NEPAL: The conflict's dangerous impact on health services

Photo: Naresh Newar/IRIN

Rural health services are negligible and the problem has worsened as a result of the conflict.

NEPAL, 2 February 2006 (IRIN) -

Rural health services are negligible and the problem has worsened as a result of the conflict. The women and children pictured here in Dharan city had to travel from their village for their medical check-up as the village health post had neither a health worker nor proper medicines. Credit: Naresh Newar/IRIN

The three-day journey for 52-year-old Maniram Rai and his wife was almost too much to bear. In agony with stomach pains and a high fever, Rai’s condition worsened after walking all the way from Lekharka village in the remote, hilly Bhojpur district, to reach the Nepali city of Dharan.

“This is the reality in our village. We can’t even get proper care, there are no medicines or doctors,” said Rai from his bed at the BP Koirala Hospital in Dharan, where he has been gradually recovering after a week in intensive care.

Although Nepal's government claims that national healthcare has hardly been affected by the nine year-old Maoist conflict, health workers, especially those in vulnerable rural communities, tell a different story. They say that the rebellion has had a major impact on the delivery of basic health provision in many parts of the Himalayan kingdom.

Nepal has always had a marginal health service - villagers have had to travel to urban areas and towns for proper care for generations. The government has registered some successes in recent years, including progress in combating tuberculosis, leprosy, Vitamin A deficiency and measles.

But the bigger picture, particularly for rural Nepalis, is far less encouraging. The conflict has left most government-run rural clinics - known as health posts - short of medical supplies and skilled staff.

“The health posts are there only in name. We have to take all the pain of travelling to the cities,” explained 65-year-old Jamandwoj Rai, who spent four days getting to hospital in Dharan for treatment on a septic leg wound. “I’m lucky that I had some money to travel here, but many of our poorest villagers die at home,” he added, explaining that his village had not seen a single doctor or trained government health worker for more than a year.

“There is definitely a negative impact on our health system because of the war, especially due to the unwillingness of skilled health workers and doctors to visit villages controlled by the Maoists,” said Paras Pokhrel, a doctor from Dharan’s community medicine programme.

Although his unit has made efforts to send nurses and doctors into at least six districts where the health situation is at its worst, most are very reluctant to be based there, despite the fact that few health workers have actually lost their lives in the conflict. “I am very afraid. There is no security outside the main towns. I do want to help people in need, but I have my own safety to consider,” one nurse in Dharan explained.

According to statements by Maoist leaders, health workers have never been targeted. Despite this reassurance, many rural health staff point out that the government has not offered such guarantees, and say they fear being caught-up in clashes between the rebels and security forces.

Villagers in many parts of the country have no choice but to rely on the network of Female Community Health Volunteers, a well-meaning but untrained and under-resourced corps of rural carers.

Khalanga airport, Rukum. Flights are often the only means of transport to reach the cities from remote villages, but they are unreliable and frequently cancelled. Only a few months ago in Rukum, a woman suffering from a pregnancy-related problem who needed emergency treatment, died when the flight did not arrive. Credit: Naresh Newar/IRIN

When it comes to complications in pregnancy and childbirth, most volunteers are out of their depth. The Ministry of Health has estimated that nearly 4,500 women die every year from pregnancy-related complications, mostly due to lack of skilled birth attendants and the absence of emergency services and equipment in rural health centres.

The Maoists say they have established a health infrastructure in the rural areas they control, but villagers in some rebel areas who spoke to IRIN said this was largely propaganda and that there were very few clinics or doctors organised by the insurgents.

It is not just treatment facilities that have suffered, all-important health education programmes have also stopped in many rural parts of Nepal. “The indirect impact of the conflict is of more serious concern. Due to immense psychological fear among health workers, health education and supervision for preventive healthcare measures have been greatly reduced,” said safe motherhood expert Indira Basnet in Kathmandu.

In a country with a very low literacy rate, awareness of basic health practices – like washing hands and disposing of human waste properly - is considered of crucial importance in reducing the big killers: diarrhoea, malaria, encephalitis and acute respiratory infections. According to the Ministry of Health, diarrhoea kills about 30,000 children every year, and acute respiratory diseases affected nearly a million children all over the country.

Massive internal displacement and migration to Nepal's cities due to the war, have also taken their toll on the population. A record number of children now suffer from malnutrition. According to UNICEF, about 48 percent of children under the age of five, suffer from being underweight.

“The country’s health services at village level have been pushed 10 years back,” said Pokhrel, who added that the country’s health indicators would further deteriorate if the conflict continued.