicious day. Perhaps it was. Life was taking a new turn, and I was happy. I made it to the UK in February 2024 without paying a single paisa to any broker. The G2G scheme was unique as we were treated with dignity and valued for our skills: they covered costs for the ticket and visa, reimbursed us for exams we had taken and costs involved in the preparation and testing of the Objective Structured Clinical Examination were also covered.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071148_dc5a0d0ea3024b34a4f2735754f8eb67a650bc7f61b98c75d589676c65b02a0c.jpg" data-media-id="editor_0" data-image-id="20251106071148_dc5a0d0ea3024b34a4f2735754f8eb67a650bc7f61b98c75d589676c65b02a0c" data-rendition-name="original" width="1200" height="1600" loading="lazy" alt="Nurses NT"> </figure>  It was of course difficult to leave my son behind. But I was doing it for his future. I had the option of taking him from the start, but it was a new place and I wanted to be well-settled and knowledgeable about the options available for him before bringing him along. As I packed, he would ask me to take him with me in my suitcase. It did not seem like he was affected by my departure, and it was only later that his teachers said that he would express his feelings more openly at school. He just did not know how to tell me he missed me, and he would tell teachers he was worried I had forgotten him if we did not speak for a day.&nbsp; He missed me, and that realisation made me emotional. But I had to carry on. Life in the UK was difficult in the beginning. Even so, I wanted to prove to myself that I could do it. Fortunately I had cooperative staff who patiently answered my questions. I think I would have been irritated if I were in their place. But they did not seem to mind, and their support and guidance made it easy for me to adjust to the new work environment. APPRECIATION I still struggle to understand the accent of my English patients, and have ask the matron for help. They compliment me on my English, but I can speak better than I understand. The good thing about working in the UK is that you are appreciated for your work, which can be motivating. Sometimes, after a long day’s work you get a message from your supervisor acknowledging your work with a thank you. That’s enough to erase your tiredness.&nbsp; So far I have received 32 WOW nominations which are acknowledgements from patients for a job well done. It can be motivating, especially in the beginning. The main difference between the Alpana who first left Kathmandu for the UK and the Alpana now is that I am a much more confident person. What makes a good nurse? Skills, knowledge and qualifications are of course a given. But mostly, you need humanity. A smiling face. The way you communicate. Your empathy. These attributes can already solve many problems that patients are facing. This is my second time back home in the last 20 months. And this time, I have arranged for my son’s visa. I will go back after Tihar with my son and husband.&nbsp; I am happy, but also a little nervous about what awaits us. What kind of school will I put him in? Will it really be different from schools here? Will his needs be addressed? Will it be like here, or will he be able to adjust?&nbsp; But I am determined to make it work. Success for me would be if he adjusted well and there is a change in his condition. He still cannot recognise alphabets and read words like kids in his age group. Hopefully he will get learning support in the UK. He also has a knack for music, and this is common among individuals with Williams Syndrome. His ears perk up when he hears music, and he takes part in musical events at school. He still does not recognise letters &nbsp;but he uses voice commands to search for guitar videos on YouTube. I will enrol him in music classes, and help him develop this gift. For now, I worry how he will behave on his long flight. He has a short attention span and gets restless. He is also very social and will want to speak with everyone around him, and might irritate fellow passengers.&nbsp; I have already started trying to make him understand that he will need to behave on the flight. He nods in agreement. Let’s see how it goes. &nbsp;

“I felt like I was born to be a nurse”

A month after September’s GenZ movement in Nepal, nurses working in private hospitals took to the streets demanding better work conditions, and salaries equal to what government nurses are paid.&nbsp;
The strike started at Pokhara’s Manipal Teaching Hospital before spreading nationwide, and nurses working at government hospitals joined in.&nbsp;
Nurses at private hospitals are forced to work for far less than Nepal’s minimum monthly wage of Rs19,550 — without overtime, breaks, and other benefits and under physically and mentally taxing conditions. This is driving many qualified nurses to emigrate.
For newly-appointed Health Minister Sudha Sharma Gautam in the interim government, the strike became her first order of business. She met representatives of the Nursing Association of Nepal (NAN), the protesting nurses, and others from the health sector.&nbsp;
An agreement was reached under which private hospitals and medical colleges will pay nurses a minimum monthly salary of Rs34,730. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
“It is a shame that nurses have been working under such exploitative conditions all this time” says Radha Adhikari, at the School of Health and Life Sciences of the University of the West of Scotland. “The agreement is basic, and there is a long way to go to improve their working conditions. But it is a start.”
NAN chair Chandrakala Sharma has said the ministry’s task force to look into working conditions will also look into facilities for nurses in government hospitals.&nbsp;
“We are committed to solidifying the wage agreement by amending relevant laws within this month,” Sharma said in a video posted by NAN on Facebook. “Our movement is not over, we are still protesting and &nbsp;following up with the Ministry.”
NAN issued an ultimatum to the government to implement the agreements within 48 hours. That deadline has now lapsed and the nurses are back on strike. Many of those protesting now accuse NAN of betraying them.
Jyoti Ranabhat of the Nurses Struggle Committee was present in the meeting, but refused to sign the agreement. “It did not address what we were demanding, we will now go it alone into Plan B,” she tells Nepali Times.&nbsp;
Previous grievances of the nurses did result in similar agreements, but private hospitals failed to comply with government’s past directives — most recently the minimum salary and benefit determined by the state in December 2024.&nbsp;
The Nepal Nursing Council says there are 126,580 registered nurses, specialists, midwives, and Auxiliary Nurse Midwife (ANM) professionals in Nepal. Yet, nursing positions at hospitals remain vacant.&nbsp;
The reason for understaffing is a mass emigration of medical professionals, including nurses. Nursing student enrollment is also declining and there is disinterest in a profession that does not afford health workers quality of life, respect, or dignity.
“Our fight is not with the private sector, it is by definition profit-oriented, our grievance is with the state,” says Ranabhat. “The government is responsible to provide us dignity, respect, and fair pay.”&nbsp;
GREENER PASTURES
Poor pay and working conditions are driving doctors and nurses abroad in large numbers in recent years. Many have simply quit the profession, leading to a shortfall in medical professionals. 

The shortage of nurses is a global phenomenon, and countries like the US, UK and Australia have compensated for their own shortage by offering jobs from countries like the Philippines, India and Nepal.&nbsp;
Nepal Nursing Council data shows that outmigration of nurses rose sharply after 2002, and an estimated &nbsp;20,000-45,000 nurses have left since.
“The state’s denial, derision, and disregard of nurses has caused resentment and disillusionment in the community, driving nurses out,” says Ranabhat. “Ultimately, Nepalis will pay the price when there are no nurses left here.”
Many Nepali nurses who have gone abroad are happy with the respect and quality of life in their jobs abroad. But many others face exploitative recruiters in Nepal and employers abroad. Nursing consultancies have mushroomed as nursing colleges struggle to meet demand.&nbsp;
Adhikari herself worked at United Mission Hospital Tansen before moving to the UK 30 years ago, and remembers that working conditions then were much better for nurses.&nbsp;
“Nepal’s health sector has gone downhill since privatisation,” she states. “Medical colleges are only concerned with supplying doctors and nurses internationally, because that is what makes money.”
But once Nepal’s nurses are abroad, there is no guarantee that they will have jobs in the nursing sector. Many find themselves working outside their field of expertise, in hospitality or sales.&nbsp;
“Nepal has become a production hub for nurses, and Nepali nurses have become products for export,” adds Ranabhat. &nbsp;“People might think this will add to remittances, but no one is thinking about what will happen to Nepal’s health sector.”&nbsp;
For many, nursing has become a way out of Nepal rather than a vocation. In 2022, the government signed an agreement with the UK to send Nepali nurses to work there at zero cost, with benefits and protection equal to UK nurses.&nbsp;
The pilot phase was expected to recruit 100 nurses, and applications opened in July 2023, with 45 nurses said to be selected by Britain’s NHF representatives by the end of 2023. Forty-one of them obtained labour permits.&nbsp;
They may be treated well, but the reality of working in the international health sector is not as straightforward.
Radha Adhikari told us from Scotland: “Market saturation, exploitation, discrimination based on race, gender, and foreignness prevent nurses from finding the right, respectful jobs even here. Ultimately, migration cannot be sustainable for Nepal’s nurses.”

Nepal haemorrhaging nurses

Prime Minister Juddha Shamsher Rana built the NJJR probably to transport logs cut on his forested birta land north of Janakpur to sell in India. The 2’6” narrow-gauge railway extended north from Jaynagar, India 29km to Janakpur and another 22km to Bhutaha/Bijalpura, cost 680,000 Indian rupees to build, and opened for business December 1937. The Nepali engineer in charge of construction was Capt Tilak Bahadur Rayamajhi, who in 1908 was one of the first Nepalis to receive a civil engineering degree in India.&nbsp; After 1950, the line from Janakpur to Bhutaha had little commercial value and was out of service. Until the late 1970s, there were no proper motorable roads connecting Dhanusha and Mahottari Districts with India. The NJJR was the only transportation alternative for people who had to otherwise go on foot, bicycle or ox carts to India.&nbsp; The NJJR also played an important role in religious tourism, as hundreds of thousands Indian pilgrims visited Janakpur annually to participate in the Bibaha Panchami, Rama Navami, and Janaki Navami. For the Bihari peasant bound for Janaki Mandir in 1955, sitting on the roof of a slow-moving train was a luxury compared to trudging 29km on foot from the Indian border. The first manager of the NJJR in Janakpur was Lt Hem Bahadur Gadtaula-Chhetri. The general manager from 1942-58 was Rekha Bahadur Rayamajhi of Bhojpur, posted at the railway’s main office at Jaynagar.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_971118917423dec021d89591fe5fef4f7218698595773f6006b4d50c5c57cf94.jpg" data-media-id="editor_0" data-image-id="20251106071140_971118917423dec021d89591fe5fef4f7218698595773f6006b4d50c5c57cf94" data-rendition-name="original" width="1014" height="680" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>A steam train excursion for foreigners in 1999. The last steam excursion on the Janakpur Railway ran in 2006. Photo: GORDON EDGAR</figcaption> </figure>  Rama and Seeta, the railway’s first two appropriately named locomotives, were built in Berlin in 1936. In view of the rising power of Adolf Hitler’s Germany at that time, was Prime Minister Juddha trying to cultivate the Third Reich in hopes of reducing Nepal’s virtually total dependence on British India?&nbsp; In 1939 Adolf Hitler gifted a Mercedes-Benz 230 Pullman Landaulet to Juddha as a way to convince him not to let the British use their Gurkha regiments against Germany in World War II. The car had to be disassembled and carried over the mountains to Kathmandu and reassembled.&nbsp; The Nepali Congress-led campaign against Rana rule received considerable support in Janakpur and the eastern Tarai. In December 1951, King Tribhuvan rode the NJJR from Jaynagar to Janakpur, and thousands thronged to catch sight of a king of whom they had heard but never seen. As operations on the Nepali Government Railway came to an end, its European-made engines were transferred to the NJJR. King Mahendra ordered two more locomotives named Chandra and Surya for the NJJR in 1962. They were built in Leeds and traveled from Liverpool to Calcutta to Jaynagar to begin their service.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_55e4b768ef0ae7682dec8092169bbedc070656d46d9d0a80039fd960a23ae335.jpg" data-media-id="editor_1" data-image-id="20251106071140_55e4b768ef0ae7682dec8092169bbedc070656d46d9d0a80039fd960a23ae335" data-rendition-name="original" width="2144" height="1399" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>Inside the Nepal Janakpur Jayanagar Railway workshop at Khajuri. By the early 2000s, management was unable to control rising payroll and administrative costs nor secure adequate funds for the railway. Photo: GEOFF WARREN</figcaption> </figure>  The NJJR was renamed Janakpur Railway (JR) in 1965 and became the Nepal Railway Company in 2004. Unlike most government-owned enterprises in Nepal of that era, the JR and Nepal Government Railway operated at a profit for many years. In 1947, its total income was 225,000 Indian rupees, with a profit exceeding 100,000 rupees.&nbsp; In FY1974/75, the railway had revenues of 2.6 million rupees and a profit of 443,000 rupees. It is unclear if depreciation expenses were accounted for. Only from the mid-1980s did the railway begin to lose money. The NJJR did a booming passenger business. Ridership increased from 197,000 in 1960/61 to 1.4 million in 1977/78. Revenue increased from 770,000 rupees in 1966/67 to 2.6 million rupees in 1974/75. Yet warning signs appeared in the 1970s that the railway was living on borrowed time.&nbsp; &nbsp;A foreign consultant conducted a comprehensive study of the railway in 1975 and concluded that ‘the entire railway is very old and worn out, and unless a total rehabilitation’ of the railway was undertaken, it would ‘be forced to close in a very short time’.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_240ed714ee4cb369005439a3fb982d6142fd028e7cf6b0c0338519a8abc6afd4.jpg" data-media-id="editor_2" data-image-id="20251106071140_240ed714ee4cb369005439a3fb982d6142fd028e7cf6b0c0338519a8abc6afd4" data-rendition-name="original" width="1387" height="784" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>A second class ticket issued in 2004 costing Rs7.25 between Janakpurdham to Jaynagar. Photo: FUZZ JORDAN</figcaption> </figure>  CHUGGING ALONG An investment of two million rupees resulted in some improvements between 1976 and 1979 but rolling stock and most infrastructure were neglected for another 15 years. Yet somehow the JR’s trains kept chugging along for the next 42 years, often late, with service frequently suspended due to floods.&nbsp; Nearly every year, monsoon rains swept away some of the 135 bridges and tracks and embankments. An RSS News Agency bulletin in August 1975 noted that parts of Janakpur were ‘under 2.5 feet of water’, and the railway tracks near Khajuri were covered by four feet of water.&nbsp; The Jaynagar line was damaged in many places by the swollen Jaladi, Kamala and Jamuni Rivers. Trains to Bijalpura were suspended. For each week railway service was suspended a loss of 75,000 rupees resulted.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251108131132_4a189fa9999b50037f1774b183e62e2caad6177f594ba57a28d93bd674644163.jpg" data-media-id="editor_3" data-image-id="20251108131132_4a189fa9999b50037f1774b183e62e2caad6177f594ba57a28d93bd674644163" data-rendition-name="original" width="1202" height="770" loading="lazy" alt="NJJR MAP"> </figure>  There were also accidents. Trains made only two or three roundtrips daily between Jaynagar and Janakpur and ran at slow speeds, so there were few passenger fatalities, but there were frequent derailments due to the worn rails and overloaded carriages. A RSS report in 1976 said a train derailed near Mahinathpur, and some passengers riding on the roof fell off and were injured. ‘Such accidents occur because the coaches are not regularly maintained and repaired. The speed of the train has been reduced from 12 to 8 miles per hour, since the old and rickety coaches rattle and sway from side to side if driven too fast. The trains take an incredible 4 to 5 hours to cover 28 kilometres,’ the report noted. Gangs of dacoits occasionally boarded trains and robbed passengers. Another RSS report in December 1972 said ‘Six dacoits armed with guns and revolvers looted 13 railway passengers travelling from Janakpurdham to Jaynagar [last] Sunday. The [loot] included wrist watches, gold rings, currency notes and other paraphernalia of the passengers…The dacoits raided third-class bogie number 2 soon after the train started from Khajuri station. The dacoits after plundering the passengers jumped down from the running train about two miles from the Nepal-India border [and fled into India.]’  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_de60de1d7fdd0a9d29f19440ed68d773f754c10ef01a8c7e3385097eab6a8419.jpg" data-media-id="editor_4" data-image-id="20251106071140_de60de1d7fdd0a9d29f19440ed68d773f754c10ef01a8c7e3385097eab6a8419" data-rendition-name="original" width="1498" height="1000" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>Narrow-gauge tracks in Jayanagar in India going north toward Nepal. Photo: FUZZ JORDAN</figcaption> </figure>  Strikes and political protests also stopped the train from time to time. From the early 2000s Maoist and Tarai-based groups enforced stoppages with threats and intimidation that closed schools, shops, government offices, and brought transport services to a halt. Six minor political parties organised a strike in Janakpur in May 2001. Agitators stopped a train near Janakpur and pelted it with stones, breaking windows and injuring the driver. The railway came to a standstill in May 2004 after Maoists set fire to the Mahinathpur station. During February-March 2006, the Maoists obstructed rail service six times. A cylinder bomb exploded inside a train near Parbaha station in May 2009 injuring 30 passengers. Between 1993-2003, the railway had nine general managers who had influence with Kathmandu’s political and bureaucratic elites, but none of whom knew much about railways. Management was unable to control rising payroll and administrative costs nor secure adequate funds for the railway.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_df754214acd19eaab3b56ceaa0d96f0b66f9f0f8fd29fb4a533d860f627f483f.jpg" data-media-id="editor_5" data-image-id="20251106071140_df754214acd19eaab3b56ceaa0d96f0b66f9f0f8fd29fb4a533d860f627f483f" data-rendition-name="original" width="1700" height="1140" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>Coal was unavailable, so Seetaa-Ram, the railway’s first two locomotives, burnt wood for fuel. Photo: BASIL ROBERTS</figcaption> </figure>  Revenue ‘leakage’ was significant, as perhaps twenty percent of the passengers rode without tickets. Railway staff was bloated, in 1996 there were 340 on the payroll, many of them with political connections who needed jobs. Safety measures for railway operations were non-existent.&nbsp; There were no performance reviews, no criteria for promotion, and no training opportunities for workers to improve their skills. But the locals continued to ride their beloved railway. For 56 years, the Janakpur Railway received no foreign assistance, not even one rupee of foreign aid. That changed in 1994 when the Indian government provided two used diesel locomotives and 12 used coaches. Two years later, India supplied two more engines and 12 more coaches and promised some upgrades.&nbsp; This gave the railway a new lease on life, but the road network in the eastern Tarai had expanded,making the railway redundant. It also did not connect with the East-West Highway, the major transportation artery across the Tarai, nor could it seamlessly interconnect with India’s broad-gauge rail network at Jaynagar.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251106071140_7a52a3c5a3fe4e6320135d90632dcfcee6085a32637a3f71e1e644c5e8d3b19f.jpg" data-media-id="editor_6" data-image-id="20251106071140_7a52a3c5a3fe4e6320135d90632dcfcee6085a32637a3f71e1e644c5e8d3b19f" data-rendition-name="original" width="3239" height="1429" loading="lazy" alt="NJJR Dan Edwards NT"> <figcaption>Pashupati, Nepal's first locomotive, in retirement at Khajuri in 1996. Photo: FUZZ JORDAN</figcaption> </figure>  The railway carried no goods, all cargo traffic migrated to trucks. During the 1980s and 1990s, British and European train spotters traveled to India to ride its few remaining steam locomotives, including those of the Darjeeling Himalayan Railway. Some took a side trip to Jaynagar where they, without Nepal visas, were thrilled to ride a train to Janakpur without encountering a border check post or immigration officials. Other visa-complying tour groups arranged steam trains for 60,000 rupees or more.&nbsp; The last steam excursion ran in 2006, and after that, foreign interest in the railway evaporated. Cascading financial losses and government indifference coupled with irregular, unreliable service finished on the Janakpur Railway.&nbsp; Seventy-six years of remarkable narrow-gauge railroading in Nepal ended not with a bang but a whimper on January 20, 2014. Sic transit gloria. Dan Edwards was a Peace Corps volunteer in 1966 and is the author of several books on Nepal. This is the third instalment in a new limited series in Nepali Times on the historic transportation infrastructures of Nepal.