Philanthropy will never replace<a href="https://nepalitimes.com/news/uk-aid-for-nepal-s-covid-affected-mp4ab6lw"> public aid</a>, but it can be a powerhouse if we use it right. With global development funding under strain, <a href="https://nepalitimes.com/news/e75-million-eu-aid-to-nepal-for-covid-19-ckmyfbkq">European aid</a> budgets being redirected toward defence and rearmament, and the <a href="https://nepalitimes.com/news/how-usaid-cut-affects-nepal">United States rethinking foreign assistance</a> altogether, the aid community has been left scrambling.
The reactions so far have been of two kinds: calls for <a href="https://nepalitimes.com/here-now/philanthropy-in-the-time-of-pandemic">philanthropy</a> to fill the gap, and moralising statements shaming governments for stepping back. Unfortunately, the first is unrealistic, and the second is ineffective.&nbsp;
Private donors cannot solve systemic <a href="https://nepalitimes.com/opinion/12-full-opinion/our-uncommon-future">global challenges</a> alone, and telling politicians that they are morally bankrupt generally does not bring them around to your side. Instead, we need to meet policymakers where they are, sharpen our arguments, and focus on what actually works. The hard truth is that most <a href="https://archive.nepalitimes.com/page/foreign-aid-policy-to-balance-infrastructure-investment-with-social-sector-investment">government aid</a> is not even designed for effectiveness, because it prioritises processes over results. Nor has philanthropy been immune to this impulse.
In early years at the Eleanor Crook Foundation, we funded holistic, multisectoral programs that tried to tackle all causes of malnutrition simultaneously. But the results were underwhelming. The approach looked good on paper, but produced no measurable improvements in <a href="https://nepalitimes.com/here-now/nepal-s-epidemic-of-hunger">malnutrition</a>. So, we learned from that failure and changed course. Now, we direct our funding where the evidence is strongest and the results most immediate.&nbsp;
At the recent Nutrition for Growth (N4G) Summit in Paris, we announced a $50 million commitment, alongside $200 million from other donors, to scale up one of the most cost-effective interventions in global health: prenatal vitamins – known as multiple micronutrient supplements (MMS). This funding will go toward a $1 billion roadmap to ensure access to MMS for pregnant women no matter where they live.
The science on this issue is unequivocal. MMS replaces outdated iron and folic acid (IFA) tablets still given to many pregnant women in low-income countries. With MMS, women receive 15 nutrients, instead of just two, leading to a dramatic reduction in maternal anemia, stillbirth, and low birth weight. The estimated economic returns are $37 for every $1 invested while infant mortality is reduced by nearly one-third.
The global inequities in maternal health are profound. In London, a pregnant woman routinely has access to comprehensive prenatal vitamins. In Lagos, she might receive IFA, or nothing at all. The difference reflects a gap in will, not knowledge. Ending such disparities does not require a scientific breakthrough, just greater investment in already proven solutions.
More than two decades of research, three Lancet studies, and multiple World Bank investment cases have identified roughly ten nutrition interventions that are consistently underfunded despite their proven efficacy. These are not flashy, multisector, utopian initiatives. They are targeted, evidence-based programs that can be implemented immediately to deliver measurable results.
Solutions like breastfeeding support, Vitamin A supplementation, prenatal vitamins, and ready-to-use foods for severely malnourished children belong to a package of interventions that could save at least two million lives over five years if scaled up in nine high-burden countries. Such life-changing results would cost just $887 million per year.
Malnutrition is now the leading driver of <a href="https://archive.nepalitimes.com/news.php?id=16505">child mortality</a> globally, contributing to some three million deaths in 2023 alone. These are not mysterious tragedies. They are predictable and in many cases cost little to prevent. In a world that routinely sends tourists to space, we obviously can afford to ensure that all <a href="https://nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time">pregnant women</a> have access to a $2 bottle of vitamins.
This year’s N4G Summit may be the last of its kind. It was part of a summit series linked to the Olympics, which will next be hosted by the US. With the current <a href="https://nepalitimes.com/editorial/trump-s-second-coming">US administration </a>already signaling that it will not continue the tradition, recent commitments made in Paris have gained new urgency. Vague pledges and political posturing will no longer do.
We are not asking governments to spend like they used to. Rather, we are urging them to look at the evidence and use their remaining budgets for official <a href="https://nepalitimes.com/review/small-is-bountiful?fbclid=IwAR0wRoEdhgYO9qATGiukFQvK2fE6N8rCDZ4CBJBdkTC6_Es-6_mdVHldlic">development assistance</a> to scale up proven, <a href="https://nepalitimes.com/here-now/small-is-still-possible">cost-effective solutions</a>. A modest investment in MMS – representing less than the cost of one week of G7 countries’ defense spending – could save 600,000 lives.
Even with constrained budgets, we have a chance to save millions of lives. But only if we stop trying to do everything, and focus instead on what is the right thing to do.
William Moore is the CEO of the Eleanor Crook Foundation and Chair of Stronger Foundations for Nutrition.

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Philanthropy in an era of declining development aid

When he was a teenager years ago during the war, the Maoists who held sway over the Dalit village of Muktikot in western Nepal promised Man Bahadur Bishwakarma liberation and prosperity. Many like Man Bahadur believed in that utopia, and took up arms like others from the downtrodden Dalit community here. They even renamed the village Muktikot (Fort Freedom) from its original Dumkot. ‘Dum’ is a derogatory term used to address the Dalit community. Muktikot is spread across a steep mountainside with unirrigated terrace farms. Most of the men migrate to India for seasonal work, others never come back. The women left behind had to walk hours for water, and since there were no roads then, travelling to town for government subsidised rice took at least a week. “The Maoists told us that we would find jobs right here in the village, that every household would have tap water, they promised an end to caste discrimination,” recalls Man Bahadur. “That is why I joined the revolution in Grade 10.” He is talking while walking up a steep trail three hours from Muktikot, where his family has been living in a cattle shed after a landslide damaged his house in 2021.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_bc4d26d047714332fcdd2242229a1227d207a972439e02e3c822aaa118066b3f.jpg" data-media-id="editor_0" data-image-id="2024051804058_bc4d26d047714332fcdd2242229a1227d207a972439e02e3c822aaa118066b3f" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Th remote village of Muktikot in Bajura district in far west Nepal.</figcaption> </figure>  Most of Muktikot’s young population joined the Maoists, convinced that changing the name of the village was proof this was going to be a real revolution. Eighteen years after the end of the conflict, the only thing that has changed for the nearly 2,300 Dalits in Muktikot is the name of their village. Not that there has not been some progress. There are now motorable roads and residents do not have to walk as far as Kalikot or Dailekh to get a sack of rice. More essentials are available in local shops for those with cash. Man Bahadur himself migrates to India to earn money, and had just returned for a break when we talked to him. “I fought for the Maoists in the hope that I would not have to go to India for work, but there are still no jobs here,” he says. “The Maoists promised a mirage.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_fcd64c34f689e7a4d44f285bb6a7b6b28329941e2766440ab208c9039a855d31.jpg" data-media-id="editor_1" data-image-id="2024051804058_fcd64c34f689e7a4d44f285bb6a7b6b28329941e2766440ab208c9039a855d31" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Men in Muktikot preparing to migrate to India for work.</figcaption> </figure>  Birth and death Manbuja Bishwakarma has just turned 20, the minimum legal age of marriage in Nepal. But she has been married since age 13, giving birth to five children, three of whom died. “The babies just died one after the other,” recalls Manbuja, who just had to have more babies in the hope that some would survive. Read also: <a href="https://nepalitimes.com/banner/how-the-climate-crisis-adds-to-child-marriage-in-nepal">How climate crisis adds to child marriage in Nepal</a>, Sonam Lama Her neighbour, 30-year-old Lalkala Bishwakarma has given birth eight times, and only four babies survived. There are women in Muktikot who gave birth to as many as 14 children, and there is not a single mother in Muktikot who has not lost a baby.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_dd4d62e65cc4ac88cd46a91a62b9c60bcb2d43bbc5cb5455dc7efe4a7d2ff1b2.jpg" data-media-id="editor_3" data-image-id="2024051804058_dd4d62e65cc4ac88cd46a91a62b9c60bcb2d43bbc5cb5455dc7efe4a7d2ff1b2" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Lalkala Bishwakarma</figcaption> </figure>  Tilakhuni Bishwakarma, 40, had 10 children, and eight of them survived. Sitting outside her home, she is now surrounded by her grandchildren. Despite Nepal’s total fertility rate now dropping to near replacement level, here in Muktikot infant mortality is still high and this means women have more babies in the hope that some will survive. Child marriage and low female literacy contribute to the high rate of maternal and infant mortality. Community health records show that even in 2021, eight out of 45 infants born in Muktikot died. While Nepal’s average infant mortality rate dropped to 33 for every 1,000 babies born in 2022, &nbsp;the rate was 178 in Muktikot. “The most prominent among the many reasons for the high maternal deaths are early marriage and frequent pregnancy,” says Janaki Neupane, a community nurse in Muktikot. &nbsp; Four years ago, Bachchi Bishwakarma died of a hemorrhage while giving birth to her second child at home. Her husband Gorkha says she had barely survived giving birth to their first child. “I was home alone that day, and I took care of her,” Gorkha recounts. “Our child was born, but my wife bled to death.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040512_4718183318c77de8bb9b719346b9b19c96bef0984055585b00884f741f905c2e.jpg" data-media-id="editor_4" data-image-id="20240518040512_4718183318c77de8bb9b719346b9b19c96bef0984055585b00884f741f905c2e" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Tilakhuni Bishwakarma</figcaption> </figure>  Birthing centres were opened in Muktikot last year to address high infant and maternal deaths, but Nurse Neupane says it still lacks basic equipment and budget. Nirmala Bishwakarma got married when she was 13 and was &nbsp;pregnant soon after. She had her first baby, but soon got pregnant again. “Birth brings death here,” Nirmala, now 20, says simply. Nirmala and her children all look emaciated and she weighs only 33kg. Bajura’s district headquarters in Martadi provides nutritional allowance, but Nirmala cannot afford to travel that far to get it. &nbsp; Nepal’s development indicators, including lifespan (page 1) and poverty rate have shown dramatic improvements over the past three decades. But here in Muktikot, hunger stalks the land. In fact, a recent survey showed that 95% of women, children and young adults in Muktikot are undernourished. Most men, on the other hand, look well fed because they are mostly away in India for work. &nbsp; Only 12% of the land in Bajura is arable, but even then there is lack of irrigation, frequent droughts, and now climate breakdown contributing to the lack of food. “The harvests are just not enough to sustain the families,” says Bharat Bahadur Rokaya, chair of Swamikartik Khapar Rural Municipality where Muktikot is located. Here in the rugged mountains of northern Bajura bordering Humla and Mugu, the families grow millet, maize, and wheat, but Nirmala Bishwakarma says the harvests hardly last a month. “If it was not for the subsidised rice we would have empty stomachs,” she says. Hindrances to hygiene Down the mountain from Muktikot, the green waters of the Karnali River are visible. But the 400 Dalit households here have to share just three community taps for drinking water. Half the households do not have toilets, and defecation in the open is common. Donor agencies have helped build toilets, but these are mostly used to store fodder because there is no water. “How can we use water for the toilets where there isn’t enough for drinking?” asks Ward chair Ajay Bishwakarma. &nbsp; Families have to walk for four hours to bathe and do washing. “We do not wash our clothes for months on end,” says Kushi Bishwakarma, 40.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_e234d5b4fac4fa24e62e65a35f2eafbfb044a32a5f8ef8172932eca96eeaa17b.jpg" data-media-id="editor_5" data-image-id="20240518040516_e234d5b4fac4fa24e62e65a35f2eafbfb044a32a5f8ef8172932eca96eeaa17b" data-rendition-name="original" width="960" height="733" loading="lazy" alt="Muktikot hygiene"> </figure>  The lack of water has compromised hygiene and sanitation in the village, resulting in diseases like diarrhoea, allergies, and other health issues, especially among children. Lack of water in the village has also led to uterine prolapse among the women in Muktikot since they primarily face the task of ferrying heavy jars of water from the communal taps to their houses The ‘One house, one tap, one toilet’ campaign introduced by the rural municipality this year hopes to solve water-related issues for Muktikot residents. But that is yet another election promise. Testing times This underserved village is not just affected by structural inequality and state neglect. In 2021, a landslide swept away 54 houses in Muktikot, and most families lost homes and what little arable land they had. “Earlier, we at least had a house to live in, now we don’t even have that,” says Muktikot resident Asal Bishwakarma. “We have been living with relatives since. How will we survive?” More than two years after the landslide, not a single house in the village has been rebuilt. Each family was allocated Rs500,000 in relief on an instalment basis, with aid from all three tiers of government.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_26ebf9b2f52722180b1b403b1410f19ea5c7d0321047b099a574a35519706914.jpg" data-media-id="editor_6" data-image-id="20240518040516_26ebf9b2f52722180b1b403b1410f19ea5c7d0321047b099a574a35519706914" data-rendition-name="original" width="1200" height="1433" loading="lazy" alt="Muktikot landslide"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_bbe50221dca556ac0e798843d672f1190abafacb82fa792bfec289eeb31ad013.jpg" data-media-id="editor_7" data-image-id="20240518040516_bbe50221dca556ac0e798843d672f1190abafacb82fa792bfec289eeb31ad013" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot landslide"> </figure>  Asal has only received Rs35,000 so far, and has spent it all on buying food. No one knows where the promised money went. Muktikot residents now want their entire village relocated somewhere safer. &nbsp;The local government agrees that resettlement is necessary, but it was unable to find a suitable alternative. “It is not possible to resettle such a large number of people at one go,” says Bajura MP Badri Pandey. “We also cannot create jobs for all of the population at once.” Muktikot might have been declared liberated on paper during a war fought in the name of Nepal’s downtrodden, but this Dalit village is emblematic of promises not kept. Looking around the landslide scarred village he has spent half a century of his life in, Muktikot’s Dhanajay Bishwakarma laments, “We are not even considered humans by the state.”

Muktikot still waiting for liberation

Over the last two decades, Nepal has made notable progress in maternal and neonatal healthcare. The<a href="https://mohp.gov.np/uploads/Resources/Final%20Report-26%20March-%202023-UPDATED.pdf"> maternal mortality ratio (MMR</a>) has declined from 536 per 100,000 live births in 1996 to 151 by 2021.
Driving this process were the country’s <a href="https://mohp.gov.np/program/safe-motherhood-programme/en">Safe Motherhood policy</a>, an increase in skilled healthcare providers, free delivery services for expectant mothers, incentive schemes for antenatal care, as well as postnatal visits.
Other measures, such as birth preparedness packages along with systematic planning for managing potential complications during childbirth, amplified these achievements.&nbsp;
There has been a remarkable rise in institutional deliveries, an increase in antenatal visits, and an impressive 70% of women receiving postpartum care from healthcare providers within the first two days after giving birth.
Quality improvement initiatives such as the Maternal and Perinatal Death Review, minimum health facility assessment standards, routine clinical monitoring, and supportive onsite supervision visits, have been outlined in policy documents and guidelines to elevate the overall quality of care.&nbsp;
However, it is when analysing province-wise MMR. that we still see significant disparities. Maternal deaths are still high in Lumbini Province (207 per 100,000 live births) and Karnali (172). The MMR in Bagmati Province (98) correlates with better figures for higher education, awareness and access to health service and providers.
In contrast, 83% of women in Karnali face challenges in seeking medical care, primarily due to financial constraints and long distance to healthcare facilities.
Half of the maternal deaths in Nepal are of mothers within the age groups of 15-34. Despite the legal marriage age being 20, child marriage is still widespread and contributes to the highest number of pregnancy-related deaths.&nbsp;
Read Also: <a href="https://nepalitimes.com/news/remove-barriers-to-life-saving-drug-to-prevent-maternal-deaths">Remove barriers to life-saving drug to prevent maternal deaths</a>, Marty Logan
The median age of marriage in Nepal is 18.3 years, with the lowest median age in Madhes province at 16.6 years and the highest in Bagmati province at 19.9 years. The Muslim community reports the lowest at 16.5 years, while the Janajati and Brahmin/Chettri communities have generally higher median ages for marriage.
In Madhes and Sudur Paschim Provinces early marriages among girls under 15 contribute to heightened adolescent mortality, mainly due to difficulties accessing timely health facilities. Disparities persist among ethnic groups, particularly among doubly marginalised Madhesi Muslims, who face high mortality rates due to early marriages.
Health facility deliveries have improved from 10% in 2001 to 79% in 2021. But again, progress is uneven and these disparities need to be overcome to<a href="https://nepalitimes.com/editorial/more-equal-than-others"> meet the UN’s Sustainable Development Goals</a> (SDGs) target of 90% institutional delivery rate by 2030.
Wealth inequality and provincial variations, especially in Madhes, pose challenges that need nuanced understanding of women’s reluctance to seek health services.&nbsp;
Despite Nepal’s success in maintaining population growth close to replacement levels, the total fertility rate (TFR) is significantly higher among those without formal education. The proportion of postpartum family planning uptake is also lowest in Madhes and Sudur Paschim at only 0.2%.
Breastfeeding is in decline, with less than three out of five mothers following recommended practices. Regional variations highlight the need for targeted interventions, particularly in provinces like Bagmati, where breastfeeding rates are lower among well-educated city dwellers.&nbsp;
Read Also: <a href="https://nepalitimes.com/here-now/why-has-progress-in-saving-women-s-lives-stalled">Why has progress in saving women’s lives stalled?</a>, Marty Logan
Anemia persists as another risk factor, with Madhes Province again carrying the highest burden.
Comparing Nepal with Bangladesh, India, and Pakistan shows that we are doing better in under-five and infant mortality rates. Nepal’s institutional delivery rate surpasses Bangladesh, but lags slightly behind India.
Even so, alarming disparities persist in neonatal and maternal mortality rates within disadvantaged groups, reflecting inadequate coverage of routine maternal and neonatal health visits and suboptimal care.&nbsp;
This points to both limited access to recommended interventions for disadvantaged women and potential inefficiencies in delivering crucial interventions during routine these visits.
Nepal should prioritise rural pockets of the country and employ a comprehensive strategy that includes delivering antenatal care through primary health care outreach, home visits, distributing essential medicines, vaccinations, and identifying appropriate health facilities for birth preparedness.
Read Also: <a href="https://nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives">“What can be more fulfilling than saving lives?</a>”, Naresh Newar
The quality of antenatal care must be improved by talking about nutrition with pregnant women and families, emphasising awareness of danger signs that necessitate timely health facility visits, and ensuring local governments can efficiently refer complicated cases, with airlifting as a viable option for emergencies.
Adolescent Sexual Reproductive Health with a targeted focus in provinces with early marriages and childbirths combined with education, awareness, and easy access to reproductive health services are imperative.
More effort is needed to meet the SDG target of reducing the MMR to 70 per 100,000 live births. Mitigating disparities among provinces demands political commitment, active local leadership, community engagement, especially leveraging the youth force, and fostering public-private partnerships at all levels.
Surya Bhatta is Executive Director of One Heart Worldwide that works primarily on maternal health in rural Nepal.

Saving more mothers and babies

Like any mother, Sharmila Chadara just wanted to get home to see her child. It was this primal urge, and other unrelated factors, that directly resulted in her death on the night of 24 November. It was easy for journalists to assume that she had died from ‘the cold’ following the <a href="https://nepalitimes.com/news/deadly-earthquake-hits-w-nepal">earthquake on the night of 3 November</a> that killed 150 people outright in Jajarkot and Rukum West. Many of Sharmila’s neighbours in Ward 4 of Nalgad Rural Municipality and the surrounding mountains were forced to sleep outdoors after their houses collapsed.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_b6edcb6e1b6f52540dfdbc84bdbc23a1701dc9b1f113b7d5da30cf7f8e277898.png" data-media-id="editor_1" data-image-id="20240102150116_b6edcb6e1b6f52540dfdbc84bdbc23a1701dc9b1f113b7d5da30cf7f8e277898" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Jajrkot earthquake"> <figcaption>Damaged homes in Nalgad, Ward 1. Many locals are living in tents, below. All photos: MARTY LOGAN</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_d992b10f8725c5d0415191b0606b33f23c2cff8941e495199a2cea5528542da6.png" data-media-id="editor_2" data-image-id="20240102150116_d992b10f8725c5d0415191b0606b33f23c2cff8941e495199a2cea5528542da6" data-rendition-name="original" width="2000" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Tents in Nalgad Municipality, Ward 1, Jajarkot. Occupants had their houses destroyed or damaged in the November 3 earthquake.</figcaption> </figure>  A local politician was quoted saying that Sharmila had become the latest post-earthquake victim because she was sleeping under a flimsy plastic sheet as night temperatures dropped. The <a href="https://annapurnapost.com/story/447108/">news was picked up by the media</a>, and there was outrage across the country. Read also: <a href="https://nepalitimes.com/here-now/jajarkot-one-month-after-the-earthquake">Jajarkot: One month after the earthquake</a>, Ramu Kharel and Maggie Doyne Had she survived, Sharmila Chadara would probably be sleeping inside the tiny home of her husband Dinesh in Nalgad located down a dusty path, a 15-minute walk from a narrow road. It was damaged but is habitable.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_1e7562050e0b55135f28e96726d6a003c699dbf02214b3849c38e64540b7cfd8.png" data-media-id="editor_5" data-image-id="20240102150116_1e7562050e0b55135f28e96726d6a003c699dbf02214b3849c38e64540b7cfd8" data-rendition-name="original" width="2000" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>The home where Sharmila Chadara lived in Nalgad Municipality. It was damaged in the earthquake but is still habitable.</figcaption> </figure>  Dinesh, 26, sheltered from the sun against the house as he told us about Sharmila’s final trip home. It was on Dasain Tika day in early November when Sharmila felt labour pains and they took a vehicle down to the local hospital.&nbsp; There were no doctors and the couple was advised to go to the hospital in Khalanga, where doctors in turn referred them to Surkhet. Sharmila had twins and it would be a risky delivery.&nbsp; In Surkhet, she delivered the first baby, a girl. The boy was born lifeless. The doctors advised them to keep the girl in the hospital so she would gain weight. After five days, staff noticed that Sharmila, who till then seemed healthy, developed a cough. They diagnosed severe pneumonia and put her in the ICU. But fluid built up in Sharmila’s lungs and she underwent dialysis, recalled Sakuntala Sapkota, the matron at the Surkhet hospital. “She had many ups and downs,” Sapkota told me. Sharmila had five dialysis treatments as she was shuttled back and forth between ICU and the general ward. At one point a doctor told Dinesh and relatives they might not be able to save Sharmila because her body was “completely infected”. After nearly three weeks, Sharmila had enough. She was missing her son and wanted to return to Jajarkot. But staff urged her to stay two more weeks until she was fully recovered. In Ladakh Three years earlier, Sharmila had travelled to Ladakh where Dinesh was working, as were her own parents. It is normal for at least one member of each household in Jajarkot and surrounding districts to migrate for work in India and beyond. Increasingly, many are taking illegal routes destined for the US. In Athbiskot Municipality we met one woman whose brother had been gone a year, and had only made it to Turkey after paying traffickers Rs10 million.&nbsp; Sharmila stayed and worked alongside her husband at a cement factory in Ladakh, returning for the first time this past Dasain. Dinesh remembers her falling ill in India and coughing up blood. A local doctor diagnosed it as ‘weakness’ and gave her medicine.&nbsp; “But she didn’t finish it,” her husband told us. “She never finished medicine, even vitamins. I don’t know why she was like that.” A neighbour remembers Sharmila as being honest and friendly. She did not like working in Ladakh, she added, but the pressure to earn money must have been strong. At the hospital in Surkhet, Sharmila threatened to pull out her IV drip, remove her oxygen mask, and die in her hospital bed if she was not taken home. Dinesh relented and booked an ambulance for the family’s return trip to Nalgad. The oxygen ran out on the way. “I was not even sure if she was breathing,” he recalled. When they reached the hospital emergency in Radi Bazar at 2AM her vital signs were nil, staff told him. Sharmila had died. Dinesh wanted to take her home. He hired a vehicle to carry her to the foot of the hill and rounded up people in the dead of night to carry her on a stretcher, reaching home at 4AM. Sharmila was finally reunited with her son.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150120_2713c13b4d2ba22fe28bc1bf96cfbcfd87a7ede9cc67678b67d69efbe4a4d851.png" data-media-id="editor_6" data-image-id="20240102150120_2713c13b4d2ba22fe28bc1bf96cfbcfd87a7ede9cc67678b67d69efbe4a4d851" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Dinesh Chadara with his son Ganesh at home in Nalgad Municipality recently.</figcaption> </figure>  Dinesh told us he has not made up his mind about returning to work in India. His in-laws have given him Rs150,000 to pay medical bills and he has borrowed more, but was still in debt. Sharmila’s baby has been released from hospital, and continues to gain weight and get routine vaccinations.&nbsp; Left out in the cold When we visited Jajarkot and Rukum West nearly two months after the earthquake, survivors were still living in tents and plastic shelters.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150124_1efe377bce5e1b8b264308d2378871aba0fc34c13046cabc6fffbdb940c7bb86.png" data-media-id="editor_7" data-image-id="20240102150124_1efe377bce5e1b8b264308d2378871aba0fc34c13046cabc6fffbdb940c7bb86" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Jajarkot earthquake"> <figcaption>A health post destroyed in Chinabagar, Ward 1, Rukum West.</figcaption> </figure>  A female community health volunteer (FCHV) in Athbiskot told us she was having trouble finding a good tent for a mother just discharged from a health facility with her newborn. Up the mountain, we reached the house of Seema Chand Malla, 28, who was eight months pregnant. Her brother-in-law was hammering together a door for a wooden shelter while waiting for the government’s Rs 50,000 temporary shelter allowance. Sitting on a windy ridge, Seema said: “It’s very cold, but so far we're OK – let’s see what happens.” Read also: <a href="https://nepalitimes.com/news/below-zero-at-ground-zero">Below zero at ground zero</a>, Durga Rana Magar Like many women we spoke to, Seema seemed to be receiving some, but not all, routine health services. She had gone for six pre-birth (ANC) visits, was taking calcium and iron supplements regularly and had been given medicine to prevent worms. As one of her three children, a son, played on her lap, she said her health was good. The local FCHV used to visit to provide vitamins or information about the children’s health, but Seema had not seen her since the earthquake. The family had received one blanket, a small tent, 25kg of rice and some buckets from the government and various agencies. When we returned from Seema Chand’s house four tractors arrived towing carts piled high with sleeping mats, rice and other goods. We saw such relief deliveries mixed with various stages of reconstruction work across the affected areas.&nbsp; Read also: <a href="https://nepalitimes.com/news/demographics-of-disaster-in-nepal-quake">Demographics of disaster in Nepal quake</a>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_7f6c045a4fccc3bb87f6746e702f4db8362b2cfd1d960c55e6ed326fe2bca183.png" data-media-id="editor_10" data-image-id="20240102150116_7f6c045a4fccc3bb87f6746e702f4db8362b2cfd1d960c55e6ed326fe2bca183" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Seema Chand Malla, with her son, in Aathbiskot, Ward 14.</figcaption> </figure>  In Radi Bazar a crowd had gathered to get the forms needed to apply for government cash for shelters.&nbsp; <a href="https://nepalitimes.com/news/mass-cremations-for-nepal-quake-victims">The damage</a> seemed mostly random, with single houses on village roads reduced to rubble, but there were also whole clusters of homes that had fallen. On a slope overlooking the scenic, glacier-fed aquamarine Bheri River, there was a line of orange and blue tents. New mother Samjhana Bitalu, 19, crawled out from one of them to tell us that her house nearby was <a href="https://nepalitimes.com/here-now/grief-stricken-survivors-are-cold-and-hungry">damaged in the earthquake</a> and uninhabitable.&nbsp; She and her 55-days-old baby Monika were staying here with her husband, who did not want to leave them alone to return to his job in Khalanga. Samjhana said she gave birth at a nearby health post, but no staff visited her afterwards. The only help the family had received was a tent and 25kg of rice from the Ward office.&nbsp; “When it rains it’s hard to keep the baby dry because the water comes inside the tent, and she has diarrhoea,” the mother said. Following local custom, she did not think the baby should receive any treatment before she was two months old. But a health worker urged Samjhana to get medical care for the baby. “It’s more difficult because I have to manage everything alone,” Samjhana said stoically. “Otherwise, everyone would have been together at home.” Nearby, Amrita Gharti, 22, was still living in her in-laws’ house with her husband. She was almost two months pregnant.&nbsp; Amrita previously had a miscarriage, despite being told by ANCs that she was healthy. This time, arriving at her local birthing facility for her first checkup, she was told to return when she was exactly two months pregnant. “They didn’t do my checkup. They were too busy,” she said.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150120_e6d6fd29a04a5c3fa20fc6bd50c2236287fce0b7ddce0e508fefb329644ecf91.png" data-media-id="editor_13" data-image-id="20240102150120_e6d6fd29a04a5c3fa20fc6bd50c2236287fce0b7ddce0e508fefb329644ecf91" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Amrita Gharti is pregnant and living in her in-laws' house in Nalgad, Ward 1.</figcaption> </figure>  Aruna Chaudhary of the Radha Paudel Foundation spent two weeks in Nalgad providing menstrual kits to 450 women and adolescent girls.&nbsp; Demand for her support was great and the cold was especially hard on children, she told us.&nbsp; “Many children have pneumonia and cholera and have to take medicine,” she added. “There was lots of diarrhoea and many had injuries from the earthquake itself.”&nbsp; Pneumonia and other cold-related illnesses were also growing in Chinabagar where lack of water and sanitation was worsening the situation, especially for <a href="https://nepalitimes.com/news/remove-barriers-to-life-saving-drug-to-prevent-maternal-deaths">women and adolescent girls</a>. Dhani Kumar Giri from the group WOREC was assisting arrivals at a tent while the group also provided care door-to-door. In a nearby tent an organization was providing psychological counselling to those troubled by the disaster. Some good news Around noon on 6 December, Man Kumari Singh arrived with labour pains at the health post in Athbiskot-4 of Jajarkot. She was pregnant with twins, but had been declared healthy during previous visits to the facility. But by 4PM her labour had not progressed and Man Kumari was starting to shake in distress. Staff decided to request a helicopter rescue, but by the time permission was granted from Kathmandu it was too late in the day.&nbsp; Health post staff decided to send her to the municipal hospital in Dali, but doctors there referred her to the mission hospital in Chaurjahari instead. They sent an ambulance carrying two nurses to accompany her. At 1AM that night Man Kumari’s twins were delivered normally. By noon she had been transferred to the ICU at the provincial hospital in Surkhet. Soon after she was moved to the general ward and by 19 December she had recovered and been discharged. The twins were also reported to be in good health. Author thanks One Heart Worldwide for arranging logistics for reporting on this story.&nbsp;

Poverty killed a mother, not the quake

Remove barriers to life-saving drug to prevent maternal deaths

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

When Sajadi Khatun felt the familiar pain, she knew what to do: she, her husband, her mother and a neighbour quickly left their house in Laxmipur village and started the 20-minute walk to nearby Sundarpur Health Post. They did not get far. Ten minutes later, Sajadi delivered a baby boy on the roadside.&nbsp; After delivery, the tired new mother returned to her home on the outskirts of Sarlahi’s district headquarters Malangwa while the rest took the newborn — the family’s fifth child, and third boy — to the health post for a check-up. A nurse visited and found both mother and child health.&nbsp; “I wasn’t worried about giving birth on the roadside," says Sajadi, stoically, although she and her husband had wanted to deliver the new baby in the health post, like her previous three children. The first was delivered at home as there was no health post in the community at the time.&nbsp; Ahead of the last birth, Sajadi had gone to the health post for check-ups (known as ante-natal care, ANC, visits) eight times before her due date. Recently, Nepal increased the recommended number of ANC visits from four to eight, but in 2022 just 68.4% of women in Madhes Province did four or more ANCs.&nbsp; The local Female Community Health Volunteer (FCHV) had also visited her house many times. On the advice of those health workers, Sajadi was eating as healthy as possible to keep up her own weight and that of the baby.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080636_18c6ee1ef9c231899017a764b9a89ff1ab5d9d3cd4eb417cf91e4868d2041f1f.png" data-media-id="editor_0" data-image-id="20230623080636_18c6ee1ef9c231899017a764b9a89ff1ab5d9d3cd4eb417cf91e4868d2041f1f" data-rendition-name="original" width="1496" height="828" loading="lazy" alt="Map Sarlahi"> </figure>  At the health post, Sajadi, who is not sure of her age but is probably about 30 according to the FCHV sitting nearby during our interview, also started taking calcium and iron supplements and got a tetanus/diphtheria vaccination. Because the facility did not have an ultrasound machine, she and her husband, who do not own a vehicle, paid to go to a nearby private clinic and get the examination. It revealed no problems but staff there estimated her due date 20 days later than the actual delivery day.&nbsp; We do not know what would have happened if the ultrasound had been done at the health post, and produced a more accurate delivery date, but the roadside birth highlights again how lack of resources plays a role in maternal and child health in Nepal, despite the best intentions of health personnel and, of course, families. There was no ultrasound machine at the health post, and no ambulance to call when Sajadi’s labour started.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080612_a44aa91ec02c4b2996c3b0bbdfc17847b279fefd6720b65fb5d2cf0fa5d40e78.jpg" data-media-id="editor_1" data-image-id="20230623080612_a44aa91ec02c4b2996c3b0bbdfc17847b279fefd6720b65fb5d2cf0fa5d40e78" data-rendition-name="original" width="3007" height="2619" loading="lazy" alt="Sajadi Khatun"> <figcaption>New mother Sajadi Khatun, holding her fifth child, talks to nurse Sunita Rai in front of her home near Malangwa in Sarlahi district. </figcaption> </figure>  “The problem is that we don’t have an ambulance in the municipality,” says Auxiliary Nurse Midwife Sunita Rai, who accompanies us to Sajadi’s house. “If we had an ambulance when a woman has a problem like a roadside delivery, we could send it right away and reduce the number of home deliveries.” Sarlahi district, and Madhes Province overall, still have a high number of home deliveries. Statistics from the district health office show that 53.5% of births happened in health facilities in 2021-22. That leaves 46.5% occurring at home or en route to facilities. The Nepal Demographic Health Survey (NDHS) 2022 found that 66.6% of births in Madhes Province occur in a facility versus 79.3% for Nepal overall.&nbsp; “The health situation in Madhes Province is a little worrisome to us, despite all the facilities there,” said the secretary of the Ministry of Health, Roshan Pokhrel. “We’re thinking about giving different targets to different provinces, rather than having a central target,” he added.&nbsp; Nepal is aiming to reach the global Sustainable Development Goals (SDG) target of 70 maternal deaths per 100,000 births. The 2022 rate was 151, according to the NDHS.&nbsp; 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 In Sarlahi, health infrastructure is a key factor affecting maternal health. Medical Superintendent of Malangwa Hospital, Nawal Kishore Jha, told us that the facility has burst its seams. For example, when the Covid-19 pandemic displaced the emergency and in-patient departments, they moved to what was the waiting area, where they remain when we visit in April.&nbsp; Also, two years ago the hospital delivered one or two babies daily, but today it is closer to 20, including a growing number of Caesarean sections, yet the facility lacks a gynaecologist, meaning that non-specialists perform the 3-5 ‘C-sections’ done daily.&nbsp; Reached again on budget day, 16 June, Jha has good news: his hospital will be upgraded to a 100-bed facility. That could mean more buildings, more trained staff and equipment, including a CT scan machine.&nbsp; In case of a maternal emergency, accessing the district hospital — the best-resourced health facility in Sarlahi — should not be an issue as it is only a one-hour drive away from anywhere in the district, unless there is monsoon flooding, adds Jha. Yet as Sajadi’s example shows, lack of resources — like ambulances — can still be a barrier.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080636_749b8cb16b39c940e487ba9770a57df181a69ce80f9878240eb273c16e5d4096.png" data-media-id="editor_3" data-image-id="20230623080636_749b8cb16b39c940e487ba9770a57df181a69ce80f9878240eb273c16e5d4096" data-rendition-name="original" width="2880" height="1800" loading="lazy" alt="Mothers of Sarlahi 2"> <figcaption>Women harbest wheat during the pre-monsoon Tarai heat wave recently in Malangwa.</figcaption> </figure>  While Jha and the nurses at health posts all say people’s awareness of maternal health and its potential complications could be higher overall, in the diverse communities near Malangwa, most women and their families are motivated to use health facilities, both to get as healthy as possible before giving birth and for the actual delivery.&nbsp; Besides awareness, living conditions are a major factor, says nurse Kanchen Rai at Laxmipur Khodra Health Post: “We can provide education, but the biggest problem is people’s lack of money. There has been some improvement but the poorest people still don’t have clean water and toilets.”&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080620_b68ff8cb3b3aa01e13dd5ae964c1a4b71296a0ac601a42d47eaa2ce4698db618.jpg" data-media-id="editor_4" data-image-id="20230623080620_b68ff8cb3b3aa01e13dd5ae964c1a4b71296a0ac601a42d47eaa2ce4698db618" data-rendition-name="original" width="4032" height="3024" loading="lazy" alt="Rabena Khatun"> <figcaption>First time mother Rabena Khatun with her baby in front og her house near Malangwa in Sarlahi district. ALL PHOTOS: MARTY LOGAN</figcaption> </figure>  “Pockets” that are away from urban areas and further marginalised by diverse factors are where home births still happen, and must be targeted for improvement, says Jha.&nbsp; First-time mother Rabena Khatun, 22, told us she felt “very happy” when she knew she was pregnant. Within three months she had visited the health post for her first ANC, following it up “3 or 4” more times before delivery, accompanied by her mother-in-law.&nbsp; Read Also: <a href="https://www.nepalitimes.com/opinion/midwives-to-the-rescue-in-nepal">Midwives to the rescue</a>, Laxmi Tamang “The nurses told me I should eat more nutritious food so that I gain weight,” she tells us, crouching on the ground outside of her small thatch-roofed bamboo home, cradling her son Ehsan, now 37 days old, on her lap.&nbsp; When Rabena’s labour pains began, she went to the health post with her mother-in-law and two other relatives. After 10-12 hours the baby was born, without complications. Instructed by a nurse, the first-time mother started breastfeeding within 30 minutes.&nbsp; She tells us that no one in her family or community suggested during her pregnancy that she deliver at home, adding, “All the facilities are there (in the health post) so I felt confident.”&nbsp; <h2>Promise of a healthier district</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023062308068_9211b4979e6bafea6f5138663b56b17c33b42294bb53e81c7d3280b5a34fe400.png" data-media-id="editor_6" data-image-id="2023062308068_9211b4979e6bafea6f5138663b56b17c33b42294bb53e81c7d3280b5a34fe400" data-rendition-name="original" width="1297" height="664" loading="lazy" alt="saving lives"> </figure>  The Medical Superintendent of Sarlahi District Hospital in Malangwa, Nawal Kishore Jha, sounded upbeat after hearing in the Madhes Province government budget on 16 June that the facility will be upgraded to a 100-bed hospital.&nbsp; “I’m very happy with the decision, it responds to all our demands,” Jha said on a call from Malangwa. The larger facility will receive more trained staff, more space, including to provide maternal healthcare services, and more equipment such as a machine for CT scans.&nbsp; The government also announced it would build two 50-bed hospitals elsewhere in the district, and that all other municipalities would have 15-bed facilities.&nbsp; The budget revealed that Sarlahi will become a 'completely safe motherhood district'. Among other things, that means all births will be in health facilities, accompanied by skilled health workers, and all pregnant women will have the required number of pre and post-natal checkups.&nbsp; “It is possible,” says Jha, “but it will take some time.” <h2>Bumpy ride triggers birth</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623070656_11438bd7c592e3d356ed26bfcb7de4ae014f8b23549bcafe2f383d6083c61224.png" data-media-id="editor_7" data-image-id="20230623070656_11438bd7c592e3d356ed26bfcb7de4ae014f8b23549bcafe2f383d6083c61224" data-rendition-name="original" width="2794" height="1608" loading="lazy" alt="Mother of sarlahi 1"> <figcaption>Anita Kumari Yadav with her baby and husband. </figcaption> </figure>  Anita Kumari Yadav had felt a pain for three days that she thought meant she was going into labour for her first baby. She walked to nearby Sisautiya Health Post, but was always told it hadn’t started.&nbsp; On the third day, nursing staff referred her to the district hospital because of the delay. When she arrived with her in-laws after a bumpy ambulance ride, she was told she would need a Caesarean section.&nbsp; “I was scared to have an operation,” says Anita, 20. She called her husband, a bus driver who was en route from Kathmandu. He told the family to wait until he arrived. But they didn’t have to. The baby was born half an hour later, one positive outcome of the bone-jarring ambulance ride, speculates Auxiliary Nurse Midwife Ringku Kumari Raut.&nbsp; Like the other women interviewed in the Malangwa area, Anita diligently did her ANC check-ups, once also visiting the district hospital to have a test confirmed. She took iron and calcium supplements (when in stock) and added fortified flour to her diet to gain weight.&nbsp; Nurse Raut says she is happy with how she and her colleagues managed Anita’s delivery, despite the health post’s limited resources: “Everything is fine now but if something had happened, the hospital had resources and facilities to deal with it.” <h2>Maternal deaths deliver lessons</h2> A day before the central government budget was released on 29 May, officials in the Family Welfare Division (FWD) of the Department of Health were resigned to the fact that the status quo was the most they could achieve in programming for the 2023-24 fiscal year.&nbsp; But Section Chief Gauri Pradhan had her fingers crossed that a verbal promise of more funding would allow the section to expand at least one program — for <a href="https://www.nepalitimes.com/news/3-nepali-mothers-still-die-daily-at-childbirth">maternal and perinatal death</a> surveillance and response (MPDSR).&nbsp; Started in Nepal at the Maternity Hospital in Thapathali in 1992, guidelines were created for the program in 2015 and revised in 2021. Today, MPDSR takes place in 42 districts, both in hospitals and where there are maternal and newborn deaths in communities.&nbsp; The promised funding, from an external partner, will permit the program to expand to more hospitals and communities. Pradhan displays the WhatsApp app on her mobile, which shows a group for reporting of mother and newborn deaths in hospitals and another for community deaths.&nbsp; Asked why this one program is likely to be the only maternal and newborn health initiative in the FWD to expand next year, Pradhan says: “It is the basic thing to take action to learn the cause of death. Without knowing the causes, how can we develop activities to make childbirth safer?”&nbsp; Expenses for this trip were paid by One Heart Worldwide.

Mothers of Sarlahi

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbc9c7e80680e0b7884jpeg.jpg" alt="" width="720" height="540"/><figcaption>Nurses Puspa Pandhak and Sumnima Khapung delivering the baby inside a jeep late at night on 3 March, after concluding that they could not reach the Tehrathum district hospital in time because of the bad road. Photo: DINESH BHATTARAI</figcaption></figure>Puspa Pandhak was just finishing her duty at a rural hospital in Tehrathum district last week when a 19-year-old woman was brought in on a stretcher, writhing in pain.As a birth attendant nurse, Pandhak had performed more than 100 safe deliveries in the past five years, but this maternity case was the first breech she was having to deal with.“As soon as I saw the position of the baby, we decided not to take the risk and take her to Tehrathum Hospital,” Pandhak says.Read also: <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">Birth and death during a pandemic</a>, Nunuta RaiBut, as is often the case in rural Nepal, they could not get an ambulance. The condition of the mother and baby was deteriorating, and every second counted.Luckily, a four-wheel drive jeep just happened to pass by and gave them a lift. Pandhak and fellow nurse Sumnima Khapung got on with their patient, taking along their delivery kits.The road was bumpy and dangerous, made worse by the previous day’s heavy rain and the pitch black night. It was already 9:30PM, and they were nowhere near their destination.“It was a rough ride, and we were being thrown about inside the car, but I tried to reassure the young expecting mother since this would be her first baby,” Pandhak recalls.Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener noreferrer">Who will save Nepal's poor new mothers</a>, Rojita AdhikariIn the front seat, the patient’s mother and husband were panicking, and that was not helping at all. Then driver Dinesh Bhattarai also started getting unnerved, and that was not a good sign.It was now nearly 11PM, and it did not look like they would get to the district hospital in time. Pandhak made the tough decision to stop the journey in the small bazar of Tukre.“The trip was becoming too long due to the poor road condition and I knew we would never reach the hospital where an emergency doctor and midwife team were on standby to receive us,” Pandhak recounts. “I was very nervous, but knew that the mother was in bad shape and I needed to help somehow.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbe9c7e80680e0b7885jpeg.jpg" alt="" width="1070" height="1600"><figcaption> </figcaption></figure>The two nurses then decided the safest course was to deliver the baby inside the car. In a breech case, the baby’s body is upside down, which means the head is stuck. Pandhak and Khapung tried to help the mother push the baby, while aware that this could injure her.Finally, the nurses managed to carefully pull the baby out, without the mother suffering a serious tear.Read also: <a href="https://www.nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time/" target="_blank" rel="noopener noreferrer">Saving one Nepali mother at a time</a>, Aruna Uprety“I cannot describe the elation and relief that we felt, and I am sure the mother and her relatives were much happier than us, we had delivered a healthy baby inside a cramped car, and mother was also fine,” Pandhak told us on the phone from Tehrathum.After the enroute delivery, the jeep with one extra person on board, continued the journey to Tehrathum District Hospital. When they got there just past midnight, the emergency team could not believe what they saw.Says Pandhak, “They were so proud of us as they took charge of mother and baby at the birthing facility. It was a nerve-wracking experience, but it all ended well.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc19c7e80680e0b7886jpeg.jpg" alt="" width="794" height="854"><figcaption> </figcaption></figure>Pandhak and Khapung are on the frontlines of Nepal’s efforts to <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/" target="_blank" rel="noopener noreferrer">reduce maternal and infant mortality</a>. Thirty years ago, 10 in 10,000 women in Nepal used to die in childbirth. That number has come down to 2 in 10,000. But progress has now flat-lined, and 1,500 mothers still die during delivery every year in the country.Even though such individual acts of heroism never make it to the news, it is the work of Female Community Health Volunteers, dedicated Skilled Birth Attendants (SBAs) like Puspa Pandhak and Sumnima Khapung, and local governments that are helping save lives every day across Nepal.In this case, it was also the support for renovating and equipping the birthing centre and midwife training provided by the organisation One Heart Worldwide (OHW) to Menchhhyayem Rural Municipality that helped raise the capacity of the two nurses.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc39c7e80680e0b7887jpeg.jpg" alt="" width="640" height="853"><figcaption> </figcaption></figure><a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" target="_blank" rel="noopener noreferrer">OHW uses a partnership approach</a> with rural municipalities to upgrade birthing centres through cost-sharing to encourage local ownership. When the work is complete it moves on to other districts.“I still feel so relieved and excited that we saved the lives of the mother and baby, and it was also a life-changing moment for me,” Pandhak says. “I feel so happy to see the family so thrilled. This is the greatest reward that a nurse can ever have.”Pandhak says it was the OHW training that gave her the confidence to make the right decision to deliver in the car and not wait to get to hospital. She adds, “The successful outcome has also given us new confidence to deal with complicated cases in future.”

Another baby's life is saved in rural Nepal

<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/20221110141136/636cfe469c7e80680e0a0c2ejpeg.jpg" alt="" width="2529" height="1427"/><figcaption>Photo: HIMALMEDIA</figcaption></figure>A white-coated nurse holding a blue and white, half-litre bag of milk stands in front of a small group of mothers seated near the entrance of the Nutrition Rehabilitation Home in Kathmandu.She is explaining the importance of feeding milk to their children, who are lolling on their mothers’ laps. On a table behind the nurse are containers of pulses and legumes and leaning against the wall, charts displaying leafy vegetables.But later, listening to the women’s stories, it is apparent that solving their children’s problems will require more than a healthy diet. Through tears, Chandra, 24, says she brought her son Raju, 21 months, to the Home after a routine hospital check-up found that he was malnourished.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe499c7e80680e0a0c2fjpeg.jpg" alt="" width="3706" height="2170">His father, who Chandra was forced to marry, bought barely enough food for them to survive, says the woman. That deprivation, plus physical beatings and “mental torture” caused Chandra to flee their village home for Kathmandu.Mother and son arrived in January at the 24-bed facility perched on a hill on the outskirts of the city, where housing colonies sprout on former farm fields. In the month since then, Raju has gained 1kg in weight and is much stronger.The boy will stay at the Home for a few more weeks, says Sunita Rimal, coordinator of the Malnutrition Prevention and Treatment Program at the Nepal Youth Foundation, which runs the Home. By then she hopes to have found some work in Kathmandu for Chandra via her informal channels, so that the mother-son pair don’t have to go back.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe4d9c7e80680e0a0c30jpeg.jpg" alt="" width="901" height="786">Epidemic of hungerNina Parajuli, 45, brought her daughter Anushka, 7, to the Home weeks later on the advice of staff at a local non-governmental organisation. Nina had gone there for skills training after losing her house-cleaning job in Kathmandu.She was forced to find work unexpectedly after Anushka was born, when her husband deserted them. The family that hired her ate their first meal of the day only in the afternoon, which meant the girl left for school in the morning having eaten only snacks, while her mother worked. Eventually, Anushka grew dangerously thin and was considered severely malnourished when she arrived.Nina “was too concerned with her own problems to notice,” Rimal explains. Like her husband, she is HIV positive. She also has a heart condition and is on a waiting list for a uterus operation.Though unique, the stories of Nina and Chandra share a common thread — the causes of their children’s malnutrition are multifaceted. Rimal says that is the norm: “Most of the people who come here have other socioeconomic problems.”Past achievements Nepal is celebrated globally for its success in fighting malnutrition from the 1990s until recent years. Most notably, rates of stunting (low height for age) fell from the world’s highest, 68% in 1995, to 36% in 2016.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe509c7e80680e0a0c31jpeg.jpg" alt="" width="2410" height="1064"><figcaption> </figcaption></figure>New research has teased out exactly which development efforts had what impact on stunting. Indirect (also known as ‘nutrition-sensitive’) approaches were surprisingly effective. For example, better educated parents accounted for 25% of the improvement, <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">environmental factors</a> like building more toilets contributed 12% and economic growth made up 9%.Direct (‘nutrition-specific’) efforts included: improved nutrition of mothers (accounting for 19% of the gain), and maternal and newborn health care (12%), according to the research, published on the website <a href="https://www.exemplars.health/topics/stunting/nepal">Exemplars in Global Health</a>.“The exemplars that we picked were countries that did (development) much faster than others. Nepal is not necessarily the best example but it is an important example,” says Zulfiqar A Bhutta of the Centre for Global Child Health at The Hospital for Sick Children in Toronto, one of the leaders of the research.“One thing is very clear, no one country has done it alone by only investing in health and nutrition sectors,” explained Bhutta via Zoom from Toronto. “And no one country has done it alone by only investing in poverty alleviation strategies. So the truth is that you have to do both in combination.”Nepal has continued that broad approach, investing in health both directly and indirectly, <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">yet the progress has plateaued</a>.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe549c7e80680e0a0c32jpeg.jpg" alt="" width="1628" height="1255">While stunting continues to fall, the 36% rate is greater than the developing country average of 25% and the Asia average of 21.8%. In fact, the country is on target to hit only one of its nutrition goals for 2025 set by the World Health Assembly — for underweight children under 5 — says the <a href="https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/nepal/">Global Nutrition Report 2020</a>.So what happened?“The one thing that I was surprised by is that inequity has increased,” says Bhutta, “and I have a feeling some of that may have had to do with the urban poor or rural to urban migration.”Nepal, he adds, should work to pinpoint the who’s and why’s of poverty, but otherwise, it should maintain its balanced approach.Investment on nutrition A recent analysis from UNICEF found, however, that spending on indirect approaches to fight malnutrition was rising while declining for direct interventions. This goes against the direction given in the government’s <a href="http://nnfsp.gov.np/PortalContent.aspx?Doctype=Resources&amp;ID=330">Multi-sector Nutrition Plan</a> (MSNP), the blueprint for tackling malnutrition.<a href="https://www.nepalitimes.com/editorial/hunger-for-governance/">Hunger for governance</a>, EditorialThe first phase of the MSNP ran from 2013 to 2017, and the current plan ends next year. The analysis in UNICEF’s <a href="https://www.unicef.org/nepal/media/13296/file/Nutrition%20-%20Budget%20brief.pdf">Nutrition Sector Budget Brief</a> also pointed out that the cost of programs in phase two (Rs48.9 billion) of the multisector plan is just 54% of phase one (Rs88.5 billion). In addition, the gap between budget numbers and actual spending has been growing.Kiran Rupakhetee of the Good Governance and Social Development Division at the National Planning Commission secretariat, helped shape MSNP-II. In an online interview he suggests that rather than the current plan’s budget being too low, the budget for MSNP-I might have been “over calculated at the time”.As to the growing gap between allocations and real spending — it results from many factors, including “rigidities and structural barriers” in the system, he explains.Another major challenge for MSNP-II is federalism, which introduced three levels of government after elections in 2017. “It’s a Herculean task… because at the moment it’s not only one government—we have 761 governments… There are some difficulties in ensuring coordination among them,” adds Rupakhetee.The pandemic challenge The Covid-19 pandemic <a href="https://www.nepalitimes.com/latest/covid-19-leaves-millions-of-south-asian-children-hungry/" target="_blank" rel="noopener noreferrer">has added to the challenge</a>. “It definitely has hampered our activities,” says Rupakhetee, “but we tried our level best to keep the programme going.”For example, parents were trained to measure the arm circumference of infants to detect signs of malnutrition, a task usually done by female community health volunteers, who have been unable to do so due to frequent lockdowns.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe579c7e80680e0a0c33jpeg.jpg" alt="" width="960" height="640"><figcaption> </figcaption></figure>Nepal’s school feeding programme was also modified because of the pandemic, with food rerouted to students’ homes, says World Food Programme (WFP) Country Director Jane Pearce, in an online interview.“Whereas most of the world stopped all of their school meals programmes, Nepal has continued, which has meant that we’re maintaining the nutrition that we’re providing through our locally-managed school meals programmes by giving households take-home rations,” she said.WFP has also teamed up with UNICEF and other UN agencies to press the government to expand its malnutrition treatment to include not only children who are severely wasted (low weight for age) but moderately wasted, says WFP’s Head of Nutrition Anteneh Girma.“With the impact of Covid and others, if they’re not treated they will become severely malnourished, then chronically malnourished, or stunted,” he adds.In June <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/">this paper reported</a> on how severe malnutrition was killing children in the poorest communities in Nepal’s eastern plains. It told the story of Raju Devi Sada, whose first daughter died at 3, after being malnourished. A second daughter died soon after birth, a year later.A third daughter is underweight and local health workers have recommended feeding her nutritious food. But Raju Devi cannot afford vegetables, eggs, milk and meat, and what she earns as a daily wage labourer is barely enough to feed the rest of the family.“We have found that up to 70% of children who die every year in Province 2 do so due to malnutrition, and the main reason for that is extreme poverty,” said Kedar Parajuli at Nepal’s Family Welfare Division. “Without alleviating poverty, we can’t solve malnutrition.”WFP is doing mapping, using mobile data, to create what it calls a vulnerability index. It documents people’s access to water and sanitation services, health and other factors, in addition to nutrition, says Girma.He adds, “Our nutrition response, food security response, is informed by that index… it indicates those who are vulnerable for not having access on time, for being exposed to various inequalities.”The private sectorGirma points out that WFP, both in Nepal and globally, supports the multisector approach. In that vein, the UN agency is working closely with the government to establish the <a href="https://sunbusinessnetwork.org/">Scaling Up Nutrition (SUN) Business Network</a> in Nepal. To date, 10 companies, all working in the food industry, have become members.Ending malnutrition and other food-related diseases “will happen only if the private sector is responsible for what they are producing, and producing something safe …  so their engagement, bringing them to the table, is very important,” says Girma.Leading collaboration with the private sector on the ground is <a href="https://www.baliyonepal.com/en/">Baliyo Nepal</a>, a non-profit company that generated headlines when it launched in 2019. The initiative was funded by the Bill &amp; Melinda Gates Foundation through the Chaudhary Foundation, the charity arm of the Chaudhary Group, makers of Wai Wai instant noodles, which are widely considered junk food.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/junk-food-is-making-nepali-children-shorter/" target="_blank" rel="noopener noreferrer">Junk food is making Nepali children shorter</a>, Marty LoganToday Baliyo Nepal is set to expand a pilot project that has been running in Lumbini Province since 2020 — raising awareness about nutritious food among school children, including via a cricket program, and educating shopkeepers to sell the nutritious foods in the first phase of its ‘Baliyo Basket’: eggs and a single-portion Rs10 sachet of fortified porridge for infants.“Seventy percent of the sachets in the market were sold, according to the sales report,” says Baliyo Nepal CEO Atul Upadhyay, a nutritionist, in an interview in his Kathmandu office. “The feedback we’re getting from mothers is ‘Now we want it in a bigger package. We can’t go to the shop every day and buy the Rs10 package’.”Upadhyay says manufacturers will start making the larger packs by year end. That is just one of many plans he is cooking up — besides expanding pilot activities to Bagmati and Gandaki provinces, the company will soon be adding to its Baliyo Basket a fortified drink for pregnant and lactating women and fortified porridge for 2-5-year-olds, once they are approved by the government.Upadhyay notes that both the government and private sector are gradually embracing his innovative approach but stresses that new ways to fight malnutrition, like this public-private partnership model, are essential if Nepal is to reach its nutrition targets.“It’s not important who works for nutrition. It’s important that someone works for nutrition, whether it be WFP, Baliyo Nepal, company A, company C — I don’t mind,” he adds.Target StuntingStunting, low height for age, is a sign of chronic undernutrition. It can hinder brain development resulting in reduced mental ability and learning capacity, poor school performance in childhood and lower earnings and higher risks of nutrition-related chronic diseases, such as diabetes, hypertension and obesity, in adulthood.Nepal cut its stunting rate dramatically in recent decades, and it is one form of malnutrition that the country might be on track to reduce in line with coming targets: MSNP-II (2022), World Health Assembly (2025) and SDGs (2030).The UNICEF Nutrition Sector Budget Brief says that the average yearly rate of stunting reduction since 2001 (3.25%) must increase to 3.8% to meet the MSNP-II and WHA targets, and rise to 6.5% to meet the SDG target.According to Kiran Rupakhetee at the National Planning Commission: “The Nepal Multiple Indicator Cluster Survey has brought some encouraging results, but it may still be difficult to make the WHA target... but since the SDGs deadline is quite far away I’m very much optimistic and hopeful that we can meet it.”Stunting rates and targets 2016: Nepal Demographic and Health Survey – 36%2019: Nepal Multiple Indicator Cluster Survey – 31.5%2022:  Target: Multi-sector Nutrition Plan-II – 28%2025:  Target: World Health Assembly – 25%2030:  Target: SDGs – 15%

Marty Logan

A tall order

Architecture can be a powerful agent of change, shaping not just spaces but the way people live, connect, and experience the world.&nbsp; For Nepal, which is <a href="https://nepalitimes.com/banner/natures-fragile-gift-to-nepal">gifted by nature</a> and rich in <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/ambassador-fund-cultural-preservation-nepal,2092">cultural heritage</a>, &nbsp;reviving rural architecture with modern amenities could hold the key to more <a href="https://nepalitimes.com/here-now/what-sustainable-tourism-means-in-practice">sustainable tourism </a>that benefits local people more. “<a href="https://nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award">Design and architecture</a> are amazing tools to create a unique experience for visitors,” says Spanish architect Tomeu Esteva of Esteva i Esteva Architecture Studio. “Difficult destinations have beautiful hotels with design and comfort.” Esteva was in Kathmandu with his colleagues at an event organised by the Spanish Honorary Consulate at Dwarika’s Hotel last week to showcase buildings which Nepali architects can adapt with local material and design inputs.&nbsp; Rural architecture holds a unique significance: it is more than a shelter and must reflect <a href="https://nepalitimes.com/here-now/inking-an-idenity">local identity, culture</a> and <a href="https://nepalitimes.com/here-now/saving-humla-from-heritage-loss">heritage</a>. An area’s natural and cultural harmony can be upset by <a href="https://nepalitimes.com/here-now/protecting-protected-areas-from-infrastructure?fbclid=IwAR1wK0MDFlFST_2EYb3f54LS4-fPt6rYfLG1DJ1JaQsU3w8-ezyXIxGOqzk">poorly planned development</a>, speakers at the event said, but the environment can be improved and revitalised by well-integrated structures.&nbsp; Another Spanish architect, Belen Moneo, has designed hotels at elevations of 3,700m in her home country Spain that supply natural spring water spas. “<a href="https://nepalitimes.com/banner/lost-in-reconstruction">Creativity in construction</a> must be encouraged. Rural architecture always shows possibilities of what we can do better,” Moneo explains, adding that designs must enhance <a href="https://nepalitimes.com/opinion/the-healing-power-of-nature">the beauty of nature</a> and give a natural feel at a time when steel, glass and cement dominate <a href="https://nepalitimes.com/here-now/rebuilding-kathmandu-after-the-1934-quake">urban design</a>.&nbsp; This is why the <a href="https://nepalitimes.com/here-now/weaving-nature-into-craft">use of natural products</a> such as bamboo, local timber, straw and rammed earth are in demand from customers who want a fresh eco-friendly look encouraged in construction of rural architectural structures. The demand for boutique hotels has increased world over, with &nbsp;more and more tourists favouring aesthetics, experience and comfort over price. While creativity is an important part of <a href="https://nepalitimes.com/here-now/architecture-for-mountains">construction and architecture</a>, incentives to build and use <a href="https://archive.nepalitimes.com/article/nation/Building,370">rural construction materials</a> still remain minimal, and Moneo emphasises the significance of design and execution.&nbsp; Esteva helped design the Vana Retreat in Dehradun that kept the natural environment in focus, with the structure giving an elaborate aesthetic experience to visitors. Another example is Hotel Las Mercedes in the Dominican Republic which was designed and constructed by Moneo and the company she co-founded Moneo Brock, respecting and revaluing the traditional architecture of the area. Hotels providing such experience could attract tourists and revenue. The Spanish ambassador to Nepal Juan Antonio March Pujol said, “The role of architecture and architects in developing tourism is crucial, not only in urban areas but rural settings as well.”&nbsp; The concept of rural boutique hotels gained traction in Spain during the 1990s, particularly in regions like Majorca with economic and environmental sustainability as the main focus. In Nepal <a href="https://nepalitimes.com/opinion/12-full-opinion/guiding-nepal-s-tourism-industry">the tourism industry</a> directly employs about 1 million people, and makes up about 8% of the country’s GDP. In Nepal, the stone homes of <a href="https://nepalitimes.com/news/reviving-himalayan-vulture-and-culture">Mustang and Manang</a>, bamboo and mud structures of <a href="https://nepalitimes.com/here-now/the-tarai-s-shrinking-forests">the Tarai</a>, and the Kathmandu Valley’s terra cotta tile skylines, graceful temples, and tranquil bahal courtyards are all examples of <a href="https://nepalitimes.com/here-now/nepal-s-traditional-seismic-resistant-designs">Nepal’s traditional architecture</a>.&nbsp; Nepali architect Sarosh Pradhan has been working for the past eight years on the Brakka Village project in Manang Valley north of <a href="https://nepalitimes.com/banner/municipalities-want-to-manage-annapurna">the Annapurnas</a>. Other examples of this kind of rural architecture for high-end tourism are the Shinta Mani Hotel in Mustang and Khumbu Lodge below <a href="https://nepalitimes.com/news/mt-everest-pvt-ltd">Mt Everest</a>. Says Pradhan, “There are places in Nepal that radiate purity and embrace simplicity. Creating projects in such settings require deep reflection and thoughtful planning.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421030444_a07a23f6b60fa89c0f35b9dc1aaf19937da4881e6bfb2e1858f3c27dff91729f.jpg" data-media-id="editor_19" data-image-id="20250421030444_a07a23f6b60fa89c0f35b9dc1aaf19937da4881e6bfb2e1858f3c27dff91729f" data-rendition-name="original" width="4608" height="2184" loading="lazy" alt="A new architecture for Nepal's tourism"> </figure>  Rural architecture is not easy, and sometimes more expensive. Inflation, energy efficiency, <a href="https://nepalitimes.com/here-now/those-who-stay">the climate crisis</a>, and <a href="https://nepalitimes.com/banner/cost-of-living-in-a-big-city">increased costs of living</a> pose obstacles to sustainable rural architecture. Read also: <a href="https://nepalitimes.com/here-now/forgotten-international-starchitects-in-nepal">Forgotten international starchitects in Nepal</a>, Anne Feenstra and Varun S Bapu Esteva says faith and trust between client and architect is necessary for any project to be successful. He adds that architects must practice being humble, the process of designing always involves learning and not imposing their ideas on clients. Nepal is uniquely positioned for the growth of <a href="https://nepalitimes.com/banner/hiking-up-the-benefits-of-tourism">rural tourism</a> because of its stunning countryside as well as its internationally renowned traditions in holistic wellness. Creating infrastructure that is small, thoughtfully planned and that respects both tradition and contemporary hospitality standards is crucial. “Projects in Nepal can be made cost effective by using materials from houses that have been brought down,” says Esteva. “Pilot projects involving <a href="https://nepalitimes.com/banner/local-government-by-the-people-for-the-people-of-the-people">local people </a>and simple designing also helps the process.” <a href="https://nepalitimes.com/banner/vacant-homes-become-homestays-in-nepal">The growth of homestays in Nepal</a> is a step in the right direction, but they are still a bit too rustic for the international traveller who also wants comfort and is willing to pay extra for it. Upgrading the facilities in homestays and ensuring that the <a href="https://nepalitimes.com/here-now/an-archive-of-nepali-heritage">architectural heritage</a> of the locality is preserved using locally sourced building material could allow owners to charge more. Says Sangita Shrestha of Dwarika’s Hotel, “Our effort is to build upon rural architecture by empowering local communities and using what is available locally. We can fine tune and encourage indigenous design and training.” The vision goes beyond just boosting the economy, it is about building a future where tourism helps villages grow in a healthy and lasting way. Instead of using up resources, it gives back to the land and the people. It supports local communities by<a href="https://nepalitimes.com/opinion/staying-in-nepal-to-create-jobs"> creating jobs</a>, improving infrastructure, and protecting natural beauty. When done right, tourism can be a tool for <a href="https://nepalitimes.com/editorial/progress-and-or-preservation">preserving culture and nature</a>, not harming them. Architects must therefore see their work as more than just designing buildings, they also need to care deeply about people and places, especially in rural areas that can benefit the most.&nbsp; With global interest in sustainable and off-the-beaten-path travel increasing, Nepal stands at the cusp of a <a href="https://nepalitimes.com/news/missing-out-on-nepal-s-tourism-potential">tourism transformation</a> that values community-driven, eco-conscious hospitality. A mix of modern ideas and traditional knowledge could transform rural tourism in Nepal. Says Shrestha, “Young architects should spend time with <a href="https://nepalitimes.com/latest/the-unsung-heroes-of-conservation">local and indigenous communities</a>, listen to their stories, and learn from their <a href="https://nepalitimes.com/banner/life-and-livelihood-in-remote-nepal">ways of living</a>. These communities have deep knowledge about the land, materials, and climate. If this wisdom is used in new designs, it can help create tourism spaces that truly benefit everyone.” &nbsp;

A new architecture for Nepal's tourism

Extract from an addendum to Nepal's Two Wars, Chapter 2 in the updated edition of Essays on Nepal: Past and Present by Sam Cowan, a retired British Army general with a long association with the Gurkhas. The book was first published in 2018, and republished earlier this month by FinePrint exclusively on Amazon. The addendum details a one-to-one conversation the author had in the <a href="https://archive.nepalitimes.com/news.php?id=8884">Royal Palace </a>with the <a href="https://archive.nepalitimes.com/news.php?id=8371">King Gyanendra</a> in November 2002 just after he had taken his initial steps on the road that ultimately led to <a href="https://archive.nepalitimes.com/news.php?id=14681">the abolition of the monarchy</a> in Nepal in 2008. In the early evening of September 16, 2002, in my role as Colonel Commandant of the Brigade of Gurkhas, I had my second and last official audience with King Gyanendra to give him an update on the Brigade’s activities over the previous 12 months. I had some 6 or 7 such audiences with <a href="https://nepalitimes.com/here-now/preserving-king-birendra-s-family-home">King Birendra</a>.&nbsp; These were official affairs with the British ambassador of the day present, along with key <a href="https://archive.nepalitimes.com/news.php?id=12233">palace officials</a> and a representative from Nepal's Foreign Ministry. The two monarchs were very different in character and temperament, but both treated me with the utmost civility and made the audiences as relaxed and easy for me as possible.&nbsp; It is, however, worth recording that when the official business had been covered, King Birendra, with a twinkle in his eye, often ended by asking, “Now General, what’s the gossip in London?” The second audience with <a href="https://archive.nepalitimes.com/news.php?id=8026">King Gyanendra </a>was my last official act in uniform. We came back to Kathmandu in the first week of November (after treks) to stay for a few nights with our Defence Attaché before heading back to the UK. Waiting for me was a message from the Palace saying that King Gyanendra would like to meet me informally: <a href="https://archive.nepalitimes.com/news.php?id=6933">no uniform</a> and no ambassador.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080420_f9046f9882d4481781d14f2b64f18c7fbbea62562e1d74e3465de6d01fb43750.jpg" data-media-id="editor_7" data-image-id="20250421080420_f9046f9882d4481781d14f2b64f18c7fbbea62562e1d74e3465de6d01fb43750" data-rendition-name="original" width="1750" height="2406" loading="lazy" alt="Gyanendra crowned page 1"> <figcaption>Nepali Times Special Edition of 6-14 June 2001 with enthronement of Gyanendra. </figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_21333d6ae21828eb47fe3f849438d215fe2804460d47bb2896ef4aee4e895ad2.jpg" data-media-id="editor_8" data-image-id="20250421080424_21333d6ae21828eb47fe3f849438d215fe2804460d47bb2896ef4aee4e895ad2" data-rendition-name="original" width="1500" height="1857" loading="lazy" alt="Royal massacre"> <figcaption>Nepali Times 22-29 June 2001 covering the royal massacre after which Gyanendra became king. </figcaption> </figure>  Although I had no idea what the purpose of the meeting might be, events in Kathmandu since I last saw the king put me on edge. On October 4, 2002, Gyanendra had dismissed Prime Minister Sher Bahadur Deuba, allegedly for failing to hold <a href="https://nepalitimes.com/news/what-goes-on-in-nepal-s-elections">elections</a>. He had put in place a new prime minister and a cabinet personally selected by him. When I heard the news on my travels, the people I met were generally supportive of the king’s actions. There was a general view that something had to be done, the country was going nowhere, and the king deserved his chance, not least to solve<a href="https://nepalitimes.com/latest/14-years-after-conflict-no-closure-in-nepal"> the Maoist </a>problem. Back in Kathmandu, views were not so sanguine. The chosen prime minister, Lokendra Bahadur Chand, was a relic from <a href="https://nepalitimes.com/here-now/mob-movement-and-mayhem">the Panchayat period</a> whose party had failed to win a single seat in the last elections held in 1999. Some of the chosen cabinet ministers had, to put it mildly, dubious reputations, and others had no record of proven competence in any field. There was a fear that the king’s real motive in dismissing <a href="https://nepalitimes.com/editorial/deubas-denouement">Deuba</a> was to start to reverse the democratic gains made since 1990. I informed <a href="https://nepalitimes.com/news/nepal-britain-mark-centenary-of-1923-treaty">the British ambassador</a> about the invitation. He was strongly against accepting it, which was probably the clinching reason for my decision to do the polite thing and accept it. On the evening of November 7, 2002, I presented myself at the royal palace, alone and in civilian attire.&nbsp; As in the past, the Military Secretary, Major General Vivek Shah, met and escorted me into the presence of the monarch. This time, however, he was politely asked to leave the room and shut the door behind him. King Gyanendra greeted me warmly and invited me to sit down.&nbsp; Read also:<a href="https://nepalitimes.com/news/the-ghost-of-monarchy-returns-to-haunt-nepal"> The ghost of monarchy returns to haunt Nepal</a>, Shristi Karki  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_e382af945d0ad2a04ae41fabe5393f793dd10f54cb1220f111c7c9e7423eb558.jpg" data-media-id="editor_15" data-image-id="20250421080424_e382af945d0ad2a04ae41fabe5393f793dd10f54cb1220f111c7c9e7423eb558" data-rendition-name="original" width="1000" height="993" loading="lazy" alt="Gyanendra coup"> <figcaption>Nepali Times 4-10 February 2005 after king Gyanendra's coup imposed media censorship. anendra became king. </figcaption> </figure>  I had wondered, and to be truthful, had worried, not just about the purpose of the meeting, but about how the conversation might start and develop. I reduced my resolve to two points: be polite but speak candidly. The latter resolve was quickly put to the test with the king’s opening words: “Sam, [in previous meetings it had been ‘General’, you walk the highways and byways of this land more than most, tell me what the common man is thinking?” &nbsp;“Your Majesty, I have no idea what they are thinking, but they are waiting.” “Waiting?” “Yes, Your Majesty, they are waiting to see whether what you did some weeks ago in appointing your own prime minister and cabinet ministers is going to make any difference to their lives or whether it is just going to be more Kathmandu hot air.” “Everything is going to be difficult and is going to take time, a lot of time.” “Your Majesty, time is the one thing you don’t have. You must act quickly and decisively to take advantage of the opportunity you have created. Everyone knows that you have appointed these new ministers. Why don’t you get them in here one by one and tell them that they have three months to deliver a programme in their area of responsibility that is going to make a difference to people’s lives? Most will fail to do so. Sack them! It will be a powerful signal of your strong intent to deliver real change.” I can express the opening of our conversation in this way because just about every word is still etched in my mind. The king’s response to my last quoted words was to challenge me to give an example of something that could be delivered quickly. I can give a verbatim record of what I said in response to this unexpected challenge: “Health posts, Your Majesty, there is no shortage of them throughout the country as building them has been one of the sources of local corruption, but very few have any medicine to issue at present or have skilled people to assess and meet medical needs. Your Majesty, children are dying for lack of a few pills. Given the right priority, over a period, say of six months, every health post could be fully stocked with medicine and manned with trained people. This is something I could help to lead for you as I know it would have strong international backing. At last, people would know that you mean business.” As I warmed to the theme, I could see no sign of the king having any enthusiasm for the idea, and I quickly disengaged as it dawned on me, as it had clearly dawned on the king, that the reason for the deficiencies in health posts was to prevent any Maoist combatant from gaining access to any <a href="https://nepalitimes.com/opinion/tech-away/nepal-s-health-tech-industry-is-here-to-stay">medical support</a>, and if this meant people suffering, so be it. The subject of the Maoist insurgency inevitably came up, and I took the opportunity to elaborate on what is written in the final four paragraphs of the article above. I advised King Gyanendra that, self-evidently, since there were three parties in the conflict—him, the Maoists, and the political parties—it was imperative that he form an alliance with one of them, preferably the political parties; otherwise, he would find himself isolated, as the other two parties would inevitably, at some stage, form their own alliance. However, it quickly became apparent that the king’s mind was on a totally different track. On the Maoists, he told me that he had channels open to them, but he was scathing about the political party leaders. He made it clear that they would be waiting for a very long time before he gave any power back to them, and that is a polite way of expressing the actual words he used, but “crawling through the door” is a phrase which has stuck in my mind.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_5403455ff6168f0d202a96cb53edea69136d74d59b989cfcc7cc4a1d57672cb5.jpg" data-media-id="editor_17" data-image-id="20250421080424_5403455ff6168f0d202a96cb53edea69136d74d59b989cfcc7cc4a1d57672cb5" data-rendition-name="original" width="2000" height="1317" loading="lazy" alt="fall of monarchy"> <figcaption>Nepali Times 28 April-3 May 2005 with cover image by Ajay Joshi of jubilant protesters after street demonstrations sidelined king Gyanendra, paving the way for a ceasfire and restoration of democracy. </figcaption> </figure>  As the conversation developed, it became ever clearer that King Gyanendra had decided to go in alone, relying on the misleading assurances he was constantly receiving from <a href="https://archive.nepalitimes.com/news.php?id=14954">the army</a>, and no doubt his close advisers, that the Maoists could and would be quickly defeated militarily, and taken out of the equation. This would obviate the need for him to do any deal with the political parties.&nbsp; Thus, the way would be clear for him to establish a version of his father’s Panchayat system, under a constitution that would be granted to the people by him, their sovereign, as his father and brother had done in 1962 and 1990. As in those constitutions, ultimate power would have remained in the sovereign’s hands. This proposed direction of travel was very clear from what the king said to me. In sum, King Gyanendra was motivated by a desire to emulate his immediate predecessors by granting his people a constitution that would restore his father’s Panchayat system in a modern form and give him a central role in decision-making. What was particularly dispiriting was that beyond this single objective he had no plan worthy of the name, nor demonstrably did he have the people with the skills to implement an appropriate plan even if one had existed. Crucially and depressingly, there was little or no indication from the king that he realised that such a course of action could put Nepal’s monarchy into serious jeopardy, as indeed proved to be the case. <h2>King Twice</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250420110436_315d519fe3d68d2406ebe1480fed54720fbf21b8907a4da5cde751fdc623d445.jpg" data-media-id="editor_19" data-image-id="20250420110436_315d519fe3d68d2406ebe1480fed54720fbf21b8907a4da5cde751fdc623d445" data-rendition-name="original" width="1302" height="632" loading="lazy" alt="“Tell me what the common man is thinking!”"> </figure>  <a href="https://archive.nepalitimes.com/news.php?id=8371">Gyanendra Bir Bikram Shah has been king twice</a>. In 1950 he was enthroned briefly as a child king (left, above) by the Rana Prime Minister Mohan Shumsher when his grandfather, King Tribhuvan, fled to exile in India. In 2001 he was crowned king again after the massacre in the royal palace in which his brother King Birendra and nine other members of his family were killed by Crown Prince Dipendra.&nbsp; During his second reign, Gyanendra gradually asserted power by sacking Prime Minister Sher Bahadur Deuba in 2002, and then taking full control after the 1 February 2005 coup. He was sidelined after the ceasefire in April 2006, and became a commoner after the Constituent Assembly finally <a href="https://archive.nepalitimes.com/article/from-nepali-press/Ftnp-abolishing,624">abolished the monarchy in 2008</a>. In the past year, Gyanendra has tried to exploit public dissatisfaction with the political parties to restore the monarchy.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080432_26ef4a4b0e3cee9fdc6794446702efe16550d293904b4f6dd46fe35d4d10c788.jpg" data-media-id="editor_22" data-image-id="20250421080432_26ef4a4b0e3cee9fdc6794446702efe16550d293904b4f6dd46fe35d4d10c788" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Essays on Nepal by Sam Cowen"> </figure>

“Tell me what the common man is thinking!”

“It's Kathmandu.” Just as the family was sitting down for one of its extended lunches, that jubilant cry was from François Driard’s grandfather announcing the next posting for his diplomat parents.&nbsp; Driard (pictured) was 18 in the summer of 1996,<a href="https://nepalitimes.com/opinion/suburban-tales/chasing-a-nomad"> a bit of a hippie</a> already, and his life was about to change forever with the magical word “<a href="https://nepalitimes.com/banner/time-capsule-of-kathmandu">Kathmandu</a>”. “I was awed with that information from my grandfather, nothing else mattered … In France <a href="https://nepalitimes.com/here-now/tales-of-courage-and-suffering-cx95f89e">in the 1990s</a>, Kathmandu had a mythical aura,” Driard recalls. He came to Kathmandu for Christmas that year to visit his stepfather, the French Ambassador Michel Lummaux. It was to be the first of many visits during school holidays, before he decided to permanently settle down in Nepal. “Kathmandu, and Nepal, were very different then, it was magical, I liked the nature, the people, civilisation, temples, trees,” says Driard, who explored the country sitting on the top of buses. “Visitors talk about the crazy <a href="https://nepalitimes.com/banner/cost-of-living-in-a-big-city">urbanisation</a>, traffic jams today, and all that is true. But Kathmandu has not <a href="https://nepalitimes.com/here-now/loss-of-soul-and-soil">lost its soul</a>.” After his stepfather’s tenure in Nepal ended, Driard worked as a business reporter for international publications but decided he did not want to be anyone’s employee anymore. In 2007 he landed in Kathmandu with €20,000 in savings to invest.&nbsp; He knew a few crucial things about himself: he liked food and nature, which is very much tied up with his upbringing--full of lively conversations during lunch and dinner at the family table between <a href="https://nepalitimes.com/here-now/nepals-yak-cheese-is-on-world-map">abundant cheese, wine and cigars</a>. So he decided it would be cheese, and registered Himalayan French Cheese and went to the French Alps for a month to learn how to make Tomme de Savoie. “<a href="https://nepalitimes.com/banner/the-story-of-langtang-cheese">Cheese making is such an ancient craft </a>and so I thought I won’t need much money or studying which I hated and indeed, if you have a tamako bhado and fire you are set,” explains Driard. But Nepal’s temperature and humidity were not ideal, even at higher altitudes. The first customers for his cheese were the Hyatt Regency and Nina and Hager. But he needed to create a market for cheese in a country which only knew hard churpi in the north and soft paneer in the south. He started selling his cheeses at the Summit Hotel weekend market, expanding to his own 1905 Farmer’s Market which later moved to Le Sherpa in Maharajganj, where it is now, and also a market at Labim Mall in Pulchok. He had cow dairies in Nuwakot and Dhulikhel, and finally a yak cheese unit at 3,379m in Ramechhap. It was the yak blue cheese from here that went on to win a Gold Medal in France, putting Nepal’s French cheese on the world map. “People come and try our cheese at the market, they ask questions. There is a lot of education to be done about cheese,” adds Driard, who also has three cheese shops in the Valley. Driard now makes 25 types of cheese. The products are being noticed and every year he has French students coming to Nepal to learn the art of yak cheese making. “In France, one family or company makes one kind of cheese for generations. In that I’m very unique as a cheese artisan,” he says. “The students come in to learn but I tell them to also teach us something too, add another cheese to my collection.” Read also: <a href="https://nepalitimes.com/here-now/langtang-after-10-years">Langtang after 10 years</a>, Sonia Awale Being a foodie, Driard is now also dabbling in meat with his own charcuterie at Meatini with bacon, ham, sausage and pâtés. All of this is now served at his Emilio’s Pizza, a leafy hideaway in Lazimpat. His South Side in Moksh is probably the smallest wine bar in the world. “I call the process sublime,” says Driard of his ventures, which have grown organically. “You need the same temperature and humidity of 12°C and 80% for cheese, meat and wine.” Emilio’s speciality is the eight-cheese pizza (which has eight types of cheeses), and a pizza with bhutan topping (not the country but fried intestines and organs Nepali-style). He has opened a small branch at Courtyard in Pokhara.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250426070456_bacae302c040dc18eeecdeafda72ddf06a6d2cec138ea9be7e45fe94cdf8b5b3.jpg" data-media-id="editor_8" data-image-id="20250426070456_bacae302c040dc18eeecdeafda72ddf06a6d2cec138ea9be7e45fe94cdf8b5b3" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="8 cheese pizza"> <figcaption>Eight-cheese pizza</figcaption> </figure>  With two artisanal cheese units, two farmers’ markets, a <a href="https://nepalitimes.com/here-now/the-meat-of-the-story">meat processing unit</a>, a bakery, and wine bar he now envisions a vineyard so he can add Nepali wine to his repertoire. Another future plan is to start up an agri-tourism business where customers can drink, eat and work in peace. In the past 20 years in Nepal, Driard has not always succeeded in his ventures but this hasn’t curbed his enthusiasm. He is learning as he goes, and like an old wine, Nepal is growing on him. Its slowness suits his French art de vivre with eating slowly outdoors, having conversation, importing less.&nbsp; “I have proven that with even a little money you can do a lot of things in Nepal,” adds Driard. “In the West, they easily invest half a million euros on a cheese factory, I invested 10 times less.”&nbsp;

Fromage, vin et charcuterie Népalais

Bhuthan भुठान starts with Bishnu Bahadur KC played by <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/dhuwa-smoke-telefilm,2671">Hari Bansha Acharya</a> on a call, requesting to speak to the visa officer. By this point, he had <a href="https://nepalitimes.com/here-now/nepal-should-now-allow-visa-on-arrival">applied for a visa </a>to Bhutan 10 times, but was denied each time. KC was a <a href="https://nepalitimes.com/here-now/nepal-s-women-excel-in-sports-in-2024-z9ramyct">national football player </a>in Bhutan in 1988 before he and other Nepali-speaking Lhotsampa people were forced out of the country in the 1990s as part of the Druk regime’s ‘One Nation One People’ campaign. Over 100,000 Bhutanese Nepalis were forced out, driven across India and dumped in Nepal where they lived in seven<a href="https://nepalitimes.com/here-now/elderly-left-in-bhutan-refugee-camp"> refugee camps</a> supervised by the United Nations and other charities until they were resettled in the United States, Australia, New Zealand and some European countries starting in 2007. In the fictional movie with the satirical English title The World’s Happiest Man, KC has resettled in the state of Ohio in the US but wishes to visit his home country once before he dies. Between flashbacks, we learn KC has died without having fulfilled his wish. &nbsp; The drama then focuses on KC’s two families from two marriages as they debate whether to cremate him as per <a href="https://archive.nepalitimes.com/article/from-nepali-press/muslim-hindu,2996">Hindu rites </a>or give him a Christian burial. A mediator played by Hollywood actor Bruce Dern urges them to take a firm decision before it is too long.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250430140420_b398a08091b866da2b0b8f6c1e6e26781609749aba896bfd2c68a10a519295c3.jpg" data-media-id="editor_5" data-image-id="20250430140420_b398a08091b866da2b0b8f6c1e6e26781609749aba896bfd2c68a10a519295c3" data-rendition-name="original" width="945" height="945" loading="lazy" alt="Bhutan, the movie"> </figure>  There are drawn out scenes of KC being baptised and when he is confronted by his first wife from Darjeeling played by Anuradha Majumdar, he says he changed his religion in the hope that he will be <a href="https://nepalitimes.com/opinion/comment/bhutan-s-refugees-between-hope-and-despair">allowed back in Bhutan</a>.&nbsp; We find out KC has a second wife, a Christian Nepali played by Puja Chand. Dayahang Rai as the younger son doesn’t have much screen time to flex his acting chops. &nbsp; Acharya competently portrays a man that is equal parts haunted by the memories of and longing for his home country. KC’s pain and loss is acute when he is teaching football to Gungun but between mid-scene, he freezes, perhaps lost in memories of being in Bhutan’s national team. &nbsp; In another scene, KC recalls his mother singing a lullaby in Dzongkha. He also has a box filled with medals, photographs and a football which he deflates with a knife in a powerful depiction of his <a href="https://nepalitimes.com/here-now/searching-for-a-homeland-away-from-home?fb_comment_id=1506516030025634">complicated emotions about his homeland</a>. KC keeps checking his mailbox in the hopes that his <a href="https://archive.nepalitimes.com/news.php?id=4977">visa application</a> has been accepted. He says in Nepali: “If a tree that has already struck roots in one place is shifted to another, it will not survive.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250430140420_4a9c27410326489576c04dedf40016bda3825e8f9663317f54fbfec4cbda6d34.jpg" data-media-id="editor_9" data-image-id="20250430140420_4a9c27410326489576c04dedf40016bda3825e8f9663317f54fbfec4cbda6d34" data-rendition-name="original" width="1422" height="2048" loading="lazy" alt="Bhutan, the movie"> </figure>  Dern’s character says that the <a href="https://nepalitimes.com/opinion/comment/nepal-s-transitional-justice-and-the-west-s-recalibration">western world</a> has become “lonely in pursuit of happiness”, another reference to Bhutan’s obsession with its Gross National Happiness index. Scenes shift quickly throughout making the story difficult to follow at times. The use of symbolism is a trite overdone. Nonetheless, भुठान is a nuanced depiction of raw pain and agony of losing one’s homeland. But one cannot help but leave the theatre feeling deflated. KC dies without having visited <a href="https://nepalitimes.com/here-now/small-bhutan-dreams-big">Bhutan</a>, but perhaps he does in his afterlife. It is up to the audience to create its own ending to this sad story of exile. भुठान Mad Monkey Films, 2025 Directed by Binod Paudel 102 minutes In cinemas in Nepal

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