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

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Unique hospital handover in Dolakha

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

Bayalpata Hospital in Nepal wins global design award

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179b9c7e80680e02c286jpeg.jpg" alt="" width="1400" height="905"/><figcaption>IN GOOD HANDS: Community Health Worker Bhajan Kunwar checks patient Namsara Tamrakar at her home in Chandika village of Achham. Pics: Marty Logan and Srawan Shrestha</figcaption></figure>Rounding a steep curve on the road to the district capital of Mangalsen a startling set of modular structures comes into view. The modern buildings look out of place in this scenic, but underserved, region of western Nepal.The construction is part of a $4 million expansion of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">Bayalpata Hospital</a>, a unique medical facility that is a model for public-private partnership to improve medical care in Nepal’s remote interior.Inside the ward, orthopaedic surgeon Mandeep Pathak is examining an elderly man with a swollen knee. Clearly visible on an x-ray monitor is a short pin inserted by a general practitioner a few weeks ago, after the patient fell and broke his kneecap.https://www.youtube.com/watch?v=SuWvlDGasEAIn the same room with the surgeon today is Community Medical Assistant (CMA) Khagendra Pant, who is wrapping plaster around the arm of a small boy. Thanks to training at the hospital, Pant was able to diagnose the boy’s injury as a clean fracture that did not require an operation.Such training means Bayalpata now has to refer just 10-20% of orthopaedic cases to hospitals in Dhangadi and Nepalganj, compared to nearly 70% two years ago.“I am proud to say that all the basic trauma care can now be done by general practitioners. Plus they can diagnose cases and decide which need to be referred to outside centres,” says Pathak.Training is integral to Bayalpata’s mission, says Director of Medical Education <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Bikash Gauchan</a>: his hospital has continuing medical education for clinicians, and on the job training for future nurses and other staff. General practitioners from various centres learn rural surgery at Bayalpata while mid-level staff come to improve their clinical knowledge.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179e9c7e80680e02c287jpeg.jpg" alt="" width="1400" height="650"><figcaption> </figcaption></figure>For some <a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">patients who travel many days</a> to reach Bayalpata, access to basic surgery here means avoiding an expensive trip to the city. People whose limbs were fractured as long as three years ago delayed treatment until surgery was available at the hospital because they couldn’t afford the trip to a city hospital.Treatment at Bayalpata and at another hospital in Dolakha run by the non-profit Possible, is <a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">free</a>. The group believes healthcare is a fundamental human right protected by Nepal’s Constitution, and should have no cost at point of delivery.Possible is funded by donations and Nepal government grants, which will grow as its hospitals attain clinical targets, such as the percentage of women who give birth in a facility with a trained clinician. Operating expenses last year were $4.8 million, of which 9% came from the government.Arrivals are registered in the hospital’s Electronic Health Record (EHR), which puts patients’ information at the fingertips of clinicians throughout the hospital, and eliminates bulky paper records.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a19c7e80680e02c288jpeg.jpg" alt="" width="1400" height="823"><figcaption> </figcaption></figure>One patient already on the EHR is Namsara Tamrakar. Sitting cross-legged on a raised, wooden platform outside her home in Chandika village (left), the elderly woman shows visiting hospital staff that she knows how to use her inhaler, but it is empty.Three years ago, a doctor at Bayalpata diagnosed her with chronic obstructive pulmonary disease and prescribed medicine via inhaler. Now Community Health Worker Bhajan Kunwar (see box, left) visits regularly to follow up. Like others, Tamrakar’s house has a small blue metal tag on an outside wall with a unique household ID. The houses are also geo-tagged.Kunwar’s visit is guided by CommCare, a software developed by Dimagi and customised by Possible that includes counselling information and checklists for each patient. Plans are to integrate CommCare with the EHR so that field followups are immediately reflected in the hospital’s system. Eventually, Bayalpata’s EHR will be linked to a national data system.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a49c7e80680e02c289jpeg.jpg" alt="" width="1400" height="1024"><figcaption> </figcaption></figure>Kunwar takes Tamrakar’s blood pressure: 120 by 80. The woman is happy to hear the news and to see Kunwar again: “She comes, does a check-up, and tells me what sickness I have, and if it is getting better or worse. She insists I go to Bayalpata for a follow-up.”The hospital's <a href="http://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">community health program</a> focuses on maternal and child health as well as non-communicable diseases such as hypertension, diabetes and respiratory ailments. Possible employs 56 community health workers looking after more than 80,000 people in Achham and Dolakha. It is planning to more than quadruple that number next year.Bayalpata Hospital started in 2009, when the group <a href="http://archive.nepalitimes.com/article/nation/Crowding-it-out,1003">Nyaya Health</a> (now Possible) took over an abandoned government facility. Then it had five beds and treated up to 12,000 patients a year. Last year, Possible saw 86,000 patients at Bayalpata: the goal is to treat 150,000 people annually after the new wards, emergency room, administration building, a dormitory and remaining small houses for on-call staff are added.“Our integrated, hospital-to-home approach will be a model for Nepal, and beyond,” explains Gauchan, “and we will be proving that in a resource-limited setting, health care expansion, providing universal health coverage to people is possible.”But is the Bayalpata model really replicable? Skeptics say that two hospitals could have been built for the cost of the new buildings, which feature rammed earth technology, solar energy and rainwater collection, and that only substantial donor support made the expansion possible.Gauchan admits that the initial investment may seem high but says it will be more cost-effective in the long run.He adds: “The existing infrastructure for rural health care is way less than the minimum needed to address the emerging burden of non-communicable diseases and road accidents as well as infectious diseases. That is why we are investing in a very robust infrastructure.”<h2>Community spirit</h2>In 2011, Bhajan Kunwar (pictured above) was living an “Ok” life with her husband Purna and children in Bhageswor village of Achham when her sister-in-law Shavitra asked for a favour.Shavitra had been hearing rumours that her husband, who was working in India, was having an affair or had even remarried. Would Purna take her to India to find out? Purna agreed, and brother and sister set off with a friend. En route, Purna received a phone call from Shavitra’s husband warning them not to come, or there would be trouble.They continued anyway, and after crossing the border got on a train. That night, a group of men, perhaps including police, boarded the train and took Purna away. He later called Shavitra’s husband to say he had been kidnapped and would be killed unless help came quickly.Police found Purna’s body the next morning, on the roadside in Ahmednagar, east of Mumbai. It looked like he had been run over, but Bhajan believes he was murdered.Widowed at 25 and with two small children, Bhajan spent the mourning period worrying about how she would afford to send the children to school, and if her mother-in-law and community would accept her becoming the breadwinner for her husband’s four younger brothers and sisters and their families. (Her father-in-law had died earlier).That month, Bayalpata Hospital had a vacancy for a community health worker for the area. Bhajan was hired and six years later, still visits on foot the more than 700 households in her catchment area, checking that patients are taking their medicines, and much more (see main article).“This hospital made me strong,” she tells us. "Before I didn’t know anyone in my village and I didn’t know so many things.” Now with a college certificate, Bhajan advises young women to get educated before they get married. “I tell them ‘if I can do it, you can do it too’. I believe in myself and don’t care what others say about me. If you are true and honest, no harm will come to you.”Bhajan says she will never forget her husband. “But I have to live for my children, and control my mind and my heart. If I am strong, they can have a regular life. The hospital is now my husband, I cannot imagine leaving it.”Marty Logan in Achham<h2>Operating remotely</h2>When nine-year-old Samir Tamang was bitten by a dog on his way to school in Rayale village of Kavre last week, he had to take a two-and-a-half hour long bus ride to Kathmandu with his grandfather Suk Bahadur Tamang, for a rabies vaccination at Teku Hospital.Samir missed school and his grandfather, who works as a driver in Kathmandu, had to ask for leave from his employers.“We are relatively close to the capital, but imagine what it must be like for people living in remote parts of Nepal where there are no roads,” says Suk Bahadur.Indeed, despite the spread of basic health care in Nepal, emergency treatment and procedures like mending broken bones or caesarean sections are not yet available in rural areas. This means families have to sell property or borrow from moneylenders to be able to afford treatment in the cities. Studies have shown that many Nepali families are driven to poverty if relatives are referred to private hospitals.Unmet surgical needs in remote districts remain a major public health issue in Nepal, according to a recent study in 39 remote area hospitals commissioned by the Nick Simons Institute (NSI).One day this week, an informal survey of patients at the government-run Bir and Teaching Hospitals in Kathmandu showed that a majority of the patients were from remote districts, some as far away as Piuthan and Jajarkot.The NSI study shows that except for caesarean sections in Dolakha, Lamjung and Panchthar, very few government hospitals elsewhere were able to do simple operations of the abdominal cavity, or even mend broken bones.Nepal’s surgery rate falls well below the Lancet Commission target of 5,000 operations per 100,000 population. If the goal is to have a surgical facility within two-hour travel distance for patients, at present only a third of the population can reach an orthopaedic surgeon, and only 22% have access to abdominal surgery.However, the survey reaffirms that the presence of a medical general practitioner (MDGPs who can perform caesarean sections and other relatively simple surgical procedures) can change this. District hospitals with resident MDGPs can eliminate the need for patients to make expensive and extended trips to the cities for treatment.The minimum personnel at a district hospital should include an MDGP, obstretrics doctor, anaesthesia assistant, staff nurse and biomedical technician. However, Nepal’s density of hospitals with such staffing is very low (0.4-3.1 per 100,000) as against the Lancet Commission target of 20 per 100,000 population.“In the long run we need specialists but placing three of them in each district hospital will take a long time. For the next 5-10 years, MDGPs will be the answer to solve surgical problems throughout the country,” explains Anil Shrestha, NSI’s Executive Director.The study recommends an MDGP-led generalist surgical team with proper staff, drugs and equipment to upgrade emergency surgical care in all district hospitals.Adds Shrestha: “The government has to strengthen strategically located district hospitals and make them functional to take care of surgical needs throughout the year. It is entirely possible to do.”Sonia Awale in KavreRead also:<a href="https://www.nepalitimes.com/editorial/poor-health/">Poor health</a>, Editorial <a href="http://archive.nepalitimes.com/news.php?id=17650#.Wrydky5ubIV">Resurrection Accham</a>,  Paavan Mathema<a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">Boy walked eight days to treat broken arm</a>,  Tsering Dolker Gurung<a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">Free-for-all health</a>,  Duncan Maru and Roshan Bista

Marty Logan

State of the art rural hospital

The winter air pollution season started early this year with emissions, Diwali firecrackers and crop residue burning making the air unbreathable across north India. Much of the pollution was transboundary, with prevailing winds carrying the suspended particulates from Pakistan, across India to Nepal and beyond. All this pollution and domestic emissions killed 41,300 in Nepal in 2023, and 85% of all deaths were because of noncommunicable diseases such as heart and lung disease, lung cancer, diabetes, and dementia, according to the State of Global Air (SoGA) 2025 report released Thursday. With the onset of winter, Kathmandu Valley’s own emissions are trapped in a surface inversion layer and as in previous years will have some of the worst air quality in the world.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251023131016_7c42a4e8b0dce01dfeeaaf89dbb10dbfa036b41163f3ebada88c7ce17dbded49.png" data-media-id="editor_0" data-image-id="20251023131016_7c42a4e8b0dce01dfeeaaf89dbb10dbfa036b41163f3ebada88c7ce17dbded49" data-rendition-name="original" width="921" height="850" loading="lazy" alt="Air pollution killing season starts early NT"> </figure>  The SoGa report says air pollution has now become the leading risk factor for deaths in Nepal, ahead of tobacco and high blood pressure. Interestingly, while the health impacts due to environmental risk factors such as unsafe water and sanitation have reduced significantly since 2000, the opposite is true for ambient PM2.5 (particles smaller than 2.5 microns). Globally, 7.9 million deaths were attributable to air pollution– about 1 in 8 deaths – in 2023. Of this total, 4.9 million deaths were attributable to PM2.5 exposure, 2.8 million were from household air pollution, and 470,000 were from ozone. Similarly, dementia attributable to air pollution resulted in 626,000 deaths and 40 million healthy years of life lost. And 95% of air pollution attributable deaths in adults over the age of 60 are due to noncommunicable diseases. The burden of noncommunicable diseases in relation to air pollution is rising worldwide and in Nepal. The SoGA report shows that nearly nine of ten global air pollution deaths are from chronic ailments, and half of all respiratory disease deaths are attributable to air pollution.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251023131020_8577f464b4a73007de5dd018b8ac91dae3a9c732dbb81a44b6aa5a0ced7df3df.png" data-media-id="editor_1" data-image-id="20251023131020_8577f464b4a73007de5dd018b8ac91dae3a9c732dbb81a44b6aa5a0ced7df3df" data-rendition-name="original" width="1080" height="1080" loading="lazy" alt="Air pollution killing season starts early NT"> </figure>  In Nepal, air pollution is responsible for three out of four COPD deaths, one out of three heart deaths and one out of five diabetes deaths. More than one third of lower respiratory infection deaths were due to air pollution. “The data presented in the State of Global Air report highlight the significant impacts of poor air quality on the health and well-being of billions of people around the world, especially those living in Asia and Africa,” says Pallavi Pant of the Boston-based Health Effects Institute (HEI) that released the report in collaboration with the Institute for Health Metrics and Evaluation and the NCD Alliance. She adds: “Growing momentum on air quality management across those hard-hit locations, including expansion of air quality monitoring, adoption of air quality regulations, and sector-specific interventions are yielding improvements for those most impacted.” Low- and middle-income countries stand to gain most by reducing air pollution, with particularly strong impacts on children, older populations, and people with pre-existing health conditions. Indeed, of the 41,300 air pollution deaths in 2023 in Nepal, 31,600 were in adults over the age of 60 years and 3,500 in children below five years. Death rate for air pollution in Nepal, which is 178 per 100,000, is more than 10 times higher than high-income countries, which is at 17 per 100,000.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251023131020_604e852aed4ffde0dc7d1df72fcd3e73d904136dfb1bb2407e53b7445f3ef72c.png" data-media-id="editor_2" data-image-id="20251023131020_604e852aed4ffde0dc7d1df72fcd3e73d904136dfb1bb2407e53b7445f3ef72c" data-rendition-name="original" width="1078" height="423" loading="lazy" alt="Air pollution killing season starts early NT"> </figure>  “Win-win solutions for air pollution and NCDs exist, with added benefits for climate, physical activity, nutrition, and many other global development priorities,” says Alison Cox, Policy and Advocacy Director at the Geneva-based NCD Alliance. “These policies are effective and deliver a strong return on investment - for the sake of our people and the planet we need to implement them faster.” Fine particle pollution (ambient PM2.5) is the largest driver of air pollution’s burden of disease worldwide as kit attributed to 4.9 million deaths and 124 million healthy years of life lost in 2023. Vehicles, power plants, factories, and homes, as well as agricultural and industrial activities, waste burning and wildfires are some of the biggest sources of pollutants. South Asia is among the regions of the world with the highest exposures to ambient PM2.5 , while more than 36% of people around the world live in areas where PM2.5 levels do not meet even the least stringent interim target. As per the report, 78% of Nepal’s 30 million population lives in areas where annual PM2.5 exposure exceeds the least stringent WHO Air Quality Interim Target of 35 µg/m3. Meanwhile, exposure to household air pollution due to the use of solid fuels for cooking remains an important driver for the disease burden in the country. “Ongoing efforts to meet global development goals are not achievable without directly addressing air pollution,” says Maria Neira, Commissioner of Our Common Air. “Countries and cities must focus their efforts toward reducing air pollution emissions, including household air pollution, which has particularly severe impacts on young children and older people across Asia and Africa.”

Air pollution killing season starts early

This year, the <a href="https://nepalitimes.com/opinion/quo-vadis-un-80-9vthn7mg">United Nations is marking its 80th anniversary</a> and it is being celebrated with special events across the world to commemorate its establishment on 24 October 1945. It has also been 75 years since the first UN adviser, the Swiss geologist Toni Hagen, was sent to Nepal to explore development opportunities. In 1950, there were no roads and Hagen walked on foot across the length and breadth of Nepal’s mountains, valleys and plains. This year also marks the 60th anniversary of the United Nations Development Program (UNDP) in Nepal, and much of Hagen’s work laid the basis for the UN’s involvement in education, health, and connectivity in Nepal’s future development. Despite frequent changes in government and political system, Nepal has made remarkable progress. The poverty rate has gone down by half in the past 30 years to 20.27% of the population. Much of it has to do with remittances from Nepalis working overseas, but it is also a result of the Nepal government’s investment in education, health care and social welfare.&nbsp; There have been special initiatives like the Prime Minister’s Employment Program that have provided jobs to nearly 800,000 people in the country’s 743 municipalities — especially in those areas with lower Human Development Index (HDI) like the far-west and the Tarai.&nbsp; This year’s HDI report by UNDP shows that Nepal’s score had risen to 0.622, whereas it was only 0.404 in 1990. In the past 33 years, the average lifespan of Nepalis has risen by 15.6 years to 70.4 years, whereas it was only 54.8 in 1990. However, the country’s HDI ranking is still 145 among the world’s 193 countries. “Yes, there has been significant improvement in living standards in the past 60 years, road connectivity has improved, the maternal mortality rate has gone down dramatically, almost everyone has phones, there are schools,” says Saru Joshi of the thinktank Nepal Policy Institute. But, she adds: “It is still difficult to get citizenship papers, especially in the name of the mother, and this has excluded many women from banking services, inheritance. After all our progress in physical infrastructure, Nepal now needs to prioritise inclusive social development.”&nbsp; Some of this is also happening. Eighteen years ago, Nabaraj Subedi, 49, of a village in Baglung decided not to join his peers &nbsp;fleeing the Maoist conflict to find work overseas. He invested Rs500,000 to buy a diesel generator and start a small furniture business.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251024071044_eeef308e19a73de507a425b2c6afc47269884549cf4c8fac07ca9a4898c8e031.jpg" data-media-id="editor_1" data-image-id="20251024071044_eeef308e19a73de507a425b2c6afc47269884549cf4c8fac07ca9a4898c8e031" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Nawaraj Subedi"> <figcaption>Nawaraj Subedi, 49, proprietor of Tarakhola Furniture Factory. </figcaption> </figure>  Today, with the installation of the 380 kilowatt small hydroelectric plant, he does not need to depend on his unreliable generator to power his equipment anymore. There is now a road connecting his village, and Subedi has generated local jobs, opened a sales branch in the city, and gets orders from as far away as Pokhara and Chitwan. “My costs have gone down drastically because of the electricity, and sales have gone up because of the road connecting my furniture to markets. My business has expanded,” Subedi says. Back in 1960 in a report he prepared for the Nepal government on behalf of the United Nations, Toni Hagen had emphasised just this: investing in electricity generation and connectivity to uplift the remote rural areas of Nepal.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251024081024_188ab121dc3cf2816ee71a72cb3687493eda37ab99ecc04802d647c8c9b4cd2d.jpg" data-media-id="editor_2" data-image-id="20251024081024_188ab121dc3cf2816ee71a72cb3687493eda37ab99ecc04802d647c8c9b4cd2d" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Tarakhola Furniture Factory"> <figcaption>Subedi's staff at the Tarakhola Furniture Factory.</figcaption> </figure>  Subedi’s furniture factory gets its electricity from the nearby Tarakhola Hydropower, a company set up eight years ago with financial and technical support from UNDP’s Renewable Energy for Rural Livelihood (RERL) project. &nbsp; “The project completely transformed living standards in this village,” says municipality chair Dhan Bahadur BK. “It has helped create jobs locally, there is now money to invest in education and healthcare. Households can pay their electricity fees electronically through smart billing.”&nbsp; After working with the government on rural electrification, UNDP is focussed on using that power for local employment creation. A women’s group, for example, has bought an electric-powered potato processing machine that can produce chips.&nbsp; “We are 12 of us mothers, daughters, daughters-in-law who process, package and market the potato that we grow ourselves, and it has raised our income,” says Sukmaya Roka, 57, who chairs the group.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251024071044_70b22418699178bcdd0abb0aa308796980ecd29634bcda6ff113a7624e709751.jpg" data-media-id="editor_3" data-image-id="20251024071044_70b22418699178bcdd0abb0aa308796980ecd29634bcda6ff113a7624e709751" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Sukamaya Roka"> <figcaption>Sukamaya Roka, 57, chair of Sipa Aalu Chips Utpadan Samuha from Tarakhola Rural Municipality, Baglung. </figcaption> </figure>  Today, 6.1 million households in Nepal (92.2% of total) have electricity in their homes, up from 17.9% 30 years ago. Access to electricity has not just brought lights to homes, but improved everything from productivity, quality of education, healthcare and phone connectivity.&nbsp; “To see what electricity and roads can do, just look at our municipality,” says chair Dhan Bahadur BK, “citizens have become more self-reliant, more aware of the outside world.”&nbsp; NETTLES INTO CASH&nbsp; Just a little bit of training, resource backup and local empowerment can uplift the living standards of Nepalis. The progress made in harvesting abundantly-available allo (nettles) and turning it into household products is an example. When a landslide swept away his home and farm in a flood 40 years ago, Buddhi Purja of Parbat became destitute. But he took part in a government training program supported by UNDP and Australia to harvest the wild nettles that grew on mountain slopes and turn the fabric into bags.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251024071048_56c440c478dffbc13911369b6f4133baf658cc3667773cdb44b7c40e006463ce.jpg" data-media-id="editor_4" data-image-id="20251024071048_56c440c478dffbc13911369b6f4133baf658cc3667773cdb44b7c40e006463ce" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Rhitu Saugat Handicraft"> <figcaption>A worker at Rhitu Saugat Handicraft making a bag out of nettles.</figcaption> </figure>  “After the landslide, we had to go hungry if we did not get a day job,” Purja recalls, “but after this training we have found that we can turn nettles into cash.” His allo bags are now hanging in tourist shops in Pokhara Lakeside and Thamel.&nbsp; The idea that nettles can be processed into useful fabric has not spread across the country, and new ecologically conscious consumers in Europe and elsewhere now import Made in Nepal nettle products.&nbsp; Purja started out with an investment of Rs500,000, and had a Rs20 million business that employed 25 workers. The Covid crisis in 2020 affected the sales, but Purja has recovered from it, sent his daughter off to study abroad, and is thinking of diversifying his product range.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251024071044_ab6d15abcbb9a643e12a384f4bc488b7e210a8c95303fbe1b2f77716d26eede9.jpg" data-media-id="editor_5" data-image-id="20251024071044_ab6d15abcbb9a643e12a384f4bc488b7e210a8c95303fbe1b2f77716d26eede9" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Buddi Purja"> <figcaption>Buddi Purja, proprietor of Rhitu Saugat Handicraft in Pokhara.</figcaption> </figure>  While UNDP’s project has made successful businessmen out of people like Purja, nationwide it has created 187,000 jobs in rural medium-scale industries. Much of what has worked in Nepal has been at the community level with decentralised projects like these that use the entrepreneurship of people like Buddhi Purja, Navaraj Subedi, and Sukmaya Roka. It is tantalising to imagine how much more progress Nepal would have made if their work could be replicated nationside and upscaled to the state-level.

Think locally, invest locally

Public anxiety about immigration has become a powerful political currency across many liberal democracies. In Australia, as elsewhere, legitimate concerns about housing and economic fairness can be, and increasingly are exploited by anti-democratic actors who frame migration not as a policy issue but as a cultural threat.&nbsp;
When these narratives move from online spaces to public rallies, they do more than divide opinion; they erode the social trust and pluralism on which democracy depends. Understanding how populist and far-right movements weaponise migration debates is crucial to recognising the early challenging signs of liberal democracy.
Immigration has become one of the most politically charged issues in Australia, not only because of the numbers but because of its entanglement with cost-of-living pressures, housing shortages, and rent spikes.&nbsp;
The latest Household, Income and Labour Dynamics in Australia (HILDA) <a href="https://www.unimelb.edu.au/newsroom/news/2025/september/how-we-live-latest-hilda-data-gives-insight-into-a-changing-australia">data</a> shows rising household financial stress as Australian households spending more on rent and income tax. These changes likely reflect a mix of economic and policy factors but create a lot of room for people to hold inaccurate and occasionally contradictory attitudes on these issues.&nbsp;
While net overseas migration has started to decline from its post-pandemic peak, public concern remains high, amplified by populist rhetoric. Some surveys have <a href="https://www.theguardian.com/australia-news/2025/feb/04/australians-want-less-migration-but-oppose-cutting-international-student-numbers-study-finds">revealed</a> a nuanced picture: most Australians want lower migration overall but oppose cutting international student numbers, and support targeted skilled migration to address workforce gaps.&nbsp;
As former Home Affairs Minister Clare O’Neil <a href="https://minister.homeaffairs.gov.au/ClareONeil/Pages/how-australia-broke-its-migration-system.aspx">argued</a> in 2023, Australia’s migration system is “broken and un-strategic”, not delivering for business, for migrants, or for the larger population. This is a situation that frustrates both sides of the debate and makes immigration an easy political flashpoint.
The recent <a href="https://marchforaustralia.org/">March for Australia</a> rallies turned these anxieties into street-level mobilisation. Tens of thousands <a href="https://www.bbc.com/news/articles/czjmre371l1o">protested</a> at what they called ‘mass immigration’, while far-right groups seized the opportunity to inject xenophobic slogans and calls for ‘remigration’ into the public space. These demonstrations were not only about visa caps or housing and jobs; they became performances of who is entitled to belong.&nbsp;
When immigration is framed not as a policy question but as a cultural test of Australianness, it risks shrinking the demos, the very community that democracy is meant to represent.
What made the March for Australia so striking was not only its size but its composition. Recent investigative reporting <a href="https://www.theage.com.au/politics/victoria/don-t-mention-hitler-and-you-re-sweet-the-great-march-for-australia-deception-20250909-p5mtlc.html">revealed</a> that neo-Nazi groups were not merely present at the March for Australia rallies but played a role in covertly organising them. They amplified messaging online, coordinated attendance, and sought to mask their involvement to broaden appeal.&nbsp;
This highlights that democratic erosion is rarely spontaneous; it requires actors who deliberately exploit social grievances, mistrust, and polarisation to mobilise anger for their anti-democratic ends. The banners reading ‘<a href="https://www.theguardian.com/commentisfree/2025/sep/01/how-do-i-feel-safe-after-march-for-australia-anti-immigration-protest-ntwnfb">Stop Immigration</a>’ revealed that public hostility towards migrants, <a href="https://www.afr.com/politics/federal/pressure-mounts-for-price-to-apologise-to-indian-australians-20250908-p5mt7x">particularly</a> from the Indo-Pacific, is growing.
For many migrants, these displays are more than conceptual debates about white national identity. They are experienced emotionally. Writing shortly after the rallies, Melbourne-based writer Jafrin Kabir <a href="https://www.theguardian.com/commentisfree/2025/sep/01/how-do-i-feel-safe-after-march-for-australia-anti-immigration-protest-ntwnfb">reflected</a> that she had never felt so foreign on Australian soil. She pays taxes and inflated rents, contributes skills in the national interest, cheers for the Tillies and calls Melbourne “home”, yet suddenly felt unsafe because of the origin and colour of her skin.&nbsp;
Similarly, Chinese national interviewed by media outlet <a href="https://www.scmp.com/news/china/diplomacy/article/3325127/i-feel-insecure-chinese-nationals-australia-blindsided-anti-immigration-marches">reported</a> cancelling weekend plans and feeling “blindsided” by the scale of the marches.
Scapegoating migrants especially in times of economic stress is an age-old phenomenon and is not just limited to Australia. Across the democratic world, from the United States to the UK and parts of Europe, hostility toward migrants and minorities has become a route for anti-democratic forces. Populist actors often <a href="https://www.theguardian.com/australia-news/2025/mar/27/peter-dutton-keeps-blaming-migration-for-the-housing-crisis-but-can-it-really-be-that-simple">use</a> cultural anxiety and demographic change to justify illiberal and undemocratic measures, claiming to restore order while actually dismantling checks and balances.
By analysing democratic decay, scholars like Lydia Khalil at the Lowy Institute, <a href="https://interactives.lowyinstitute.org/features/democratic-erosion/">argue</a> that democracies rarely break down at once. Instead, they incrementally weaken through vicious cycles: declining trust in institutions, entrenched division based on hate, the normalisation of political violence, and the bit by bit removal of norms and guardrails.&nbsp;
Though some of the conditions are present in Australia to be exploited by anti-democratic actors, for example, almost two-thirds of Australians believe their leaders intentionally mislead them, according to the <a href="https://www.edelman.com/au/trust/2025/trust-barometer">2025 Edelman Trust Barometer</a>, &nbsp;but their presence is not determinative.
Australia’s democratic guardrails remain strong: independent courts, transparent elections run by the AEC, and a free press continue to hold power to account. Federalism and active civil society further diffuse power and create space for contestation.&nbsp;
But if public trust continues to erode and social divisions deepen, these safeguards will come under strain. Early recognition and action are crucial to ensure that today’s street-level hostilities do not translate into institutional regression.
Preventing such outcome requires a socially embedded understanding of migration, an understanding that goes beyond simplistic optimistic and pessimistic views. Policy makers should go beyond Push-Pull models, functionalist and neoclassical and historical-structural theories.&nbsp;
Consulting the work done by <a href="https://www.guilford.com/books/The-Age-of-Migration/Haas-Castles-Miller/9781462542895#:~:text=International%20Population%20Movements%20in%20the%20Modern%20World,-Hein%20de%20Haas">Hein de Haas</a> et-el, migration should be conceptualised as an intrinsic part of broader processes of development, social transformation and globalisation rather than a 'problem to be solved'. We need more nuanced views that have an eye for the complexity of migration processes and the diversity of its causes and impacts.
Sohail Akhtar is a Melbourne- based researcher focusing on governance, public policy, and migration. He contributes to Lowy Institute Sydney.
This article was issued by the Toda Peace Institute and is being republished from <a href="https://toda.org/global-outlook/2025/is-street-level-hostility-a-challenge-to-liberal-democracy-reflections-from-australia.html">the original</a> with their permission.

Is street-level hostility a challenge to liberal democracy?

Intricately painted Buddha, Aryatara, Krishna, and Parvati gaze serenely at visitors at the Kathmandu Art Gallery under muted amber lights. Moving from one artful devotion to the next, a quiet, profound connection to the divine envelopes the visitor. This transcends art to the realm of the spiritual. &nbsp; The gallery’s latest exhibition, Masters of Devotion, features art by 22 artists all from Bhaktapur. They also include Ajay Karmacharya, Purna Prasad Hyoju, Nhuche Kaji Bajracharya, Rajani Sinkhwal, Shashi Dhar Sainju, Surya Bahadur Chitrakar and Sundar Sinkhwal from the Khowpa Paubha Chowmi Pucha. Paubha are religious and devotional art depicting deities and mandala that date back to the 7th century, when Newa artists began to paint images of the gods on cloth. For the artists who practice this craft, the art form is as meditative as it is meticulous.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251025041028_de34b51d48bcee50ae391301e2ff1890be7ecba3df7e563537c273818825aad5.jpg" data-media-id="editor_0" data-image-id="20251025041028_de34b51d48bcee50ae391301e2ff1890be7ecba3df7e563537c273818825aad5" data-rendition-name="original" width="1280" height="960" loading="lazy" alt="art review "> </figure>  The exhibition at the newly-opened space Kathmandu Art Gallery coincides with the festival season and is a collection of extravagant works done in mineral and stone colour, sakura and gouache. The vintage art space is located at Babar Mahal Revisited and is a fitting accompaniment to the paubha featured in the exhibit.&nbsp; Sundar Sinkhwal’s vividly painted Harihara is among the more eye-catching works. “Half of the painting is Shiva and half is Vishnu, hence the name Harihar,”explains Sinkhwal. “Together with their consorts Parvati and Laxmi, I have painted Uma-Maheswor and Laxmi-Narayan.” Nandi and Garuda, the vehicles of the two gods, complete the vibrant painting.&nbsp; In contrast, for his piece titled Lakshmi, Sinkhwal shrouds his canvas in dark colours to paint Kuber, the deity revered as the custodian to the wealth in the Hindu pantheon, accompanied by two khyak apparitions —one black, the other white— both mythical creatures in Newari folklore.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251025041032_1bde6de442b742c300bb8c9278ea8886445aa8df47076fd9aa362ce1f8bef903.jpg" data-media-id="editor_1" data-image-id="20251025041032_1bde6de442b742c300bb8c9278ea8886445aa8df47076fd9aa362ce1f8bef903" data-rendition-name="original" width="1280" height="960" loading="lazy" alt="art exhibition"> </figure>  “The black khyak is considered inauspicious, while white ones are a symbol of good luck,” explains Sinkhwal. Purna Prasad Hyoju has used mineral paint on canvas for a powerful depiction of Ardhanareswar, the composite form of Shiva and his consort Parvati.&nbsp; “I drew inspiration from the Newari Swasthani story about the separation of Shiva and Satidevi,” says Hyoju. Legend has it that Shiva, unwilling to part from his consort, reincarnated as a unified dual gender form of himself and Parvati. Hyoju has painted goddess Parvati in bright yellow, in homage to one of her other manifestations, Gauri, which means radiant.&nbsp; Meanwhile, Ratna Gopal Sinkhwal’s Kurkula Devi, done in stone pigment, is radiant on the cotton canvas. “Kurkula Devi is a tantric goddess whose traces are found in the Sadhana Mala,” says Sinkhwal. “The stone pigment is what makes the goddess look like she is gleaming.” One of Sinkhwal’s other works draws from stories in the Mahabharat to depict Bhimsen, Draupadi, Dushasan and Akash Bhairav in confrontation, expressions fierce.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20251025041028_72eea52c8504eccb8b3be7cd4cef616dfb8efd821e8b1e1ae8f440f10782be11.jpg" data-media-id="editor_2" data-image-id="20251025041028_72eea52c8504eccb8b3be7cd4cef616dfb8efd821e8b1e1ae8f440f10782be11" data-rendition-name="original" width="1280" height="854" loading="lazy" alt="art exhibition"> </figure>  The opening of the exhibition last week also featured a music session, during which some of the artists sang traditional songs. Their voices joined the rhythm of the madal and melody of the harmonium, adding warmth to the crisp autumn evening.&nbsp; Each painstakingly detailed paubha reflects the artists’ devotion to divinity and mythology, as well as their heritage. Masters of Devotion showcases the work of veritable masters of their craft, and is a must-visit for art connoisseurs and devotees alike. Says the gallery’s Sangeeta Rana Thapa: “It is our honour to celebrate the artists’ work—to stand among pieces that embody both devotion and mastery, and to witness a tradition that continues to inspire us.” Masters of Devotion Kathmandu Art Gallery Baber Mahal Revisited Until 22 November