Medical Outreach

Here is the number one reason why medical outreach is so urgent in Nepal. The ambulance service in Nepal is very poor,” says Rajesh Gongal, dean of Patan Hospital and president of Nepal Ambulance Service(NAS). Even the capital city of Nepal, Kathmandu, with almost two million inhabitants, has just 21 officially registered ambulances, government figures show, most of which are owned by NGOs and community-based organizations. Many hill and mountain districts do not have any registered ambulances. The recent news published by Nepal Ambulance Service is even more alarming.

Because no pre-hospital emergency care system exists in Nepal, victims of trauma or medical emergencies in Kathmandu are transported to hospital either by taxi or private vehicle, with no medical care en route. Since there is no three-digit emergency phone number, such as 999 in the UK or 911 in the US, many patients are not transported to the hospital in time for meaningful medical intervention.

Many patients suffer grievous complications or even die as a result. According to a study by Patan Hospital, of patients arriving at emergency rooms, only 10% arrive by ambulance. 54% arrive by taxi. only 10% of them arrive by ambulance. The consequences of being delivered to an emergency room by taxi or nonprofessional ambulance are serious. In addition to increasing trauma, many victims currently die en route to the hospital because there is no professional medical help to staunch bleeding or clear breathing passageways.

If the patients in the capital city, Kathmandu, suffer in such a way that they are found on the verge of death due to the lack of good ambulance services, it’s not hard to imagine the miserable plight of the patients in remote areas whose lives stand in sheer hopelessness and helplessness when in need of ambulance services.

IRIN News, the world’s leading provider of humanitarian news and analysis, published this shocking news on the medical situation of one of the most remote areas of Nepal, Achham.

Ram Hari Bista had to carry his 60-year-old sick mother, Nona, on his bare back for nearly six hours to reach the nearest functioning hospital. His local health center in the remote village of Rimikot in Accham district, 800km northwest of the capital, Kathmandu, ran out of medicines several months ago.

“The health care access is so bad in most villages that people die from simple diseases that can be cured with ordinary pills,” said Dhana Thakula, a 33-year-old Female Health Care Volunteer (FCHV) who has seen villagers die from diarrhea, pneumonia, typhoid, and several other curable diseases. “For how long can the poor villagers wait to get proper health access near their homes?” asked Sula Devi Nagarji, another health care volunteer.

Of the people living in Nepal, 25 percent are living below the poverty line, on 50 cents per day. This makes Nepal one of the poorest countries in the world. Rates of disease, malnutrition, & child mortality are high. Poverty in Nepal contributes to high child mortality rates. In 2016, for every 1,000 children born in Nepal, 35 died before their fifth birthday. This can be attributed to the lack of health care & education access in impoverished regions, & there are many such regions in Nepal.

With drugs at prices unaffordable to most Nepalese, who on average earn less than a dollar a day, the World Health Organization has produced the following statistics:

• Women who have accessed healthcare during pregnancy 1 in 4 (28%) Of women who have a trained assistant during birth 1 in 10 (11%)
• Women who die during childbirth 1 in 24
• Children who are very underweight Half (48%)
• People using adequate sanitation 1 in 3 (35%)
• Children with diarrhea Half (43%)
• People using improved water 9 in 10 (90%)
• Children with suspected pneumonia 1 in 4 (23%)
• Children who are stunted Half (51%)

One of the leading newspapers, The Kathmandu Post (May 10, 2016) published the following news that highlights the shocking reality of the superstitions prevalent in many rural parts of Nepal. Seventy-five-year-old Chheju Tamang of Gati VDC in Sindhupalchok has suffered from persistent fever for several months. Besides fever, she also has a cold and breathing difficulty.

Cheeju has not gone to see a doctor yet. She has no intention of seeing one. Her preferred recourse at this time of ill health is one Bir Bahadur Tamang, a popular witch doctor in the area. After seeing Cheeju, Bir Bahadur decides her suffering is caused by some evil spirit. The cure, he decides, is beating a double-sided drum in her front yard. Bir Bahadur has built quite a reputation in the village as a healer. Sought after by every sick and infirm, he is never short of clients.

Seventy-eight-year-old Choiduku Tamang suffers from chronic asthma and he has made a point of seeing Bir Bahadur for treatment. He has been on Bir Bahadur’s waiting list for the past week. “There are many ill people in the village. I’ve been helping them get better,” Bir Bahadur said. He believes in what he does and so do many villagers. The closest health post from Gati is a six hours walk to Dadakateri. People rarely visit there. They are happy with Bir Bahadur who makes house calls. Bhim Bahadur Tamang, a local man, says Gati is not the only village that relies on witch doctors in times of illness. Witch doctors are also widely counseled by the people in other villages like Dharpakahani, Anthali, Golchi, and Mandra.

Bhim Bahadur says since the health facility is far off, the sick villagers naturally see witch doctors instead of real doctors. Moreover, he adds, the health post at Dadakateri is always having a shortage of medicines. “I recently took my ill wife to the health post. But we had to return after learning that there were no medicines,” Bhim Bahadur said. According to Tanka Sherpa, chairman of the Health Post Management Committee, besides the proximity factor, the villagers’ dependency on witch doctors has also been influenced by the fact that the health post at Dadakateri faces several operational hiccups. “There are some outstanding disputes regarding the operation of the health post that has led to the shortage of medicines and essential services,” he said.

IRIN news highlights the following gruesome picture of Nepal’s poor road conditions. Nepal has built about 7,000km of roads nationwide over the past decade, according to the World Bank, but this still leaves more than half the population without access to all-weather roads in a country where millions struggle to reach safe, nutritious food, which ranks as one of the world’s worst places for a child to fall ill (out of 161 countries evaluated by NGO Save the Children) due to women’s and children’s poor access to health care.

Nearly half of Nepal’s 27 million people live in rugged hill and mountain areas. People living in the mountains (roughly 7 percent of the population) report some of the weakest development indicators nationwide. The national average for children under the age of five who are chronically malnourished is 41 percent; this figure exceeds 60 percent in the mountains. According to the government’s most recent Nepal Living Standards Survey in 2011, Nepalis living in rural areas – especially in hills and mountains – report roads in their areas are unsatisfactory.

Traveling across difficult terrain has been cited by HIV service providers as one reason patients fail to adhere to treatment regimens. Due to the lack, or poor quality, of roads in rural Nepal, maternal healthcare facilities may be more than a day’s walk away which, practitioners say, can be deadly. “If women can’t get to a healthcare facility in time, they either die or have a fistula,” Shirley Heywood, a gynecologist who has been working in rural Nepal for a decade with the International Nepal Foundation, told IRIN.

Obstetric fistula is a condition caused by prolonged and obstructed labor resulting in a hole in the birth canal, leading to continuous urine leakage. According to the UN Population Fund, an estimated 4,602 women in Nepal are living with fistula; there are up to 400 new cases annually. “I have had patients who are carried for more than two days to us for fistula treatment. I hear all the time how we need to increase capacity for fistula surgery in Nepal, but I don’t think that’s the whole picture – access is a huge issue, and roads are a vital part of that,” Heywood said. Analysts have also pointed to the lack of reliable road access as a factor in weak education achievements, including the 35 percent of Nepalis who remain illiterate.

While the private hospitals are mushrooming in the capital city, the rural villages of Nepal are deprived of access to health services due to the apathy of the government. The total population of Nepal is approximately 27 million people, more than 80% of whom live in very rural, inaccessible areas. Given this fact, the health services of rural people are of paramount importance, but Nepal’s government does not seem to recognize this. The following statistics will shed some light on this dismal fact :

The shortage of healthcare workers in Nepal is reflected in the population per doctor at 18,439 and per nurse at 4,987. The number of public sectors hospital beds for a population of 24 million is very low at 1 bed to 5,435 population; the situation is made more difficult by the reported under-staffing and hence under-utilization of district beds (MOH, 2003). Furthermore, the rural to the urban disparity is reflected in the physician-to-population ratio of 1:850 in Kathmandu and 1:30,000 outside of the capital (NSI, 2004). The overall distribution of staff in terms of the mix of skills shows a deficiency in the middle technical grades, particularly managerial staff.

Staff vacancies and absenteeism are common with only 85% of sanctioned posts filled and only 70% manned (MOH, 2003). Some of the push factors leading to poor retention of healthcare workers in rural areas include poor infrastructure, lack of opportunities (e.g. further training, career mobility, good schools for children, and jobs for spouses) for themselves, their children, and family, low salary and lack of support, lower social recognition compared to urban areas, and lack of security. Frequent changes in government and thus, leadership also lead to a cascade of staff changes down to the level of division chiefs and lower (Agarwal, 1997).

One of the leading newspapers,The Guardian, reports the following news: Nepal’s department of foreign employment throngs with crowds queuing for the permission they need to migrate. “We process 1,200-1,500 applications a day,” said Chiranjibi Adhikari, the acting director of the department, sitting at his desk surrounded by stacks of dusty files. “So many want to go abroad for work. Even if they have a job here, they think they’ll get more money abroad. Migration is not good.

Even unskilled workers go outside, which leaves a shortage here, and if skilled workers go, Nepal will suffer. According to the department’s figures, the number of migrants leaving annually has almost doubled in the last five years to almost 400,000. And despite the stories of horrific suffering faced by migrants abroad, many here are returning to jobs they have held for years – a sign of the lack of opportunities in Nepal and the fact that for many Nepalese, migration works.

With the increasing migrants from Nepal to gulf countries, especially youngsters from rural areas, only the women, children and elderly are left behind in the villages with no one to take care of them. Whenever they face common or emergency health problems, most of them are not able to help themselves. Shockingly, this has included a sizeable out-migration of health personnel, especially doctors and nurses as well, to countries of the global North as well.

Typically, in a male-dominated country like Nepal, women have no say in many household affairs. They suffer so much silently. One of the worst practices in Western Nepal is known as a chhaupadi system for Hindu women which prohibits a woman from participating in normal family activities during menstruation because they are considered impure. The women are kept out of the house and have to live in a shed. This lasts ten to eleven days when an adolescent girl has her first period and four to seven for every following one. Childbirth also results in a ten to eleven-day confinement.

Some superstitious people think that a new mother or a menstruating woman will bring bad luck on the whole household if she stays in the main house, or even believing that she can make cow’s milk into blood. One of the leading newspapers, The Diplomat (Jan 18, 2018) had this alarming news published :

In the first week of January this year, a Nepali woman who was sleeping in a hut during her menstrual cycle was found dead by her neighbors. According to the preliminary investigation, police suspected that Gauri Bayak, 23, a permanent resident of Turmakhad Rural Municipality-3 in Accham district, died due to suffocation, thanks to the narrow and congested hut where she was sleeping. She was the latest victim of the Chhaupadi custom, which is prevalent in several far-western districts of Nepal. In the last ten years in Accham district alone, nine women have lost their life while living in the huts during their menstrual cycle,” Menuka Dhunaga, a local journalist, said in a report published in Nepal’s vernacular daily, Kantipur. “Despite the announcement of destroying such huts to end such practices, women continue to die and practices go unchecked,” she reported.

Nepal has only 0.67 doctors and nurses per 1,000 population, which is significantly less than the World Health Organization’s recommendation of 2.3 doctors, nurses, and midwives per 1,000 population. One of the leading newspapers, The Himalayan Times, published the following news dated, Nov. 30, 2019 :

Patients are forced to visit private clinics and hospitals due to unavailability of health workers at the government health post even for minor health problems. Patients with severe health issues are compelled to visit private hospitals and pay exorbitant fee.

The health facility has been facing problem ever since health workers were transferred to other places as per employee adjustment process. Health workers working at the hospital have left for their assigned work stations, but the health workers transferred to the hospital have yet to join duty. Unavailability of the health workers has affected service delivery at the health post. Senior Assistant Health Worker Dharma Raj Badu said a health assistant and an auxiliary health worker were transferred from the health post as part of the adjustment process about two months ago.

Now this is very sad news. Poor people in Nepal can afford only the government hospitals but unfortunately, they are not functioning as they should due to the lack of a number of medical paraphernalia. There are many cases in which patients have to wait days together to get medical treatment for their ailments in the government hospitals due to inadequate medical facilities resulting in even premature deaths.

The following news published on The Kathmandu Post dated July 13, 2023 sheds light into the miserable plight of the government hospitals:

Laxmi Prasad Niraula was brought to Bir Hospital in Kathmandu on July 29, all the way from Ilam. Niraula was suffering from jaundice and had fluid accumulating in his stomach. He had been referred to Bir Hospital by the Nobel Medical College in Biratnagar and required immediate treatment. On the afternoon of July 30, Niraula remained on a bed in the emergency ward, awaiting treatment. Attending doctors had told his relatives that Niraula couldn’t be admitted to the hospital because there were no beds free in the general ward. He could seek treatment at a private hospital instead, he was told.

“I wouldn’t have come here if I could afford private care,” 52-year-old Niraula told the Post. “I will stay here until I receive treatment or I will die.” Every day, dozens of underprivileged patients like Niraula visit Nepal’s oldest hospital, not because it is the best medical care facility in the country but because it performs a vital public service—it treats the poor for free. But every day, numerous patients face the same dilemma that is plaguing Niraula. The hospital is overcrowded and it doesn’t have enough beds, forcing doctors to ask patients, even desperately poor ones from the country’s hinterlands, But these patients can’t afford care anywhere else, so many of them end up camping out in or outside Bir Hospital, waiting for a bed in the general ward. As one of the country’s few tertiary care medical facilities, Bir Hospital receives referred patients from all over the country, especially those who cannot afford private, or even subsidized, medical care. But the last refuge for the country’s sick and poor has long been beset by mismanagement, political interference and a lack of human resources. At the time of reporting, for two days, not even a nurse came to see Niraula. Since the hospital is so understaffed, not a single doctor or nurse works the night shift at Bir, say administrators.

“Only paramedics and medical officers see patients at night,” Dr Kedar Prasad Ceintury, hospital director, told the Post. After spending all night in the emergency ward, sharing the narrow bed with one, or at times two other patients, Niraula and his relatives were frantic. His family members were attempting to contact anyone they knew in positions of power who could help Niraula, but to no avail.

“Every day, over a dozen people—ministers, lawmakers, political leaders and others—call me for a bed on behalf of someone they know,” said Ceintury. “No recommendation is needed when we have vacant beds.”

But Ceintury conceded that every day, dozens of patients who come to the hospital for quality care at an affordable price are forced to seek private care due to a lack of sufficient beds at the hospital.

“When patients are forced to wait for days if not months for treatment or even to just meet the doctor, all their hopes shatter,” said Gagan Thapa, a former Health Minister. “They are forced to seek private care and all their expectations from the state and government are destroyed.”

Most patients seem to know that getting admitted to Bir Hospital is a long shot, and yet, there are few choices for the poor.