Poverty and lack of access to health institutions have led many residents of Rolpa to lose their newborns even as the government fails to provide basic health facilities.
Mahesh Neupane |CIJ, Nepal
Pratibha Roka Magar, 33, visited the Urban Healthcare Unit in Dhawang Rolpa district. She had reached there after trekking for more than an hour and a half. But upon reaching the unit, she was referred t0 Rolpa District Hospital in Reugha on May 20 last year.
But she returned home. The hospital is a walking distance of seven hours from her home at Bhokasiwang in Rolpa Municipality-10. Dhawang Health Post at Bhanbhane in the same ward of the municipality is a 4.5 hour walk. After staying home for two days, her health deteriorated. Her body was swollen, and her eyes closed. On the third day, a female relative carried her to the hospital. Pratibha’s husband is in foreign employment.
A patient being carried to a hospital on a makeshift carriage in Thawang. Photo: Mahesh Neupane
The doctor at the district hospital checked her health and conducted pregnancy tests. Since her health was poor, the doctor referred her to a hospital in Butwal. However, they did not have the money for treatment. So the relative took her home.
Pratibha gave birth to twins on June 3, although the doctor at the Rolpa district hospital had said she had only one child in her womb, according to Budhimaya Roka Magar, the relative who had taken Pratibha to the hospital. Pratibha suffered excessive bleeding during delivery, due to which she died the same day. One of the twins also died the same day.
Dr. Prakash Bahadur Budha, Medical Superintendent at the hospital, said while one cannot guarantee she would survive, there could be some hope if she was taken to a well-equipped hospital. “Her blood pressure was high. We had advised her to go to Butwal, but she returned home.”
Pratibha’s maternal relatives took her surviving newborn and an eight-year-old daughter to their home at Lawang in eastern Rukum. The newborn survived on goat milk for seven days and died on the eighth day.
Pratibha’s 58-year-old father-in-law used to live with her. He became helpless in the absence of his daughter-in-law and passed away last December. Pratibha’s eight-year-old daughter has not attended the school ever since Pratibha’a death. The house is empty, and the field is fallow. The family essentially collapsed after Pratibha’s death.
Saving new mothers and infants is a difficult task in Rolpa. The deaths of the infants is a blot on the image of the political parties that make grand electoral promises but fail to take action.
According to the District Health Office, Rolpa, in the last four years, 207 children under five years of age have died due to a lack of medical treatment. Among them, 165 were infants.
A mother with her malnourished daughter in Bhitri Gaun, at Sunchhahari Rural Municipality-2 in Rolpa.
Twenty-four infants had died by February of the current fiscal year 2022/23 itself. Medical Superintendent Dr. Budha said that the number of infants is much higher as many such deaths go unrecorded.
In this duration, 30 children of age between two and 59 months have died. All these children had died outside health institutions.
According to Meena Kunwar, senior staff nurse at Rolpa Hospital, there are many cases of stillbirth in the district. She recalled an incident where the mother did not know of the death of her foetus, and when she finally visited the hospital, the foetus had been decaying inside the womb for a week. Kunwar said they had taken out eight foetuses after miscarriage till mid-March of the current fiscal year at Rolpa District Hospital. “Such miscarriages occur frequently when there is a lack of routine checkup,” said Kunwar.
Most wards in Rolpa Municipality lack basic development infrastructures. It takes seven hours of trek to reach the headquarters in Liwang Bazaar from Dhansi and Dhawang of Rolpa municipality-10 as there is no motorable road. An old school established in 1962 still runs on the donations collected from the parents. Most of the students go to the headquarters for secondary education. In some cases, it takes almost eight hours of trek to reach one village from another within the same ward.
According to Sher Bahadur Thapa, a local resident and District Secretary of Nepali Congress, there is a general lack of health institutions in the district, and wherever available, they are inaccessible. “During the insurgency, the Maoists did not allow opening health institutions in the rural areas as the police would accompany the institutions. The rural areas were their base zone. And now we have come to such an impasse.”
Within the municipality itself, there is no electricity in 11 wards. Currently, there are two members in the House of Representatives, one member in the National Assembly and three representatives in the Lumbini Provincial Assembly from Rolpa. Every government formed after 2007 AD has had a representation of Rolpa. Nanda Bahadur Pun Magar of Rolpa was elected the Vice President twice. Krishna Bahadur Mahara and Onsari Gharti Magar were elected Members of Parliament. Barsha Man Pun became Finance Minister. CPN Maoist Centre leader Kul Prasad KC was elected Chief Minister of Lumbini Province. Despite this, the infant mortality rate is increasing in the district every year.
District Hospital, Rolpa
However, this does not seem to be an issue for those leaders who, during elections, promise better health facilities and other infrastructures of development in the district.
In the 2022 elections, CPN Maoist Leader Barsha Man Pun from Rolpa was elected as the member of House of Representatives and Jokh Bahadur Mahara and Dipendra Pun were elected as members of Lumbini Province Assembly. Pun is undergoing medical treatment abroad as his health is not stable.
The common commitment paper of the Nepali Congress and the Maoist Centre said, “For the development of the health sector, there will be 100 beds and dialysis service at the Rolpa Hospital.” Similarly, the parties had promised to establish 15-bed hospitals in every municipality or rural municipality, upgrade the existing health posts, make medicines and medical professionals easily accessible, and conduct psychological counselling campaigns in every village.
From the CPN-UML, Ishwari GM was elected a proportional representation member of House of Representatives and Yamuna Roka was elected a proportional representation member of Provincial Assembly of Lumbini province. From the same party, Kumar Dasaudi was elected a member of the National Assembly. The 2022 election manifesto of the UML says, “All the health institutions will be upgraded and arrangements will be made to provide people-centric services along with skilled resources and advanced tools.”
Guru Prasad Acharya, a resident of Rolpa-4, said, “The district is suffering because the representatives only focus on making money. The citizens are dying due to a lack of treatment, and the political leaders are becoming millionaires overnight. This is what is going on here.”
Effects of child marriage
Ten students of Nepal Rastriya Secondary School, at Rithabot in Runtigadhi Rural Municipality-1, got married this year. Among them, six girls and one boy were studying in grade 7, two girls were studying in class 9, and one girl was studying in grade 10.
In the previous academic year, 13 students from the school got married before marriageable age. Among them, 11 were girls and 2 were boys. According to Jhakku Oli, the principal of the school, “The average age of child marriage is 13 years. Due to early marriages, the number of students in senior classes is decreasing.”
The malnourished son of Shyam Lal Biswakarma, a resident of Rolpa-4.
According to Purnakumari Thapa, acting principal at the Nepal Rashtriya Secondary School at Syuri in Sunchhahari-4, the rate of students dropping out of school in grade 9 and 10 is 30 percent. “There are many students marrying at an early age and moving to Mustang, Manang, and Pokhara for employment.”
According to the Education Development and Coordination Unit, Rolpa, a high number of students drop out of school in all municipalities in the district. This year, 12.39 percent students in Rolpa Municipality, 10.69 percent in Thawang Rural Municipality, 21.79 per cent in Triveni Rural Municipality, 18.75 percent in Ganga Dev Municipality, 8.10 percent in Pariwartan Rura; Municipality, 10.74 percent in Lugri Rural Municipality, 12 percent in Madi Rural Municipality, 13.16 percent in Sunil Smriti Rural Municipality, and 12.45 percent in Sunchhahari Rural Municipality had left their studies.
According to Baag Bir Magar, the principal of Janata Secondary School, the main reason for dropout is child marriage and poverty.
The children marrying before the legal age leave the district for fear of punishment. Due to early marriage, they must earn for their livelihood with manual labour, and their health degrades. At the same time, the teenage girls become mothers. Harka Ram Budha Magar, the ward chairperson of Sunchhahari-4, Syuri, said that the young parents who married at an early age and moved out of the district return to their village after they turn 20 for marriage registration.
Budha Magar said, “The number of people who apply for their marriage certificates and birth certificates of their children simultaneously is increasing. Child marriage is affecting the areas of education, health, and nutrition. Attempts to prevent them have failed.”
According to the data of the Rolpa District Hospital, in fiscal year 2021/22, a total of 949 women under 20 years of age were pregnant–25 percent of the 3,785 pregnant women in the district. Child marriage, said Meena Kunwar, senior staff nurse of Rolpa District Hospital, “affects the health of women and children. So, there is a high infant and maternal mortality rate.”
The number of under-age mothers is pretty high in Rolpa.
Dr. Prakash Bahadur Budha, medical superintendent at Rolpa District Hospital, thinks that the main reason for infant and child mortality rate is child marriage and malnutrition. Dr. Budha says that women who get pregnant at an early age feel shy to come for routine tests. Moreover, they lack awareness and their physical composition is immature, which leads to complexity in mothers’ and infants’ health.
Rolpa, the epicenter of Maoist insurgency, has seen cases of malnutrition, child marriage, economic crisis and illiteracy affecting children’s health. However, the local level is unconcerned about this serious problem.
There are 73 children admitted to the District Nutrition Improvement Programme. However, Krishna Prasad Pokharel, liaison officer at the District Health Office in Rolpa, assumes that the number could be much more if a regular follow up is conducted.
Malnutrition is monitored in infants up to 23 months old, by testing the infant’s height, weight, head, chest, arms, and teeth every month.
But the number of children whose test is conducted is pretty low. It is not possible for the doctor to visit the infants for a checkup. Infants below 2 years of age should follow up 24 times, but the records of the District Health Office in Rolpa show an average of 5.9 tests in the previous year.
Jagat Budha Magar, chief of the Health Division at Sunchhahari Rural Municipality, says, “The residents are not showing interest because the health institutions are not accessible to the children and there is a general lack of awareness among the parents.”
No manpower, no policy
The seats of healthcare workers are not filled in all the health institutions of the district, with only 204 of the 342 seats filled. Apart from the district hospital, only one of the four seats allocated for Medical Officer positions in local levels has been filled while the other three are filled on contractual basis. Among the 182 seats for paramedics, only 110 have been filled, 62 of them being engaged on contractual basis.
Due to the complex geography, pregnant women in Rolpa must walk for hours to reach the healthcare centers. However, there are only 52 birthing centers for 72 wards. Among them, the majority are useless as they do not fulfil the minimum standards and there is a lack of healthcare workers.
A healthcare worker monitoring the growth of a malnourished child.
When KP Sharma Oli was Prime Minister, a total of 396 hospitals were inaugurated across the country on December 2, 2020. Seven hospitals were to be built in Rolpa. However, even after two years, the hospitals are yet to be constructed.
Even though there is a seat for 11th level specialist doctors, Rolpa District Hospital has not even seen 9th level doctors.
There are eight seats for Medical Officers in the district hospital, but only six are working. Only one of them is permanent, while others are working on contract from different organizations, the provincial government, and the Hospital Development Committee.
Rolpa District Hospital has not had a Hospital Chief for two years now. Even though the provincial government had appointed Dr. Som Bahadur Ale, an orthopaedic specialist, from Butwal, for three months, he does not visit the hospital regularly.
Rolpa District Hospital does not have necessary manpower, equipment, and medicine for surgery. Even though there are no surgeons for maternity complications, MDGP Dr. Rana Bahadur Bogati and Dr. Prakash Bahadur Budha have been providing this service. However, Dr. Budha says, due to the lack of doctors and healthcare workers and necessary facilities, the patients having complexities are referred to other places.
Sharmila Acharya, a nurse at the hospital, says there is a lack of trained nurses and paramedics for maternity service in the hospital.
Last year, Rolpa District Hospital had referred 1,299 patients from the out-patient department, in-patient department, and emergency ward to other hospitals.
Dr. Budha said, “It is normal to refer complicated cases to other hospitals, but we are trying to minimize the referral.” The district hospital does not have the facilities of ICU and NICU.
Rolpa Hospital and Primary Health Center, Holeri and Sunlinchaur have the USG (Video X-ray) services, but the other health care centers do not have this facility.
Among the 10 local levels, only two have prepared the policy of health and cleanliness. None of the local levels has prepared the guidelines for health and sanitation. Except Thawang Rural Municipality, none of the local levels has implemented maternal death surveillance and response mechanisms.
Deepa Budha Magar, 23, a resident of Rolpa-10 had delivered her second child at home on October 24, 2022. She did not have a routine check up before her maternity, and gave birth to her child in 34 weeks and 4 days. She walked for four hours to reach Rolpa Hospital after seeing a health problem in her newborn. But it was already late. The child died on October 30.
Poverty and lack of access to health institutions have led many residents of Rolpa to lose their newborns.
According to the data of Health Office, Rolpa, 165 infants died in these four years including 42 infants in the fiscal year 2017/18, 22 infants in the fiscal year 2018/19, 20 infants in the fiscal year 2019/20, 27 infants in the fiscal year 2020/21, 30 infants in the fiscal year 2020/21, and 24 infants in the current fiscal year. Forty infants among them lost their lives in health institutions and others died outside health institutions.
In the fiscal year 2017/18, among 42 infants deaths, 35 lost their lives at home, and seven died in health institutions. Similarly, in the fiscal year 2018/19, 22 infants lost their lives, 13 of them in health institutions and nine died at home. In the fiscal year 2019/20, among the 20 infant deaths, 18 died in health institutions and two outside. In the fiscal year 2020/21, among the 27 infant deaths, nine lost their lives in health institutions and 18 outside. In the fiscal year 2021/22, among 30 infant deaths, eight died in health institutions while 22 died outside. In the current fiscal year, till mid-March, five infants died in health institutions while 19 died outside.
