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;

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Saving one Nepali mother at a time

Pratikshya Roka Magar was a sickly baby ever since she was born in a faraway village in Rukum district. As years went by, the girl’s spine started to bend. Her mother Namrata Roka had given up hope that her daughter would ever get better when she heard about a Japanese doctor who was conducting a mobile health camp in the village.&nbsp; Partikshya was seven years old in 2013 when Japanese physician Ryukichi Ishida examined her, and diagnosed a rare case of spinal scoliosis that ultimately affects the lungs and heart.&nbsp; Now 17, Pratikshya has undergone six major operations in which two rods were inserted to her spine to straighten it. The Japanese benefactor has since been supporting her financially, and checks up on Pratikshya routinely.&nbsp; Read also: <a href="https://www.nepalitimes.com/here-now/nepali-doctors-love-for-urdu-poetry">Nepali doctor's love for Urdu poetry</a>, Abdullah Zahid  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_da4e6800792c2aba1c4f41e664f24db51fbc25142c2e41e46b77e2da9d602f29.jpg" data-media-id="editor_1" data-image-id="20230817070836_da4e6800792c2aba1c4f41e664f24db51fbc25142c2e41e46b77e2da9d602f29" data-rendition-name="original" width="1504" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: SUMAN NEPALI</figcaption> </figure>  “He is like god for us,” says a grateful Namrata. &nbsp; Pratikshya is not the only one who has received Ishida’s healing touch in these mountains where the health system is still rudimentary, and the ravages of the Maoist conflict still linger. During voluntary work with tuberculosis control while walking through Nepal’s remotest districts in 1968 as a 21-year-old medical student, Ryukichi Ishida made a promise that he would return one day to serve the people of this country. Back in Japan, while heading the orthopaedic department at Osaka's Ueda-Shimotanabe Hospital, he constantly felt the tug of Nepal. In 2006, he left his family and a satisfying job to fulfil his pledge to return to Nepal. A question that had nagged him all those years was why medical care around the world, including in Japan and Nepal, was not more equitable. Read also: <a href="https://www.nepalitimes.com/news/paul-farmer-on-my-mind">Paul Farmer on my mind</a>, Bibhav Acharya  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_6a2d16dbb69aaaf7f900a41835ca9e091d427f2de37a1411b5df7199749fcf6c.jpg" data-media-id="editor_3" data-image-id="20230817070836_6a2d16dbb69aaaf7f900a41835ca9e091d427f2de37a1411b5df7199749fcf6c" data-rendition-name="original" width="1494" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: JHUMLAWANG VILLAGE FOUNDATION NEPAL</figcaption> </figure>  Ishida was inspired by his physician father who also ran a clinic in the most underserved part of Japan. He has travelled through Dolakha, Jumla, Jajarkot, Rukum and Rolpa, conducting free medical camps carrying just a backpack — just like when he trekked through Nepal as an idealistic student all those years ago. He has been working at Rolpa's Jaljala Health Post since 2011, a place so remote that even Nepali health workers are reluctant to be posted there. The facility has since been turned into a hospital and research centre and is in the process of becoming a 15 bedded municipality hospital.&nbsp; The hospital has Nepali staff, but none of them stay more than a year. “The only thing constant here is Dr Ishida and his commitment to serve the people,” says Ajay Magar of the Jhumluwang Village Foundation, a non-profit that conducts health camps in collaboration with Ishida.&nbsp; Read also: <a href="https://www.nepalitimes.com/review/the-good-doctor-0pqhzm7t">The good doctor</a>, Lisa Choegyal  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_909cd240e9e4ea3b0da86e6038a2a163f6d5e9e94df5117008cbdbf0cf8946f6.jpg" data-media-id="editor_5" data-image-id="20230817070836_909cd240e9e4ea3b0da86e6038a2a163f6d5e9e94df5117008cbdbf0cf8946f6" data-rendition-name="original" width="1531" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: JHUMLAWANG VILLAGE FOUNDATION NEPAL</figcaption> </figure>  Besides treating patients, Ishida has also supported locals like Sahanshila Buda Magar who is the first female MBBS graduate from Thawang thanks to a scholarship he provided.&nbsp; Sahanshila, 27, got her degree from Changsha Medical University in China, and is undergoing a three-month training at Patan Hospital. She plans to go back home and work at the Jaljala Hospital. &nbsp; Ishida says the staffing challenges of remote area facilities in places like Rolpa can only be met by producing their own crop of young doctors with a commitment to the place they belong.&nbsp; Despite his years of experience as an orthopaedic surgeon, Ishida believes in integrating modern medical practices with traditional healing, especially for bone-setting and birthing. Read also: <a href="https://www.nepalitimes.com/banner/nepals-far-sighted-eye-care">Nepal's far-sighted eye care</a>, Sonia Awale  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_03aa6692c46a7850cb8d05acb0e89f7928a5dab973fcfa466ab9417fcd85c165.jpg" data-media-id="editor_7" data-image-id="20230817070836_03aa6692c46a7850cb8d05acb0e89f7928a5dab973fcfa466ab9417fcd85c165" data-rendition-name="original" width="3711" height="2770" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo courtesy: RYUKICHI ISHIDA</figcaption> </figure>  The only reward Ishida has for his work is the respect and affection of Thawang's people. Villagers refer to him simply as “हाम्रो डाक्टर” (our doctor) — indicating they have ownership over a surgeon who they consider to be rightfully theirs. That same recognition is not reflected in the way the Nepali state regards Ishida. Now 76, and increasingly frail, Ishida has applied unsuccessfully for honorary Nepali citizenship. His visa requires Ishida to make frequent expensive trips back to Japan, and says he no longer wants to go back and forth.&nbsp; When he is away on his visa run, Rolpa’s villagers count the days for Ishida’s return so they can be treated. The surgeon does not take a salary, lives frugally and depends on the Jaljala Hospital for food and lodging.&nbsp; “I was born in Kobe, but I want to die here in Thawang,” says the soft-spoken Ishida. “This is my home now.” Read also: <a href="https://www.nepalitimes.com/here-now/an-eye-for-two-eyes">An eye for two eyes</a>, Yugottam Koirala

Pinki Sris Rana

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The barefoot doctor of Rolpa

It is nearing 6PM and Mandeep Pathak is on the daily evening round of the in-patient ward at <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital">Bayalpata Hospital</a> in Achham District. The section is crowded with patients young and old.&nbsp; Most have respiratory problems, women with limbs broken in falls from cliffs, some have diabetes, and there is a psychosis patient in an isolation ward. There is wailing from the delivery room of the maternity ward. Pathak’s mobile phone buzzes. He listens, and rushes off to the emergency room. A crowded tractor has fallen off the road and there are mass casualties. The wounded soon arrive, and Bayalpata’s staff go into practised triage mode.&nbsp; The team declares a 12-year-old boy dead on arrival. Others are rushed into x-ray and readied for splints and plaster casts. Some are discharged after treatment to join crowds of waiting relatives outside. Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f.jpg" data-media-id="editor_2" data-image-id="20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f" data-rendition-name="original" width="1400" height="823" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Orthopaedic oncologist Mandeep Pathak consulting a patient at Bayalpata. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  Patients in this isolated hospital in a corner of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">one of Nepal’s most remote districts</a> are from all over Sudur Paschim and Karnali Provinces. One 8-year-old girl with a broken arm has been brought here by her father from Humla, after walking four days to get to a road. In the 14 years since it was established, word has spread that Bayalpata provides high quality service free of cost, and the hospital is treating 100,000 patients a year with a team of dedicated staff, surgery, lab, pharmacy and a high dependency unit.&nbsp; In the maternity ward is a 35-year-old new mother who is quietly taking her supper. She has a shining smile as her husband fusses over her. They are now happy parents of twin boys, their fourth and fifth children.&nbsp; A few beds away is another young mother recuperating from a caesarean delivery. The husband is not happy — the baby is a girl and they already have two daughters. Hospital staff try to persuade him to get a vasectomy, but he still wants to try for a son.&nbsp; Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, Editorial Unlike private hospitals in Nepal, some of which have up to 80% caesarean deliveries, at Bayalpata most births are natural. Doctors do caesareans only on complicated deliveries, or on referral patients. In one recent case a 17-year-old mother died <a href="https://www.nepalitimes.com/here-now/born-by-the-roadside-in-nepal">on the way</a> to Bayalpata from Bajura district. She had twins, only one of whom survived. Another woman who was 30 weeks pregnant suffered a stillbirth, but because it was a girl, the mother-in-law and husband did not look too perturbed.&nbsp; A mother who gave birth after a difficult delivery was nearly bleeding to death from postpartum haemorrhage. While doctors tried frantically to save her life, the family was celebrating the birth of a son.&nbsp; Despite improved literacy, patriarchy is still entrenched in these remote mountains of far west Nepal. Boys are sent to school while girls help with house chores and raise their little brothers. When children fall sick, the boys are likely to be taken to an expensive private hospital in Dhangadi, while girls are brought to free institutions like Bayalpata. 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 <div class="embed-block"><div><div style="left: 0; width: 100%; height: 0; position: relative; padding-bottom: 56.25%;"><iframe src="//cdn.iframe.ly/api/iframe?url=https%3A%2F%2Fwww.youtube.com%2Fembed%2FCJzWlnYd0ZM&key=87ca3314a9fa775b5c3a7726100694b0" style="top: 0; left: 0; width: 100%; height: 100%; position: absolute; border: 0;" allowfullscreen scrolling="no" allow="accelerometer *; clipboard-write *; encrypted-media *; gyroscope *; picture-in-picture *; web-share *;"></iframe></div></div></div> “The paradox here is that girls are getting world-class treatment while boys have to settle for less than optimal healthcare at private facilities,” says Mandeep Pathak, one of few orthopaedic oncologists in Nepal who has been working at Bayalpata for eight years. Pathak examines a 14-year-old girl from Mugu on whom he operated to remove a benign but complicated tumour that had restricted her mobility for the past two years. As he does his evening rounds, Pathak tells us: “Our patients are among the poorest and neediest and from the <a href="https://www.nepalitimes.com/editorial/devolution-for-development">remotest part of the country</a>. They would not have got a correct diagnosis, let alone get timely and affordable treatment otherwise.”&nbsp; The only cost families have to bear is for transport to the hospital. The hospital even provides free food for one relative accompanying the patient. Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar Budathoki  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e.jpg" data-media-id="editor_10" data-image-id="20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Program Associate Bhawana Bogati during a community visit.</figcaption> </figure>  <h2>Community Care</h2> Bayalpata Hospital is managed by the non-profit <a href="https://www.nyayahealthnepal.org">Nyaya Health Nepal (NHN)</a> in partnership with the provincial and municipal governments.&nbsp; Although the hospital gets much of the attention, NHN’s emphasis is on the community that provides door-to-door care to families in Achham. There are up to two <a href="https://www.nepalitimes.com/news/enlisting-female-health-volunteers-to-fight-covid-19-b4qlgy1e">Community Health Workers (CHW) </a>for every ward who regularly visit families to monitor the condition of pregnant women, provide ante-natal care, or check up on those with chronic conditions. This reduces the pressure on the hospital, and also saves families money.&nbsp; CHW can even assist while community nurses perform lab tests including for HIV, hepatitis, urine, sugar, protein, pH level, haemoglobin so patients do not have to come to hospital. The nurses even provide psycho-social counselling, since mental health is still not discussed openly. Aside from healthcare, the female CHWs also demonstrate the important role women can play in this socially conservative society. Jamuna Saud, a 24-year-old CHW, is visiting families in the village of Patalkot, and recording data of patients on her Electronic Health Record app that provides physicians at Bayalpata with instant information on the medical condition of patients in case they need to be taken to hospital. “We are still a male-dominated society here, as you can see, but things are improving,” says Saud, as she climbs up the trail to another family’s homestead. “I have seen families sending daughters to school because they see us being respected for our job. They are starting to treat their own daughters better.” Read also: <a href="https://www.nepalitimes.com/banner/altruistic-healthcare-models-in-nepal">Altruistic healthcare models in Nepal</a>, Yugeshwor Koirala and Yugottam Koirala  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae.jpg" data-media-id="editor_14" data-image-id="20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Bayalpata Hospital"> <figcaption>In 14 years, Bayalpata hospital has treated 1.2 million patients free of cost. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  The work of NHN’s community health program is already seen in Achham district’s health parameters. After a dip during the pandemic, institutional deliveries have climbed again to 80%, and this has sharply reduced <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal">maternal and child mortality</a>.&nbsp; “Mother and child health is our main focus and ensuring that we follow the progress of pregnant women means most now go to Bayalpata to deliver,” says Program Associate Bhawana Bogati, 28.&nbsp; The hospital which recently marked its 15th anniversary has so far treated 1.2 million people free of cost, and sustainability continues to be the biggest challenge for Bayalpata’s public-private partnership with the local government. Half the annual budget still comes from international donors. But more than anything else, Bayalpata is a working example that free quality medical care is possible. Other government district hospitals have larger budgets, treat fewer patients and charge fees. Given the remoteness of Achham, the other challenge is retention of doctors and paramedics. Flights to Sanfebagar are unreliable, and a jeep ride to Dhangadi takes 10 hours. Says surgeon Bhaskar Pant of HAMS Hospital in Kathmandu and a board member of NHN: “Bayalpata is a rural lifeline, we need hospitals like these in the remotest corners of Nepal and to run them we need medical staff who are willing to be posted here.” &nbsp;&nbsp; Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health">Taking wealth out of health</a>, Anita Shrestha Jamuna Saud  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301.jpg" data-media-id="editor_17" data-image-id="20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  Her baby son is only nine months old, but Community Health Worker (CHW) Jamuna Saud is already back to making door-to-door visits to advise other expecting mothers about safe delivery. Her visit today to Patalkot village, a 3 hour drive through rough roads from Bayalpata, is hindered by a sudden thunderstorm, but she is not bothered. “You need to eat for two now, it will not be good if you skip meals,” says Saud as she counsels Pabitra Auji who is six months pregnant with her first baby and looks undernourished. “Fruits, leafy vegetables, meat and egg, and don’t forget to take your iron capsules.”&nbsp; Saud has been a CHW for four years. She had originally wanted to be a doctor or a nurse, and was a class topper in school, but her family could not afford medical school fees. Moreover, young women in her community were expected to get married, not go to college. “Mine was the only family in the neighbourhood that let girls go to school,” recalls Saud. “But my parents passed away when I was in the 9th grade and my brothers were not planning to educate me further. I cried until they admitted me to +2.” Saud moved to Sanfebagar and paid her own way through college, supporting herself by doing odd jobs. She is happy to have been accepted by Bayalpata’s <a href="https://archive.nepalitimes.com/news.php?id=19559">community health program</a>, and feels a personal sense of achievement that childhood diarrhoea, malnutrition and respiratory infections among babies is decreasing, while more women accept family planning advice. Over the years, Saud has seen changes among women like her in Achham. Girls are no longer restricted to just doing housework and producing babies. She says, “I am proud to have contributed to raising the living standard of people here even if by the tiniest bit.” Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial Ramita Bogati  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7.jpg" data-media-id="editor_20" data-image-id="20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  The story of Florence Nightingale was the inspiration for Ramita Bogati, who always wanted to be a nurse herself. Back in her village, girls were actively discouraged from going to school, and were married young so as not to be a drain on the family. “My parents did not actually want to send me to a school but my mother’s side of the family were educated, and many of them were in medicine,” says Bogati. “But I had to prove myself to change my father’s perceptions about what women should be allowed to do.” Today, Bogati is one of 10 Community Health Nurses at Bayalpata overseeing 70 community health workers with her colleagues. Her passion for the job and the importance of the service she provides is all the encouragement she needs. She does not envy her staff nurse classmates who have flown to Australia and other countries. &nbsp; On a typical day, Bogati is involved in early detection of chronic and infectious diseases, tuberculosis and hypertension so that the poorest in the community do not have to borrow money for treatment or, worse, have their lives shortened due to the lack of diagnosis and treatment. Bogati has seen tangible <a href="https://archive.nepalitimes.com/news.php?id=14071">impact</a> of her work in birth spacing. In the past, women here used to give birth to as many as 15 children, and most died young. Now, they give birth to fewer but healthier children. “As a nurse, the concept of community health was new to me but I have seen that we need to look beyond those who are able to come to Bayalpata. If they cannot come to hospital, the hospital needs to go to them.” Read more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

Nepal’s rural lifeline

<figure><img width="960" height="720" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdc59c7e80680e0a0c02jpeg.jpg" alt=""/><figcaption>Suman Thapa conducting an eye examination on a patient at Chaurjhari Hospital in Rukum, where EK Ek Paila is working with the local government. Photos: EK EK PAILA</figcaption></figure>It is the aftermath of disasters that <a href="https://www.nepalitimes.com/here-now/lockdown-brings-out-the-best-in-nepalis/" target="_blank" rel="noopener noreferrer">bring out the best among Nepalis</a>. And so it was after the <a href="https://www.nepalitimes.com/latest/reviewing-lessons-of-the-2015-nepal-earthquake/" target="_blank" rel="noopener noreferrer">2015 earthquake</a>, volunteer groups sprang up spontaneously and organised relief through social media.Among them was a loosely structured group of like-minded Nepalis who used their medical expertise to provide emergency help to areas destroyed by the earthquakes. But while many such volunteer groups faded away, the volunteers continued to expand their work — calling themselves Ek Ek Paila (one step at a time).“After seeing the devastation in 2015, I thought it’d be best to use my expertise to provide medical help and do more rather than just provide relief,” says <a href="http://archive.nepalitimes.com/news.php?id=11828#.YSRhqS8w3u0" target="_blank" rel="noopener noreferrer">Suman Thapa</a>, an ophthalmologist who helped set up Ek Ek Paila.  Now, with the pandemic, Ek Ek Paila has been trying to bring health services to parts of Nepal which have rudimentary medical care even at the best of times. “After hearing about infected people having virtually no access to Covid-19 treatment in rural areas where we had previously held health camps, we created a Covid Health Package and took it to them,” Thapa adds.<a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/">Rural Nepal fights back Covid-19</a>, Masta KC <figure><img width="1000" height="745" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdc89c7e80680e0a0c03jpeg.jpg" alt=""><figcaption> </figcaption></figure>The package consists of medication, relevant information, and a direct hotline to volunteer doctors to answer any questions they might have about symptoms, tests and vaccines. The demand for the packages has now snowballed, with local governments in more districts approaching for help. Ek Ek Paila raised Rs7 million for the distribution of the Covid Health Packages — all from local donations. In fact, that is what makes the non-profit different from most other charities in Nepal, it relies almost completely on donations from Nepalis. “If foreigners and international organisations want to donate to Ek Ek Paila, we do not say no,” Thapa explains. “But 99% of the funding for Ek Ek Paila comes from local donors.” The fact that Thapa is also an accomplished musician, and a lead guitarist in the band ‘The Blue Fret’ helps with fund-raising concerts. “I had always wanted to be a musician, and being a doctor was actually the next best thing for me,” admits Thapa, grinning through his mask during a recent interview at Ek Ek Paila’s new Community Health Centre in Kathmandu.Ek Ek Paila had a humble start after the earthquake six years ago. Thapa contacted some friends and found fellow doctors who committed to spending one weekend a month for a year to provide medical care to <a href="http://archive.nepalitimes.com/blogs/kundadixit/2015/05/18/survivors-help-survivors/" target="_blank" rel="noopener noreferrer">survivors</a> in remote villages <a href="https://www.nepalitimes.com/banner/langtang-copes-with-quake-and-covid/" target="_blank" rel="noopener noreferrer">badly hit by the earthquakes</a>. In the first year alone, Ek Ek Paila organised 12 health camps in Sindhupalcok, Dolakha, and other districts. <figure><img width="1000" height="707" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdcb9c7e80680e0a0c04jpeg.jpg" alt=""><figcaption> </figcaption></figure>Nepal’s mountainous terrain has posed a <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener noreferrer">significant challenge in health care delivery</a>, made worse by government neglect and poor governance, and exacerbated during crises like the earthquake and pandemic.   All medical professionals who volunteered at health camps paid for their own trips, equipment, and even for the medicine that they prescribed. But after the 12 health camps, the regular volunteers decided to officially register Ek Ek Paila, creating a Nepali-driven and funded organisation to expand its services. Today, volunteer doctors and medical personnel also perform surgeries, including <a href="https://www.nepalitimes.com/banner/nepals-far-sighted-eye-care/" target="_blank" rel="noopener noreferrer">complex eye operations</a>, in rural health camps and carry more equipment with them, increasing diagnostic accuracy. Ek Ek Paila’s camps have become mobile primary health care centres.   <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 “What has made our work easier despite the political paralysis in Kathmandu is that with federalism, local governments are empowered and collaborate in holding health camps,” says Thapa, who has experience with rural health camps organised by <a href="http://archive.nepalitimes.com/article/Nepali-Times%20Buzz/sanduk%C2%ADruit%C2%ADtilganga,2574" target="_blank" rel="noopener noreferrer">Sanduk Ruit</a> of the Tilganga Institute of Ophthalmology.  Local governments top up the donations from the Ek Ek Paila members themselves and other local funding to run the camps. They provide Ek Ek Paila teams of 30 or so people with accommodation and two meals a day. They also help organise the space in which the health program is conducted and help disseminate information.  <figure><img width="1000" height="705" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdcf9c7e80680e0a0c05jpeg.jpg" alt=""><figcaption> </figcaption></figure>Ek Ek Paila also collaborates with other non-profits like Sparsha Nepal and the ear-nose-throat surgery specialists, Impact Nepal. Ek Ek Paila’s new non-profit Community Health Centre in Thapathali provides affordable health care to those who cannot afford hospital fees. With the flow of patients increasing, and the challenge of making the centre sustainable a tier system for small consultation fees subsidises free treatment for those who cannot afford it.The Community Health Centre was funded through private donations, including the building itself which belongs to one of the founding members. Overhead costs are low because medical personnel all volunteer their services. Besides the vital service it provides, Ek Ek Paila has also led by example to foster <a href="https://www.nepalitimes.com/here-now/youth-led-feeding-campaign-spreads-across-nepal/" target="_blank" rel="noopener noreferrer">volunteerism and philanthropy among Nepali </a>individuals and companies. Foreseeing the<a href="https://www.nepalitimes.com/banner/vaccines-variants-and-a-third-wave/" target="_blank" rel="noopener noreferrer"> third wave</a>, Ek Ek Paila is expanding its Covid Health Packages to reach more people in hard-to-reach places. The non-profit also is in talks to manage primary health centres in Jajarkot and Sindhupalchok districts. Says Thapa: “Ek Ek Paila has brought Nepalis together from all walks of life, it has helped people in need of affordable health care and given donors and volunteers a sense of satisfaction for having contributed. As for me, this is the most fulfilling thing I have done in my life.”To donate to <a href="https://www.ekekpaila.org/" target="_blank" rel="noopener noreferrer">Ek Ek Paila</a>: <a href="https://www.ekekpaila.org/page/5/donate" target="_blank" rel="noopener noreferrer">https://www.ekekpaila.org/page/5/donate</a>

Step by step for rural health care in Nepal

<figure><img width="760" height="486" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914114/636ba5ae9c7e80680e0736dajpeg.jpg" alt=""/><figcaption>Govinda KC, Nepal’s crusading surgeon and health activist, plastering a patient's ankle at the Mugu District Hospital on Sunday. He saw 177 patients for free in five days before travelling on to Jumla on foot. Photos: ACHYUTRAJ BHANDARI</figcaption></figure>Health reform <a href="https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNFQK2JWnimNdv8w4s23TLpC78KGKQ">activist Govinda KC</a>, who has been on 17 hunger strikes to pressure the government to make medical care more affordable, has been holding free clinics for patients in hospitals and COVID-19 isolation wards in western Nepal ever since the pandemic started.KC arrived in Gamgadi on 5 August after walking two days from Jumla, and immediately started free consultations with patients, performing emergency operations at the Mugu District Hospital. He has seen 177 patients since then, and performed three operations.<a href="https://archive.nepalitimes.com/regular-columns/One-To-Many/Truth-be-told%20,749" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/regular-columns/One-To-Many/Truth-be-told%2520,749&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNFtSQBKZtB-vcam4Nsz2wAtqOnl4A">KC is himself an orthopaedic surgeon</a>, and has made it his life’s mission to make medical care free and accessible to the Nepalis who need it the most. His hunger strikes were protests against <a href="http://archive.nepalitimes.com/blogs/kundadixit/page/5/" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/blogs/kundadixit/page/5/&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNHY_jV_4K2jz-1PFUWl9VPIgc1DvA">government interference in the health sector</a>, and <a href="http://archive.nepalitimes.com/article/editorial/Kleptocracy-kills,3161" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/article/editorial/Kleptocracy-kills,3161&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNH9lmHQky6NGRYp5QvehHAAxtSGGQ">collusion between politicians and tycoons</a> involved in medical education that was driving up costs.  As word spread that KC had arrived at the Mugu District Hospital last week, patients from surrounding villages started pouring into Gamgadi to have relatives examined. He has also been training resident surgeons on surgical procedures.“For us, he is god,” said 17-year-old Gagan Bham from Rara, whom KC operated on for a fracture in his ankle. <img width="1050" height="635" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914114/636ba5b09c7e80680e0736dbjpeg.jpg" alt="">Also from Rara is 10-year-old Reshma Bham who had broken her hand while grazing livestock last year. KC operated on her, and straightened out her arm which is now plastered and in a sling.“We lived up in the mountains and did not have the money get her treated. We were afraid our daughter would be disabled for life, Dr KC was sent here by god,” said Reshma’s mother Danta, who added that she had heard about KC’s arrival by chance on the radio.After working without a break for 12 hours a day, on Monday KC returned on foot to Jumla.  KC has been on a tour of remote northwestern Nepal, where health care is neither accessible not affordable for a majority of people. The need for medical attention has gone up since quarantine centres and isolation wards have been set up for COVID-19 patients in the region, most of whom are returnees from India.KC has not been welcomed everywhere. Last month, a government health post in Rimi of Dolpo district refused to let the crusading doctor see patients there, saying he did not have government permission.  KC nevertheless saw some patients before travelling on to Bajura.One of KC’s hunger strikes was in Jumla two years ago where he demanded that medical colleges should be opened in every province in Nepal, and he wanted the Karnali Institute of Health Sciences to be the centre for Karnali Province. He broke his hunger strike after government assurances in 2018. But seeing no progress has been made to fulfil that demand, last month in Jumla he threatened to go on another hunger strike.

Govinda KC treats patients in remote Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a7e9c7e80680e064764jpeg.jpg" alt="" width="850" height="567"/><figcaption>Pic: IRIN</figcaption></figure>At time of writing at noon on 21 March there were 785,855 confirmed cases of COVID-19 around the world, and 37,826 fatalities in just three months.The speed of spread and the size of population and geography affected is unprecedented in human history, after it spread from Wuhan in December.Nepal was actually only the fifth country to report its first case of COVID-19 in a student who came from Wuhan. Even though only five positive cases have been found in Nepal so far with one of them recovered, Nepal was the first country in South Asia to declare a lockdown on 17 March.There are surely more infected people out there, but for some reason there has not been a major outbreak with large numbers of elderly and vulnerable people crowding our hospitals, as has happened elsewhere.However, for us working in a community hospital here in remote Accham district the COVID-19 pandemic and need to break its transmission chain comes on top of pre-existing public health crises. For Nepal, there are multiple competing priorities – the foremost of which is <a href="https://archive.nepalitimes.com/article/editorial/Nepal-%20Multidimensional-Poverty-Index,4115" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/editorial/Nepal-%2520Multidimensional-Poverty-Index,4115&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHM5h3YUBoz4XSN7_uHJ3E6Fr6WUQ">poverty</a>.<a href="https://www.nepalitimes.com/here-now/returnees-may-be-taking-coronavirus-to-rural-nepal/" target="_blank" rel="noopener">Returnees maybe taking coronavirus to rural Nepal</a>, Mukesh Pokhrel and Sonia AwaleAlthough the percentage of Nepalis in absolute poverty has decreased <a href="http://nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098" data-saferedirecturl="https://www.google.com/url?q=http://nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNE5Rfegg0JNVXKpiotepEHWK3ctxQ">from 59.3% in 2006 to about 20% </a>today, there are large parts of the country with such grinding poverty that it forces families to ignore serious ailments because they cannot afford travelling to a hospital.At Bayalpata, we treat <a href="https://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNF4N287SaVbb8sNES0Lwkx4OhGavg">patients who have walked or have been carried for days</a> because they either do not have access to medical care, or cannot afford it. Having a sick person drives even some better off families into poverty, and men have to migrate to earn enough to pay off loans they took for treatment. For Nepal, the real pandemic is poverty.A 42-year-old woman was admitted to <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=1585722723480000&amp;usg=AFQjCNHxwuUmg6vrBxCxISbf1HiE37jNoA">Bayalpata Hospital</a> last week after fracturing both bones on her left leg after a fall while travelling to a school where her daughter was about to give her secondary school examination. The tests were postponed at the last moment because of COVID-19.A 14-year-old boy was admitted with a fractured femur after falling from a tree. Despite the lockdown fodder and firewood must still be collected, the maize needs to be planted, livestock have to be tended.Bayalpata Hospital has set up an emergency department and fever clinic as per government directives. We have trained healthcare workers to deal with coronavirus patients. But all we are encountering so far are the chronic poverty-related diseases that have always been endemic in western Nepal.<a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener">Enlisting female health volunteers to fight COVID-19</a>, Ramu Sapkota and Mukesh PokhrelThe <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2818%2930386-3" data-saferedirecturl="https://www.google.com/url?q=https://www.thelancet.com/action/showPdf?pii%3DS2214-109X%252818%252930386-3&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHN3iLt2G4_SkTyvig6g1vEBfPv5g">Lancet Global Health Commission</a> says 8 million people every year die around the world  from treatable conditions in low and middle income countries. Yet, that does not qualify as a global pandemic.<a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNFDYqLJvteBaRIZP72Pq6sigwjSkg">More than 1,200 women die</a> in childbirth every year in Nepal, that is three fatalities evry single day. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHYW7_isIE72BQ49VZGoyQMHD2gSw">Tuberculosis</a> kills 6,000 people in Nepal every year. There were 2,736 fatalities in <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNFBa59bECywSEyR8IEj4-iHamayEA">road traffic accidents</a> in Nepal last year. All of these deaths were in one way other linked to deprivation and inequities.Every day at Bayalpata Hospital we manage cases of children who are <a href="http://archive.nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNENzTMpW5lgmR02wVhfwM6ibW_H_w">stunted or wasted due to malnutrition</a>, exposing them to opportunisitic infections. Some of their families are too poor to provide enough food. There are also cases of fractures, neglected infections like abcess and bone infections every day – mainly among children because parents are forced to be busy at work in the farm, or had gone abroad to earn.COVID-19 is a dangerous, easily spread viral infection. Yet, when the pandemic does  spread to western Nepal it will just be another disease burden on top of the pyramid of poverty we have to deal with here every day.<a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHCbDoFCPznSW29oc0wSkBzQEDm4w">Bikash Gauchan</a> is the Healthcare Director for <a href="https://www.theatlantic.com/sponsored/cathay-pacific-2016/a-new-way-to-care-for-nepals-poorest/894/" data-saferedirecturl="https://www.google.com/url?q=https://www.theatlantic.com/sponsored/cathay-pacific-2016/a-new-way-to-care-for-nepals-poorest/894/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNGT68-k6h4a6jXvhDF3yPCKSdhXyA">Nyaya Health Nepal</a> in Achham based at Bayalpata Hospital.

Poverty – the real pandemic

<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 daily 10-hour curfew at Tribhuvan International Airport from 8 November that will last five months has affected tourism during Nepal’s peak season, with some hotels and trekking agencies here reporting cancellations into spring next year. The reduced hours at Nepal’s main aviation gateway till 31 March means that a third of all flights have been cut. This has also caused ticket prices to surge by up to eight times of normal fares. For example a Kathmandu-Delhi ticket that used to cost Rs12,000 is now listed at Rs50,000, and even then seats are not available.&nbsp; “Especially if they are here to trek, change in flight dates can cause tourists to miss their connections,” says Jagan Timilsina, who runs a trail running and outdoor education business. &nbsp; Pokhara is feeling the brunt as hotels report last-minute cancellations for November because of flight disorders. Some hoteliers also say although there have been some cancelled trips, most itineraries have been rescheduled.&nbsp; Hari Prasad Sharma Gaire of the local chapter of the Hotel Association of Nepal says the Kathmandu airport closure should have been timed for the off-season. He told us: “Starting construction during the peak tourist season was a mistake and will cause the tourism industry to lose a lot of business. The upgrade could have been spread out over a longer time but closed for fewer hours at night so that disruption was minimal.”&nbsp; Nearly a third of the 1.2 million tourists who visit Nepal annually come to Pokhara, which is also the gateway to Mustang, the Annapurna treks and pilgrimage tourism to Muktinath. Located by scenic lakes with a range of adventure sports like hot air ballooning, paragliding, canyoning, bungee and ziplines, Pokhara is also popular among diaspora Nepalis. “Besides its own attractions, Pokhara is really the hub for central Nepal, and we have been trying to get visitors to extend their stay here,” says Timilsina, who started out as a trekking porter and rose up the ranks to be an expedition guide and entrepreneur. &nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024111603114_0e071ce63ea9b0a9a7ee76f8c3cea0ff08c6767c41dd09f6bc4413d2db067a60.jpg" data-media-id="editor_0" data-image-id="2024111603114_0e071ce63ea9b0a9a7ee76f8c3cea0ff08c6767c41dd09f6bc4413d2db067a60" data-rendition-name="original" width="3500" height="2333" loading="lazy" alt="Pokhara's tourism woes NT"> <figcaption>Tourist arrivals in Pokhara have slumped since the disruptions at Kathmandu airport due to upgrading work. Photo: KRISHNA MANI BARAL/NEPALI TIMES ARCHIVE</figcaption> </figure>  Even without the Kathmandu airport closure affecting tourist arrivals, Pokhara was already suffering from a decline due to many factors like the poor state of the Prithvi Highway, the shortage of luxury accommodation for high-end tourists, and the reluctance of international airlines to start direct flights to Pokhara despite an expensive new airport that was inaugurated two years ago.&nbsp; “There was a lot of initial excitement on the construction of the international airport,” says Timilsina, “but it hasn’t delivered as expected due to politics. People have invested in nearby businesses, and have faced losses.” India has blocked direct flights from its cities to Pokhara because the facility was built by a Chinese company. Although tourists and pilgrims from India hit record levels this year, the poor state of the highways and the Indian bus accident on the highway to Kathmandu in July that killed 27 pilgrims from Maharashtra state dampened arrival figures. Gaire says, “While tourist arrivals to Pokhara are now approaching pre-Covid levels, we haven’t seen the improvement we were expecting. We need a better marketing strategy. What are our embassies abroad doing?”&nbsp; Indeed, Pokhara used to be a favourite destination for Chinese tourists. There was a boom in arrivals from China before Covid, especially after a popular Chinese tv serial was shot on location here. But arrivals from China have not really recovered since the pandemic because of the economic slowdown there. Promoting Pokhara airport to handle direct flights from Chengdu or Kunming could revive Chinese arrivals.&nbsp; Nepal’s Civil Aviation Authority (CAAN) has used the Kathmandu airport closure as an excuse to arm-twist international airlines to start flying to Bhairawa, which has barely been in operation for two years since it was inaugurated. So far, Fly Dubai, Thai AirAsia, Jazeera and Qatar are flying to Bhairawa, but most use it as a hop before flying on to Kathmandu, which does not reduce congestion at Kathmandu.&nbsp; An ideal situation could have been to get Pokhara to run to full capacity while Kathmandu is partially out of action. Pokhara entrepreneurs are puzzled why the CAAN and the national government have not taken more interest in promoting Pokhara as an alternative to reduce the congestion in Kathmandu. Nepal’s football team that was flying to Dushanbe this week couldn’t get tickets via Delhi, and took a domestic flight to Bhadrapur, crossed over to Bagdogra and flew on to Delhi to catch their flight to Tajikistan.

Pokhara’s tourism woes

An excerpt of a conversation between an anthropologist and linguist Mark Turin, PhD and Lava Deo Awasthi, PhD, the first Chairperson of the Language Commission of Nepal. Nepali Times: What is the role of Nepal’s Language Commission and when was it formed? Lava Deo Awasthi: The Constitution of Nepal (2015) created a Language Commission (LC) with the following four core mandates: (a) to develop eligibility criteria for gaining status as an official language and offer recommendations to the Government of Nepal about the official language(s) in each province; (b) to offer recommendations to the Government about measures to be taken for the conservation, promotion, and development of languages; (c) to suggest possible ways of using mother tongues in education by assessing their stage of development; and, (d) to conduct studies, carry out research and perform monitoring functions about the response to the constitutional provisions for the federalisation of languages in Nepal. The Commission was founded in 2016 and I was appointed as the Chairperson of the Commission in September of the same year by the Cabinet of Ministers. What in your own professional and educational background helped to prepare you for the role? I have worked with the Government of Nepal for about 30 years, alongside holding teaching appointments at universities in Nepal. Prior to assuming the role of the Chairperson of the Commission, I served as permanent Secretary to the Government of Nepal and worked as the Chief Administrator of the Central Development Region. I was appointed as Director General of the Department of Education and completed my assignments as Joint Secretary at the Planning, Monitoring and Educational Administration Divisions of the Ministry of Education.&nbsp; In addition, I have taught courses as a visiting professor at Tribhuvan University and Kathmandu University for more than three decades. Later, I also started supervising MPhil and PhD students at the Far Western University in Mahendranagar, Kanchanpur. My PhD project from the Danish University of Education was dedicated to making sense of Nepal’s social construct and commitment to multilingualism, exploring the persistence of monolingual school practices in the face of constitutional promises and state commitments to multilingualism. I conducted a survey of Nepal’s languages and carried out a qualitative study of the Tharu language in the district of Bardia. I analysed language policy statements and explored classroom pedagogies in schools. I documented how teachers showed a tendency to resist change and maintain the status quo because they were not consulted when new educational language policies were introduced. Teachers also exhibited a deeply-held adherence to the Gurukul education system which appears to have been harnessed as a way to resist newer pedagogical ideologies imported from the West. Recognising how engrained these rich traditions of knowledge transmission are, I wanted to know how students’ engagement in the learning process appeared to have dwindled, creating a gap between children’s home languages and the language(s) of the school. Whilst statutory provisions for education in the mother tongue were oriented towards promotion, classroom pedagogies remained resolutely monolingual and exclusionary. The result was that multilingual education policies that had been introduced in Nepal did not result in meaningful changes in classroom practices. My research was also a reflection of childhood traumas I had experienced at the earliest stage of formal education. My home language, Baitadeli, has a strong oral tradition and no written literature. English is my fifth language in terms of exposure and competence, and my home district of Baitadi is well-known for its loyalty to the local language. I had to drop out of school after completing my sixth grade. Staying at home, I received much attention from my family and had much greater exposure to my native language, culture and environment. My overall impression is that dropping out of school had a surprisingly positive impact on my life. The opportunity offered a surprising dividend for me as I gained mastery in my mother tongue and received extensive exposure to folk literature and Indigenous knowledge and survival skills, cultivating my interest in language, culture, literature and local cosmologies.&nbsp; Now that I reflect on it, I appreciate how language has always played a key role in my life. I grew up in a multilingual environment: brought up with Baitadeli, Hindi, Sanskrit, Nepali and English. Language played a major part in my decision to leave school and my later success is closely linked to my competence in several languages. It was rewarding to be at home with my family as I deepened my understanding of native language and culture, which in turn helped me to harness and refine my art of living. Languages matter so much to me because they are both software and hardware. Later, when I was in secondary school, I realised that my command of my home language contributed significantly to enhancing my Nepali and English. I used my mother tongue as a form of linguistic capital to strengthen my competence in both English and Nepali.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024111811110_5400ba54792bf9e4854e1c1effde8bf09804e99647f23513700b450cc49adc4a.jpg" data-media-id="editor_0" data-image-id="2024111811110_5400ba54792bf9e4854e1c1effde8bf09804e99647f23513700b450cc49adc4a" data-rendition-name="original" width="1000" height="1500" loading="lazy" alt="Dr Lava Deo Awasthi"> </figure>  In your term as the Commission’s first Chairperson, what were your strategic goals and objectives? My first strategic goal was to create an environment conducive to implementing the provisions of the Constitution of Nepal in relation to language. My priority was to prepare a detailed action plan for my six-year tenure in consultation with language stakeholders, including language experts, professionals, activists, Indigenous community members and representatives of relevant national and local-level institutions. The Commission formed a body of high-level advisors to ensure that the Chairperson’s work was well-informed and credible. The advisors to the committee had highly visible professional and social reputations in Nepal and had much experience in the field of language conservation, promotion, research and development. Another strategy we adopted was to establish close institutional linkages with federal, provincial, and local level governments for collecting opinions and disseminating information widely.&nbsp; What critical issues did you have to consider while discharging your duty? When Nepal’s new Constitution was drafted, a number of concerns could not be adequately addressed. These related to the conservation of languages, the recognition of official languages at the provincial level, and the use of mother tongues at federal, provincial, and local levels. These unresolved issues and matters pertaining to the federalizsation of Nepal’s languages were passed on to the Language Commission to address and resolve.&nbsp; Regarding the recommendations for official languages, a five-year timeline had been set by the Constitution. With great effort, we succeeded in having all provinces agree to recognise their official languages as per the recommendations of the Commission.&nbsp; What were your greatest achievements during your term? One of the greatest achievements was that we succeeded in setting a language agenda at all levels. Nepal’s language communities and other stakeholders expressed the view that this was the first time their languages were recognised and their voices heard by the state. People participated in debates and discussed issues relating to language that in all likelihood had never before happened in their lifetimes, at least not in ways that were supported by the state. We encouraged people to speak in their own language(s) and provided translators during plenary sessions and group discussions. Another major achievement was developing criteria for the status planning of languages at federal, provincial, and local levels, and to recommend 11 province-level official languages, in addition to the Nepali language. Similarly, a notable achievement was recognising Indigenous languages spoken by smaller communities, all of whom faced ongoing marginalisation and high levels of endangerment. The Commission identified 9 new languages that had not been reported in the 2011 census, and provided a framework for recognising official languages within a municipality. The commission emphasised the need for documentation and digitisation of languages for developing corpora and archives at national and sub-national levels.&nbsp; Languages of historical importance as well as classical languages were given recognition for their protection, growth, and development. Recommendations were made for the conservation, promotion and development of Nepal’s marginalised languages that are threatened by majority languages and for those languages that hold particular power at local and global levels. Recommendations were also made for how best to safeguard Nepal’s languages from the ever-growing spread of English and other powerful, globalising languages.&nbsp; A further important aspect of the Commission’s work was to emphasise mother tongue medium instruction in schools across the nation. Recognising the role of language in children’s cognitive, socio-emotional and academic development, the Commission suggested strategies for linking schools with ward-level language clusters for use in the classroom. The importance of nurturing and respecting a child’s first language was reiterated in the Commission’s recommendations for children’s learning and all-round development. By the end of my term, a remarkable change could be observed in terms of building trust within and across Nepal’s diverse language communities. A network of language groups and stakeholders across the country proved to be a powerful way of bringing all language communities under one roof for a collective review of and response to the process of federalising language policy. The many language stakeholders across Nepal appreciated the opportunity to work within a coordinated framework, and—feeling empowered by this—seemed genuinely enthusiastic about the initiatives taken by the Commission.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024111811114_b45297fdd2fedf17bdb6313e495a1062c0d87f1a19fa5349f871f220b75f93ab.jpg" data-media-id="editor_1" data-image-id="2024111811114_b45297fdd2fedf17bdb6313e495a1062c0d87f1a19fa5349f871f220b75f93ab" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Dr Lava Deo Awasthi NT"> </figure>  What were the most significant challenges for you as Chairperson? One of the major challenges was winning people’s trust in advocating for the mission of the Language Commission. I faced considerable resistance as I sought to emphasise the use of native languages in families and communities. While the Commission advocated for multilingualism and promoted linguistic diversity, the prevailing policy circles and central level institutions had been deeply influenced by a one-language discourse and ideology of Nepali only. The spread of English also poses a huge threat to Nepal’s languages. However, people in power do not seem to see this as a problem. They tend to abandon their own languages in preference for English. The way that Nepal’s municipalities are increasingly introducing English as a medium of instruction at the earliest stage of a child’s school-based education has proven to be detrimental to their cognitive development, socio-emotional wellbeing and academic success. Most of Nepal’s elites have been heavily influenced by the spread of English and remain unaware about its impact on their home languages as well as on the inter-generational transmission of Indigenous languages in the country. I wish that we could have produced more compelling evidence to show the consequences of making poor policy choices for our children’s education. Demystification calls for a collective response. To make change happen across this entire, complex and federalising country was daunting work and left like a race against time. I feel that I could have done more to offer concrete examples in favour of using the mother tongue as a medium of children’s education at the earliest stages of a child’s education. What do you see the Language Commission achieving in the next 5-10 years? The Language Commission will have to ensure that all of its key recommendations are implemented at all levels of government. In 10 years’ time, all seven of Nepal’s provinces will have their official languages in place. These languages will also be recognised as languages of federal business, alongside Nepali. I anticipate that all official languages in the federal and provincial systems will have a national portal for inter-language corpora using machine translation to fulfil their federal, provincial and local level language functions, and that all languages spoken in Nepal will be represented through a digital database in the national archive. The Office of Statistics will monitor the status of Nepal’s languages over time. By the end of the next decade, each municipality in the country will have recognised one or two official languages at the local level, based on speech populations. Other local languages will have received community-level legal recognition and official status to fulfil their functional roles. Languages that are highly endangered or at risk will be entitled to receive state grants for enhancing local level capabilities to encourage families and young learners to speak the language. Incentive schemes will be introduced in municipalities that promote language within the family and at home. Inter-generational transmission of languages will have received welcome and timely attention across Nepal. It is my hope that all schools—public and private—will have introduced mother tongue medium instruction at the earliest stage of school education, at least up to class five. Nepali, English and other national as well as classical and foreign languages will be taught as subjects. The existing policy of English medium education at the early stage of education will be abolished. The Government of Nepal will be held accountable if the number of speakers of any language decreases or if local communities face language loss and greater endangerment. Under the aegis of the Language Commission, a Centre for Language Research and Innovation will be created with world-class facilities for language documentation and archiving in collaboration with Tribhuvan University’s Central Department of Linguistics and other relevant institutions. Harnessing the vastness of Nepal’s linguistic diversity, the Language Commission will morph into a centre of excellence for national and international communities to engage in collaborative language research, to share experiences and document best practices at in service of global linguistic diversity and Nepal’s many Indigenous languages.

Languages are both software and hardware

Earlier this month, Nepal received Rs1.6 billion from the World Bank as part of its <a href="https://nepalitimes.com/news/will-nepal-ever-be-paid-for-saving-trees">Forest Carbon Partnership Facility (FCPF)</a>, rewarding the country for increasing its carbon sink capacity. Nepal is the first in South Asia to benefit from this facility, and it is specifically to recompense the country for increasing forest cover in 13 Tarai districts between 2018-2024. “We are also trying to get another Rs13 billion from the facility while also preparing for free market-based carbon trading in the international market,” says Nabaraj Pudasaini of the REDD (Reducing Emissions from Deforestation and Forest Degradation in Developing Countries) Implementation Centre. Big emitters of greenhouse gases are under pressure to reduce their carbon emissions, and many have signed agreements to do so by investing in decarbonisation projects in developing countries. Countries that emit more than a specified amount of carbon would be able to buy emission rights from countries that emit less. Nepal is internationally known for its community forestry program which has been largely credited for <a href="https://nepalitimes.com/banner/tree-mendous">increasing tree cover to over 45%</a> in less than three decades. But this achievement had not been adequately recognised or rewarded internationally before. Forests, especially in the tropics, absorb and store large amounts of carbon while releasing oxygen in a process known as photosynthesis. <a href="https://www.fao.org/forest-resources-assessment/en/">Preventing deforestation</a> and increasing canopy cover is considered a much more achievable goal than reducing emission in the scale necessary to limit global average temperature to 1.5°C above pre-industrial levels. COP11 in Montreal in 2005 first proposed reducing carbon emissions by improving forest quality by halting degradation. By 2015, a new mechanism of financial assistance was created to help less developed countries with sustainable management of forests <a href="https://www.un-redd.org/">(called REDD+)</a>. Under this new mechanism, countries receive aid based on their efforts to prevent forest degradation and increase carbon sink, and in 2021 the World Bank was entrusted with implementing it. Nepal’s FCPF receipt this month was calculated on the basis of 2.4 million tons of carbon stored at a rate of $5 per ton. In the second phase, Nepal will receive more than Rs4 billion within the next year for storing an additional 7 million tons of carbon. Eighty per cent of this amount obtained from carbon trading needs to be spent on local beneficiaries and indigenous communities.&nbsp; But carbon trading is not easy, Nepal needs to prove that protected forests will not be destroyed in future.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241121091132_c8a381c9a95aa86fec558951650d97bb87914741f01766982ba2b086af001f16.jpg" data-media-id="editor_4" data-image-id="20241121091132_c8a381c9a95aa86fec558951650d97bb87914741f01766982ba2b086af001f16" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="Greenbacks for greenery NT "> <figcaption>Photo: KUNDA DIXIT</figcaption> </figure>  Explains carbon trading expert Yugan Manandhar. “Forests should be handed over to the community and shown that they are managed sustainably. Proving this will be particularly challenging; forest encroachment and degradation is rife in the Tarai.” <a href="https://nepalitimes.com/multimedia/nepal-is-going-up-in-smoke">Deliberate forest fires</a> have also added to the challenge because they increase carbon emissions and reduce the sink capacity of forests. The basis for the amount that Nepal received was set five years ago by calculating the carbon reserves of forests in the 13 Tarai districts. In the meantime, sustainable forest management, tree plantation, forest destruction and erosion control were prioritised to increase carbon reserves in those forests. Nepal is signing another carbon trading agreement during the ongoing Baku climate conference. The <a href="https://www.leafcoalition.org/">Lowering Emissions by Accelerating Forest finance (LEAF Coalition) </a>proposes to sell the carbon stored in the forests of Bagmati, Gandaki and Lumbini provinces. For this, Nepal signed the letter of intent three years ago at COP26 in Glasgow. The target is to store 70 million tons of carbon in 32 million hectares of forest in the three provinces per which Nepal will receive Rs13 billion in four years at $10 per ton with provisions to increase the rate if various conditions are met. However, the agreement in itself doesn’t guarantee the amount. According to the targets set by Nepal, forest degradation should be stopped and carbon reserves increased by protecting tree cover. Preparations are also underway for clean air carbon trade because it has offset fossil fuel use by introducing 30,000 electric vehicles. Nepal has been selected for the first round to receive $40 million within one and a half years through the Clean Air System of the World Bank. Given that most of Nepal’s energy mix is from biomass, replacing them with electric stoves can significantly improve health by reducing indoor pollution as well as strengthen the country’s capacity for carbon trade. “Nepal's goal now is to sell carbon in the free market where carbon credits are bought and sold based on supply and demand in an open and transparent manner,” adds Pudasaini of the REDD Implementation Centre. “Nepal can now set its own price and bargain with interested buyer countries and organisations.” Lately, India has been discussing setting up a carbon market. Nepal has exported Rs12.72 billion worth of electricity to India so far this fiscal year, which can be traded under Nepal’s carbon market. “Carbon trading can create significant economic benefits for Nepal, which will help reinvest in development and environmental protection projects,” says Manandhar. “But we must prioritise sustainable management of forests, cutting older trees and allowing regrowth as well as promoting electric stoves and electric vehicles.”

Greenbacks for greenery

Nearly 750,000 Nepalis went abroad for employment in the past year, and more than 100,000 left on student visas. Most of them were young Nepali men and women, and the number has been increasing every year. As with other sections of society, Nepal’s security agencies also face a recruitment crisis. Nepal Police opened recruitment for 64 inspectors in September, and received 2,239 applications, compared to 2,718 candidates last year. Police also invited candidates for 256 assistant sub-inspectors this year for which it received 17,756 applications – down from 19,932 last year. It is the same story in the Nepal Army, the number of applicants for the post of Officer Cadet (Second Lieutenant) went down from 6,144 for 400 open seats in 2019 to 4,390 in 2020. Meanwhile, applicants in the paramilitary Armed Police Force went down from 857 applications for 75 posts in 2021 to 536 applicants for 99 posts last year. While the number of applicants appears higher than the demand, the data shows a significant decrease in applications for vacancies in Nepal’s law enforcement agencies. Security personnel are recruited on the basis of rank and age in Nepal, and the age cutoff for entry into Nepal’s security agencies is typically 25 years. Sociologist and migration expert Ganesh Gurung says that the demographic of young, physically fit Nepalis emigrating abroad in search of better opportunities has impacted recruitment into law enforcement and the military here at home. “The returns from working in Nepal’s police and army are minimal, whereas overseas job opportunities are more attractive,” Gurung says. “The work may be physically demanding abroad, but the pay is a lot higher.”  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241116041148_a7e477e0ee2f56acf16c2559fdb24d8f0377f7bc1f9e56138bc40108fc4fa33f.jpg" data-media-id="editor_0" data-image-id="20241116041148_a7e477e0ee2f56acf16c2559fdb24d8f0377f7bc1f9e56138bc40108fc4fa33f" data-rendition-name="original" width="800" height="534" loading="lazy" alt="Nepal Police"><figcaption>Nepal Police</figcaption></figure>  Nepal Police spokesperson DIG Dan Bahadur Karki agrees that the physical and mental demands of a law enforcement job is incomparable to the income that security personnel earn. “A young Nepali who works in Dubai earns enough to build a home in the village within four years, while a Nepali with the same qualifications and physical ability in a security agency here barely makes enough to survive,” says Karki. “Obviously the youth prefer foreign employment.” Security agencies are now worried about the quality of inducted manpower. “There is a difference in work ethic between an applicant chosen from a competitive pool of 50 candidates versus one chosen from a pool of three candidates,” explains Gurung. “Unmotivated employees hamper the overall performance of the state apparatus.” Nepal Army spokesperson Brigadier General Gaurab Kumar KC says recruitment has not been hampered by outmigration: “We have still been getting more than three times the applicants than there are open posts, so we are not yet worried.” Even so, the passing rates of aspirants have gone down for security forces after the Public Service Commission began examinations for military recruitment in 2015. In fact, the Nepal Army complained about the Commission’s involvement in recruitment. Still, the number of vacant military posts tends to exceed the number of passing candidates. Nepal Army’s KC says that the military will not compromise on intake criteria even if there are fewer passing applicants. “Unqualified persons will not be admitted even if there are less-than-required passing candidates. We will re-advertise if that is the case.” But Nepal’s security forces now also have to worry about retention of existing personnel. About 900 Nepal Army, 600 Nepal Police, and 300 Armed police personnel resign every year before the completion of their tenure.  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241116041148_b8cd62f70eea3aac7d3d3778615a5b70b1e20550c9bd76321f051f9c766fd2a9.jpg" data-media-id="editor_1" data-image-id="20241116041148_b8cd62f70eea3aac7d3d3778615a5b70b1e20550c9bd76321f051f9c766fd2a9" data-rendition-name="original" width="750" height="378" loading="lazy" alt="Armed police forces"><figcaption>Armed Police Force</figcaption></figure>  In 2020, Home Minister Ram Bahadur Thapa recalled almost 1,000 police personnel who had been deployed for the security of VIPs after long-standing criticism that security forces were being misused to cater to political and bureaucratic leadership. However, security personnel have continued to be assigned to high-ranking officials as glorified housekeepers. In December 2022, Rabi Lamichhane’s Home Ministry had instructed its offices to recall unauthorised security personnel assigned to high-ranking officials, following which 500 officers from Nepal Police and Armed Police Force were withdrawn from their details. But the Nepal Army does not have to follow such rules, and the practice of army personnel serving high-ranking active-duty and retired military personnel remains. Conditions here are dire enough that many active duty officers in Nepal’s military and police forces have chosen to leave their jobs to serve in the Russian Army to fight in the Ukraine war. The hierarchical culture and chain of command of politics, bureaucracy, law enforcement and military has also meant that abuse and mistreatment of subordinates is rife in Nepal’s security forces. “Feudalism is alive and well within our security institutions,” says Gurung. “When soldiers and security forces who swore to protect and serve the nation are made to be at the beck and call of politicians and bureaucrats, it is easy to understand why they are disillusioned with their jobs and why they choose to quit and find jobs abroad.”

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