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

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Nepal’s rural lifeline

<figure><img width="1641" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84419c7e80680e067784jpeg.jpg" alt=""/><figcaption>Services provided from outside of OPD due to Covid cases. Photos: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s rural health system, already underfunded, understaffed and overstretched, is struggling with the enormous added burden of the Covid-19 pandemic.  Having barely coped with the first wave last year, hospitals in the remote mountains of Far-Western Province have found that the variants in the second wave are much more lethal, there are many more patients than before, and more of them require hospitalisation.  In Achham district the administration declared a lockdown on 3 May, but by then the virus was already spreading within families and house-to-house. Till the day before the lockdown, people were still arriving by the busloads from India, Kathmandu and other cities. Testing and tracing were lax, and they were mingling in the markets.  On Sunday, Nepal added 8,850 new confirmed infections, bringing total active cases to 88,160. There were 52 fatalities but 26 more died at home. Kathmandu reported 4,198 cases in the last 24 hours. There are 832 people in ICU across the country, and 267 patients on ventilator support. In the village of Jaygad of Achham, for example, an annual fair with large crowds was being held even as 13 out of 15 sample antigen tests came out positive. The virus was spreading into the remotest villages. “We have increased awareness programs and testing, and local governments have become more active in the recent days and taken more ownership of testing and information dissemination,” says Janakraj Dhungana at Achham’s District Health Office.  But many wonder whether it is too late to be disseminating information through loudspeakers on masking and distancing, when patients and families throng ill-equipped hospitals. Dhungana himself admits that there was not enough testing and isolation because of a shortage of kits.  Like other districts of Far-Western Province, the caseload in Achham is increasing, with 2,183 positive cases and 17 deaths so far. Of this, 511 positive cases and 6 deaths are during this second wave.  The vaccination drive was also suspended after 3,000 medical personnel and community health workers were inoculated. But 15,000 senior citizens in Achham alone still have not got their second doses yet.  <figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84449c7e80680e067785jpeg.jpg" alt=""><figcaption> </figcaption></figure>The government has now asked all hospitals to also treat Covid-19 patients. Bayalpata Hospital in Achham, which is run by the non-profit Nyaya Health Nepal in partnership with the local government, was not a designated Covid-19 hospital during the first wave. This year, it is treating a flood of Covid-19 cases.“We had set aside an entire wing for coronavirus cases, but there has been such a surge in the past week that we have turned the emergency room into a Covid ward,” says Mandeep Pathak, medical director at Bayalpata Hospital. “We converted five rooms set aside for drug-resistant tuberculosis treatment for Covid patients.”Bayalpata is currently treating 26 patients with Covid-19, all of them with low oxygen saturation levels, but new cases are being admitted every day. The hospital has also had to reassign eight rooms for Covid-19 patients, including for 14 of its own staff who have tested positive. In Dadeldhura Hospital a four-hour drive to the west, all 31 beds are full with Covid-19 patients, and although there are only five ICU beds, 13 patients are receiving intensive care. In the neighbouring district of Doti, it is the same story.“Even if we have beds, we have no oxygen, it is a vicious cycle,” says Jagdish Bista, Medical Superintendent at Dadeldhura District Hospital. “The most urgent need now is oxygen, and we are also running out of PPEs.” But what worries the doctor more is the 50-70% positivity rate of testing, and what this means for the next two weeks.For the time being, the nursing staff shortage has been alleviated with new transfers. But Dadeldhura Hospital’s oxygen plant cannot cope with demand, and there are difficulties to get cylinders refilled in Nepalganj and Dhangadi. Covid-19 has taken precedence over other cases, apart from emergencies and deliveries. Most patients are in the 30-year-old range, and those turned away seek help in Dhangadi’s Seti Hospital, which is also inundated.Patients who can get to hospital and get admitted in this remote region are the lucky ones. Local municipalities have built isolation centres, but most are empty because there is no oxygen and no medical personnel, says Devraj Devkota of Panchadeval Binayak municipality. <figure><img width="1753" height="2409" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b84479c7e80680e067786jpeg.jpg" alt=""><figcaption> </figcaption></figure>“Our people prefer to either isolate at home or try to get to a hospital if their condition deteriorates,” he adds. “We have had no help from Kathmandu.”But Nepal’s cities, including in the capital, are also out of hospital beds and oxygen, so there is little hope for outside help. In fact, a reverse flow is starting: critical Covid-19 patients in Kathmandu are being helicoptered to Jhapa or Kaski where there are still hospital beds with oxygen.The need in every municipality in the far west is the same: oxygen cylinders, pulse oximeters and testing kits, and additional hospital beds for serious cases.Says Achham’s District Health Officer Dhungana: “Oxygen is a problem. We depend on Dhangadi and Nepalganj to refill cylinders. They get used up fast, which has made it a logistical challenge.” There is also a critical shortage of staff. Despite vacancy notices, there were few applicants for specialised medical personnel even pre-pandemic. For example, although the District Hospital in Mangalsen has ventilators, there is no one to run them, and there isn’t enough oxygen.Patient referrals to city hospitals offering critical care, or just beds with oxygen, are also complicated. They are also overwhelmed, and there are few ambulances with oxygen for the 8-12 hour journey across mountain highways. Ambulances are expensive, and helicopter air lifts are even more costly. Despite this, desperate families have taken loans to try to save family members in critical conditions by air lifting them to city hospitals—often too late. Then there are all the other non-Covid trauma patients needing urgent surgery, or maternity cases. With its free treatment, Bayalpata Hospital has served more than 1 million patients from Achham and six surrounding districts of Karnali and Far-West Provinces in the past 12 years. Separating Covid-19 and other cases is a challenge for doctors like Mandeep Pathak (pictured right) who do not like to turn patients away. Even though the height of the pandemic this week, the orthopaedic surgeon has performed 15 operations, including on a 13-year-old boy from Kalikot with a fractured leg. In the past month, Bayalpata Hospital has performed 77 deliveries, of which eight were caesarean sections. “The staff adjust, innovate, accommodate, reallocate, adapt and have kept working right through the pandemic,” Pathak says. <img width="1906" height="1398" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b844b9c7e80680e067787jpeg.jpg" alt="">New health protocols have been adapted to minimise disruptions, and Bayalpata is seeking resources to help with the crisis. There is fear that regular services will be increasingly impacted as the pandemic peaks.  The lockdown also means that families may wait till the very last moment to take patients to hospitals, by when it is usually too late. Bayalpata Hospital has therefore modified some of its regular services to remote care via phone calls. Bayalpata Hospital’s community health program, for example, that provides regular group antenatal care to pregnant women has been severely impacted. While the program was offered throughout the first wave, it has been interrupted during the second wave, and staff have had to resort to phone-based counselling and follow-up unless in case of emergencies.  The fear is that far-flung and traditionally neglected districts like Achham will be the last to get test kits, PPEs, oxygen, hospital beds and eventually vaccines. The progress Nepal has made over decades in rural healthcare is being undone by the pandemic.  For offers of assistance to hospitals in Far-Western Nepal, contact: Bayalpata Hospital: <a target="_blank" rel="noopener noreferrer">srijana.devkota@nyayahealthnepal.org</a> +977 9851093920   Dadeldhura Hospital: +977 9858753201 (Dr Jagadish Bista) <a href="https://give2asia.org/covid-19-pandemic-response-nepal/" target="_blank" rel="noopener noreferrer">https://give2asia.org/covid-19-pandemic-response-nepal/</a>

At the Covid-19 frontlines in rural Nepal

<figure><img width="1641" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec639c7e80680e09ad61jpeg.jpg" alt=""/><figcaption>Services provided from outside of OPD due to Covid cases. Photos: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s rural health system, already underfunded, understaffed and overstretched, is struggling with the enormous added burden of the Covid-19 pandemic.  Having barely coped with the first wave last year, hospitals in the remote mountains of Far-Western Province have found that the variants in the second wave are much more lethal, there are many more patients than before, and more of them require hospitalisation.  In Achham district the administration declared a lockdown on 3 May, but by then the virus was already spreading within families and house-to-house. Till the day before the lockdown, people were still arriving by the busloads from India, Kathmandu and other cities. Testing and tracing were lax, and they were mingling in the markets.  On Sunday, Nepal added 8,850 new confirmed infections, bringing total active cases to 88,160. There were 52 fatalities but 26 more died at home. Kathmandu reported 4,198 cases in the last 24 hours. There are 832 people in ICU across the country, and 267 patients on ventilator support. In the village of Jaygad of Achham, for example, an annual fair with large crowds was being held even as 13 out of 15 sample antigen tests came out positive. The virus was spreading into the remotest villages. “We have increased awareness programs and testing, and local governments have become more active in the recent days and taken more ownership of testing and information dissemination,” says Janakraj Dhungana at Achham’s District Health Office.  But many wonder whether it is too late to be disseminating information through loudspeakers on masking and distancing, when patients and families throng ill-equipped hospitals. Dhungana himself admits that there was not enough testing and isolation because of a shortage of kits.  Like other districts of Far-Western Province, the caseload in Achham is increasing, with 2,183 positive cases and 17 deaths so far. Of this, 511 positive cases and 6 deaths are during this second wave.  The vaccination drive was also suspended after 3,000 medical personnel and community health workers were inoculated. But 15,000 senior citizens in Achham alone still have not got their second doses yet.  <figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec669c7e80680e09ad62jpeg.jpg" alt=""><figcaption>Bayalpata Hospital in Achham run by the non-profit Nyaya Health Nepal is treating a flood of Covid-19 cases.</figcaption></figure>The government has now asked all hospitals to also treat Covid-19 patients. Bayalpata Hospital in Achham, which is run by the non-profit Nyaya Health Nepal in partnership with the local government, was not a designated Covid-19 hospital during the first wave. This year, it is treating a flood of Covid-19 cases.“We had set aside an entire wing for coronavirus cases, but there has been such a surge in the past week that we have turned the emergency room into a Covid ward,” says Mandeep Pathak, medical director at Bayalpata Hospital. “We converted five rooms set aside for drug-resistant tuberculosis treatment for Covid patients.”Bayalpata is currently treating 26 patients with Covid-19, all of them with low oxygen saturation levels, but new cases are being admitted every day. The hospital has also had to reassign eight rooms for Covid-19 patients, including for 14 of its own staff who have tested positive. In Dadeldhura Hospital a four-hour drive to the west, all 31 beds are full with Covid-19 patients, and although there are only five ICU beds, 13 patients are receiving intensive care. In the neighbouring district of Doti, it is the same story.“Even if we have beds, we have no oxygen, it is a vicious cycle,” says Jagdish Bista, Medical Superintendent at Dadeldhura District Hospital. “The most urgent need now is oxygen, and we are also running out of PPEs.” But what worries the doctor more is the 50-70% positivity rate of testing, and what this means for the next two weeks.For the time being, the nursing staff shortage has been alleviated with new transfers. But Dadeldhura Hospital’s oxygen plant cannot cope with demand, and there are difficulties to get cylinders refilled in Nepalganj and Dhangadi. Covid-19 has taken precedence over other cases, apart from emergencies and deliveries. Most patients are in the 30-year-old range, and those turned away seek help in Dhangadi’s Seti Hospital, which is also inundated.Patients who can get to hospital and get admitted in this remote region are the lucky ones. Local municipalities have built isolation centres, but most are empty because there is no oxygen and no medical personnel, says Devraj Devkota of Panchadeval Binayak municipality. <figure><img width="1753" height="2409" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec699c7e80680e09ad63jpeg.jpg" alt=""><figcaption>Achham District made this urgent plea for equipment last week.</figcaption></figure>“Our people prefer to either isolate at home or try to get to a hospital if their condition deteriorates,” he adds. “We have had no help from Kathmandu.”But Nepal’s cities, including in the capital, are also out of hospital beds and oxygen, so there is little hope for outside help. In fact, a reverse flow is starting: critical Covid-19 patients in Kathmandu are being helicoptered to Jhapa or Kaski where there are still hospital beds with oxygen.The need in every municipality in the far west is the same: oxygen cylinders, pulse oximeters and testing kits, and additional hospital beds for serious cases.Says Achham’s District Health Officer Dhungana: “Oxygen is a problem. We depend on Dhangadi and Nepalganj to refill cylinders. They get used up fast, which has made it a logistical challenge.” There is also a critical shortage of staff. Despite vacancy notices, there were few applicants for specialised medical personnel even pre-pandemic. For example, although the District Hospital in Mangalsen has ventilators, there is no one to run them, and there isn’t enough oxygen.Patient referrals to city hospitals offering critical care, or just beds with oxygen, are also complicated. They are also overwhelmed, and there are few ambulances with oxygen for the 8-12 hour journey across mountain highways. Ambulances are expensive, and helicopter air lifts are even more costly. Despite this, desperate families have taken loans to try to save family members in critical conditions by air lifting them to city hospitals—often too late. Then there are all the other non-Covid trauma patients needing urgent surgery, or maternity cases. With its free treatment, Bayalpata Hospital has served more than 1 million patients from Achham and six surrounding districts of Karnali and Far-West Provinces in the past 12 years. Separating Covid-19 and other cases is a challenge for doctors like Mandeep Pathak (pictured right) who do not like to turn patients away. Even though the height of the pandemic this week, the orthopaedic surgeon has performed 15 operations, including on a 13-year-old boy from Kalikot with a fractured leg. In the past month, Bayalpata Hospital has performed 77 deliveries, of which eight were caesarean sections. “The staff adjust, innovate, accommodate, reallocate, adapt and have kept working right through the pandemic,” Pathak says. <img width="1906" height="1398" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131116/636cec6c9c7e80680e09ad64jpeg.jpg" alt="">New health protocols have been adapted to minimise disruptions, and Bayalpata is seeking resources to help with the crisis. There is fear that regular services will be increasingly impacted as the pandemic peaks.  The lockdown also means that families may wait till the very last moment to take patients to hospitals, by when it is usually too late. Bayalpata Hospital has therefore modified some of its regular services to remote care via phone calls. Bayalpata Hospital’s community health program, for example, that provides regular group antenatal care to pregnant women has been severely impacted. While the program was offered throughout the first wave, it has been interrupted during the second wave, and staff have had to resort to phone-based counselling and follow-up unless in case of emergencies.  The fear is that far-flung and traditionally neglected districts like Achham will be the last to get test kits, PPEs, oxygen, hospital beds and eventually vaccines. The progress Nepal has made over decades in rural healthcare is being undone by the pandemic.  For offers of assistance to hospitals in Far-Western Nepal, contact: Bayalpata Hospital: <a target="_blank" rel="noopener noreferrer">srijana.devkota@nyayahealthnepal.org</a> +977 9851093920   Dadeldhura Hospital: +977 9858753201 (Dr Jagadish Bista) <a href="https://give2asia.org/covid-19-pandemic-response-nepal/" target="_blank" rel="noopener noreferrer">https://give2asia.org/covid-19-pandemic-response-nepal/</a>

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

Unique hospital handover in Dolakha

<figure><img width="1050" height="626" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a779c7e80680e064761jpeg.jpg" alt=""/><figcaption>Nepalis crossing the border into the country through the Gauriphanta checkpost in Dhangadi, Far Western Nepal. Photos: DINESH KHABAR</figcaption></figure>A week before Nepal declared a <a href="https://www.nepalitimes.com/latest/nepal-covid-19-lockdown-extended-till-7-april/" target="_blank" rel="noopener">nationwide lockdown</a> to prevent imported COVID-19 cases, close to half a million Nepali migrant workers from India crossed the border into the country without any screening.  Another 1.5 million people left Kathmandu Valley for their home districts as the government announced that all long-distance buses would stop plying after 6AM on 17 March.Tens of thousands of Nepali workers driven out of their jobs in Indian cities are still trapped across the border in India – prevented from returning to their own country as the government tries to decide where to quarantine them.Darchula police records show that 128, 022 people entered Nepal before the border was sealed, there now hundreds camping out on the banks of the Mahakali River. Health desks at border checkpoints were equipped only with thermometers. <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/">Enlisting female health volunteers to fight COVID-19</a>, Ramu Sapkota and Mukesh Pokhrel“It is easier to track people travelling by air, since they are fewer and the airport has the equipment for thermal screening,” says Sher Bahadur Pun, infectious disease specialist at the Sukraraj Tropical and Infectious Disease Hospital in Kathmandu. “Local governments should not waste any time to track down such individuals and place them under quarantine immediately.”But that is easier said than done. The Health Ministry has not even been able to carry out contact tracing of the four Nepalis who flew into Kathmandu from the Gulf and Europe in March who have tested positive for coronavirus. Local governments in rural Nepal have no record of people who have come home, and are just starting to collect information of recent returnees.  <img width="640" height="295" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a799c7e80680e064762jpeg.jpg" alt="">“If anyone is infected here, it is going to be a disaster. All we have are thermometers,” says Padam Giri, mayor of the Budhinanda municipality in Bajura, one of the remotest districts in northwestern Nepal. Four individuals who returned to Sunchhahari from India recently have been placed in isolation. Of the 46 people who arrived in Bajura from Mahendranagar after the lockdown, 16 are currently in quarantine at the district headquarters in Martadi.Adds vice-chair of the Sunchhahari Rural Municipality in Rolpa Pabitra Gharti Magar: “So far no one has shown any symptoms, but if anyone did, we do not even have test kits.” The mountainous districts of western Nepal are considered to be the most vulnerable because every family has at least one worker in India who has now returned. It was also western Nepal which was worst hit in Nepal by the HIV/AIDS epidemic in the 1990s as migrant males brought the disease home and spread it to their wives.<a href="https://www.nepalitimes.com/here-now/nepali-workers-overseas-toil-through-the-pandemic/">Nepali workers overseas toil through the pandemic</a>, Upasana KhadkaMahendra Bahadur Shah, chair of the Barekot Rural Municipality in Jajarkot admits that they failed to keep records of people returning from India because they did not initially take the pandemic seriously. Many migrant workers who entered Nepal though the Gaidachauki checkpoint before it was closed are from Bajhang, Doti, Baitadi and Dadeldhura districts.Historically neglected by the central government in Kathmandu, western Nepal has chronic suffered food shortages and epidemics. People from the region make up the highest number of returnees. Even though only one case of the novel coronavirus has been confirmed in the region and is in hospital in Dhangadi, public health experts say the virus is out there. <img width="640" height="372" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a7b9c7e80680e064763jpeg.jpg" alt="">“Hundreds of thousands of people have returned to western Nepal from Maharastra, Delhi and Bihar, which are the hardest-hit COVID-19 states in India. The one case in Dhangadi is only the tip of the iceberg,” says Bikash Gauchan, medical director at Bayalpata Hospital in Achham.Bayalpata has set up a fever clinic, and 10 isolation beds have been added. The hospital has a stock of 20 precious personal protection equipment, and is producing masks locally for staff. Municipalities, district police offices and hospitals are all on red alert for a possible outbreak of COVID-19 in the region. Adds Gauchan: “We have a few ventilators in the entire western Nepal, and a limited stock of oxygen. We will not be able to do anything if the situation is to turn for worse, but if we contact traced and isolated possibly infected people we might be able to buy some time.” Back in Kathmandu, Sher Bahadur Pun at the Teku hospital says the returnees might have already had extensive interaction with their family members and hence need to be isolated and placed under home quarantine."Even if only one person is infected, who may or may not have a symptom, there is a high chance that the pandemic will spread across the village where there is a lack of reliable healthcare services and people are not aware that they need visit the doctor even if they have a slight fever,” Pun says.Among the general public, there is now a sense of panic, and migrant returnees are being stigmatised, turning villagers against each other. Even people who die of other causes are rumoured to have died of the coronavirus. Public health experts want greater public awareness, physical distancing and expanding the so far limited testing for COVID-19.Warns Pun: “If the coronavirus has entered the country unchecked through the border, then we could have a ticking time bomb in our hands.”

Returnees may be taking coronavirus to rural Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66739c7e80680e059980jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>There used to be a time when the main public health threat in Nepal was from infectious diseases like <a href="https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, encephalitis, <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a> and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener">renal failure</a> and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">poor health</a> is making Nepalis poorer.Read also:<a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37821&amp;preview_nonce=9ce6a7c55d&amp;preview=true" target="_blank" rel="noopener">Federalism leaves Nepal’s medical sector ailing,</a> Sewa BhattaraiAlso, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">stunting and wasting among children</a> due to malnutrition.In addition, <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">worsening air pollution</a> has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.Read also:<a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all of the change in world health"</a><a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialNepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a> or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.To meet these challenges, Nepal desperately needs <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">affordable and accessible medical care</a>. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance is not as easy as it looks</a>, Sonia Awale<a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa BhattaraiA survey last year showed that half of all <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical expenditure of Nepalis families</a> is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">commentary this week</a>, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.Parts of the scheme are being tried out in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a> (which last week <a href="https://www.nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award/" target="_blank" rel="noopener">won the Global Architecture Festival award</a> in Amsterdam for its design). Insurance reimbursement covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government  can no longer keep passing the buck on providing universal insurance for its citizens.<h2>10 years ago this week</h2>Nepali Times <a href="http://archive.nepalitimes.com/issue/480" target="_blank" rel="noopener">issue #480 of 11-17 December 2009</a> carried an <a href="http://archive.nepalitimes.com/news.php?id=16572#.XfId7ZMzaUk" target="_blank" rel="noopener">interview on page 1 with Baburam Bhattarai</a>, who was then vice-chair of the Maoist party.  Excerpts:‘From the very beginning, we have said that the basis of the federal system should be nationality. In Marxist terms, nationality means a common language, geography, economy and psychological make-up. A group of people that shares these qualities is called a nationality.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66769c7e80680e059981jpeg.jpg" alt="" width="392" height="600">On this basis we have proposed to constitute federal autonomous units in Nepal and we also practised this during the People’s War. Since the very beginning we have been consistent that federalism should be along the lines of nationality.’

POOR HEALTH MAKES NEPALIS POORER

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

Bayalpata Hospital in Nepal wins global design award

https://www.youtube.com/watch?v=FQ0-JH097iA&amp;feature=youtu.beDeukali Shahi, 26, looks relieved after delivering a healthy baby girl, but her calmness belies her traumatic childbirth. Her eyes fill with tears as she speaks haltingly of the previous baby she lost and the desperation she felt this time to reach the hospital fast enough so this one would live.Soon, Shahi is overcome with grief and cannot say more. Her sister-in-law Tulaja fills in the rest of the story. The baby was in breech position, but the family did not know this until Deukali was already in labour. They took her to a nearby healthpost, where the nurse said there was nothing they could do. They went on to the district hospital in Mangalsen, which did not have a surgeon to perform a caesarean.“We drove another four hours and arrived here at two in the night, and the doctors operated on her,” Tulaja said. “Now we have a healthy baby girl.”Deukali lost her first child due to the same complication, but the family did not know why the baby would not come out. In these remote mountains of Achham, home delivery is the norm and the district has one of the highest maternal mortality rates in Nepal.Read also: <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">State of the art rural hospital</a>, Marty Logan<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54559c7e80680e0523a4jpeg.jpg" alt="" width="2000" height="1333"/><figcaption>Photos: MONIKA DEUPALA</figcaption></figure>All that is changing with Bayalpata Hospital, which serves as the informal referral hospital for <a href="http://archive.nepalitimes.com/news.php?id=17650#.XWY3DeMzbIV" target="_blank" rel="noopener">Achham </a>and six surrounding districts. The government hospital is managed by the non-profit Possible Health (formerly <a href="http://archive.nepalitimes.com/news.php?id=17650#.XWY-WeMzaUk" target="_blank" rel="noopener">Nyaya Health</a>) as a private-public-partnership, and now serves 100,000 patients per year.Bayalpata’s safe <a href="https://archive.nepalitimes.com/regular-columns/Comment/mothers-in-Nepal-still-dying-at-childbirth,1007" target="_blank" rel="noopener">motherhood</a> program is accessible at any hour of the day. In the severely understaffed Far West region, Possible is practising an experimental model of healthcare that has become a lifeline for thousands of people in nearby districts. Province 7, which includes Achham, has 13 public hospitals, 16 primary health care centres and 376 health posts, but most of these are under-equipped, under-staffed and under-funded. Aside from government neglect, geography is a further <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener">challenge in these mountains</a>. Patients like Deukali have to walk or travel for days to reach a proper hospital like Bayalpata.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54589c7e80680e0523a5jpeg.jpg" alt="" width="2000" height="855">The World Health Organiaation recommends a doctor-patient ratio of 1:1,000, and while it is 1:850 in Kathmandu Valley, the rate is 1:150,000 in rural areas. A recent report by the Nepal Government shows that 20% of staff positions in the healthcare system are not filled.When Nyaya Health took up an abandoned government hospital in Bayalpata 10 years ago, there were no doctors for the people living in the area. The unmet need was so great that the newly-opened hospital could not cope with demand, and soon expanded its facilities. (See box below)“Nepal’s per capita income is very low, and more than 70% of Nepalis <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">cannot afford private healthcare</a>. So a model like this, which makes healthcare free and accessible, is very necessary in Nepal today,” says Bikash Gauchan, medical director of Bayalpata Hospital.With grants from the government and donations from philanthropic individuals and organisations, the hospital provides free medical care to up to 500 patients a day, covering a catchment of 230,000 people in Achham’s neighbouring districts.“The perception in Nepal is that a PPP model is meant to bring in investment for large-scale infrastructure projects like <a href="https://www.nepalitimes.com/opinion/climate-risk-to-hydropower-investment/" target="_blank" rel="noopener">hydropower</a>. When we proposed a model where hospitals would utilise the government funding they deserve, it went against the grain and people found it hard to understand,” says SP Kalaunee, executive director of Nyaya Health Nepal. “But we want to get the best of both worlds: use government funding and resources, but enhance them with our knowledge, skills and management expertise.”Among many things that make Bayalpata different from the average government hospital is its Integrated Healthcare System, <a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener">digitising patient records</a>. The software is unique in Nepal and allows the facility to track the health of patients including pregnant women, children under two and those with chronic diseases. Community health workers reach out to these patients door-to-door instead of waiting for them to get so sick that they have to travel to hospital.“Each of us meets patients in our village once in 1-3 months, as per the need,” says community health worker Dwarika Rawal. “I meet women of <a href="https://www.nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor/" target="_blank" rel="noopener">reproductive age and talk to them about family planning</a>, tell them about the different methods available. I also check the weight and health of children below 5, and counsel their parents about child health and hygiene.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a545c9c7e80680e0523a6jpeg.jpg" alt="" width="3000" height="2000">Rawal also follows up with patients living with chronic diseases such as <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener">diabetes</a>, <a href="https://archive.nepalitimes.com/article/nation/ending-AIDS-in-Nepal,2707" target="_blank" rel="noopener">HIV</a>, <a href="https://www.nepalitimes.com/banner/nepal-tb-cases-grossly-underestimated/" target="_blank" rel="noopener">TB</a>, high blood pressure and <a href="https://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener">mental disorders</a>, including to see if they are taking their medicines.In the past decade, health indicators in this region have shown a marked improvement because of Bayalpata Hospital, even surpassing targets in Nepal’s National Health Strategy (NHSS) for 2020 and the UN’s Sustainable Development Goals (SDGs) 2030. In the Sanfebagar area, institutional deliveries have gone up to 96%, compared to the NHSS target of 70% and the SDGs’ 90%. Neonatal mortality has fallen to 6 per 1,000 live births, a third of the NHSS target (18), and half of the SDGs target (12).Eventually, Possible hopes to not just improve service to its patients, but push through its Integrated Healthcare System, which would make local governments more responsible for providing overall healthcare rather than just operating a particular medical facility.“What makes our model successful is more accountability, and that is what is needed in our public healthcare system. We do not necessarily need more health facilities, we need to make them functional: make sure that the staff are always available, the medicines are stocked and the equipment functions as it is supposed to,” says Kalaunee. “Public healthcare needs to incorporate the use of technology and outreach to become comprehensive.”<h2>Building a rural hospital from scratch</h2><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a545f9c7e80680e0523a7jpeg.jpg" alt="" width="3456" height="2592">When a group of Nepali and American public health students set up Nyaya Health and took over an abandoned district hospital in remote Achham district in 2009, there was not a single doctor for over 250,000 people.Ravaged by government neglect and endemic<a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener"> TB</a> and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/stigma-ostracisation-for-HIV-patients-remain-in-western-nepal,1724" target="_blank" rel="noopener">HIV/AIDS</a>, the region had some of the worst child and maternal mortality rates in Nepal, and the shortest lifespan. Subsistence farmers moved to India to work most of the year so they could support families back home.Soon, <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/upgrading-health-care-through-public-private-partnership-model,582" target="_blank" rel="noopener">Bayalpata</a> was treating 12,000 people a year out of two rooms, and today it sees 100,000 patients from Achham and six surrounding districts. Renamed Possible, the organisation needed to expand to cater to the huge unmet healthcare demand of Far West Nepal.Paid for mostly by crowd-funding the $4 million three-phase expansion of Bayalpata Hospital is now complete. Coming round the bend on the highway from Surkhet, the modern facility with its <a href="https://www.nepalitimes.com/banner/starting-nepals-green-school-movement/" target="_blank" rel="noopener">state-of-the-art architecture</a> seems like a mirage in the middle of nowhere.Today, Bayalpata Regional Hospital is not just unique for its successful model of a private-public-partnership for rural medical care, but also for its distinctive design using rammed earth technology.An obsolete government facility is now one of the most modern and eco-friendly hospitals in Nepal, providing accessible and affordable health care to the most underserved part of the country.“Our specs were to use local materials as much as possible, keep energy costs low, and respect the local context,” explains Arun Rimal, a Nepali architect with the US-based Office of Structural Design (OSD). “The rammed earth uses local clay and sand from the river. The thick walls give thermal mass for insulation, and the skylights optimise sunlight and ventilation.”<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54639c7e80680e0523a8jpeg.jpg" alt="" width="2550" height="3300">The reliance on local material turned out to be a huge advantage because the project faced unforeseen logistical problems due to the 2015 earthquake and Blockade. However, the four-year construction was delayed by just six months because it did not rely too much on bricks, steel and other imported material.The facility has a <a href="http://archive.nepalitimes.com/news.php?id=5877#.XWZGkOMzaUk" target="_blank" rel="noopener">rainwater harvesting system</a>, treats its wastewater and has a network of greywater-irrigated terraces and bioswales to control erosion and recharge the acquifer. A 100kw solar array on the roof meets most of the hospital’s electricity needs, even powering the facility’s only air conditioning unit in the surgical ward.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814114/636a54679c7e80680e0523a9jpeg.jpg" alt="" width="4416" height="3312">“It was a deliberate design decision to work with the natural environment as much as possible and also to address the cultural context,” says Tyler Survant from Sharon Davis Design in New York, which also conceptualised the unique Women's Opportunity Centre in Rwanda. “We had to plan for a different kind of hospital from the West: here you have patients and relatives who have travelled for days on foot to get here.”Bayalpata has public outdoor spaces and canopied courtyards to serve as comfortable waiting areas, while the operating theatres and wards are recessed. Unlike in the US, staff housing also had to be integrated into the facility since it has fulltime resident doctors, who live with their families.Bayalpata has been shortlisted for the World Architecture Festival 2019, and besides providing vital medical care for much of the Far West, it is sure to become a landmark for sustainability in Nepal’s architectural landscape.