MOBILE HEALTH CAMPS
Serving The Needy Women
For thousands of population living in remote parts of Nepal particularly women, who were denied basic health and Reproductive Health services for years following intensification of Maoist insurgency, Mobile Reproductive Health Outreach Services have come as a boon as it provides all health related services from diagnosis to counseling and treatment and referrals – and all these available in their villages. Funded by European Commissions Humanitarian Aid Department (ECHO) and implemented by the United Nations Populations Fund (UNFPA) in partnership with ADRA-Nepal and Phect Nepal , the Mobile Reproductive Health camps have already taken care of many needy population of far western and mid-western region. From a small financial contribution of donors, the mobile health camp is making a big difference in the lives of thousands of disadvantaged and marginalized female population who live under the sword of death
By KESHAB POUDEL in Gaira, Doti
It was cold and foggy but overwhelming number of rural women poured at the premises of Adarsha High School of Gaira village of Doti district, 500 miles far west of capital. The response indicates how much people of this region are really in need of emergency medical services. From infant to young and middle aged to old, there was assemblage of people from different religion, race, caste, creed and political ideology.
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Queue of patients : Help, at last
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Organized by ADRA-Nepal, District Health Office, District Public Health Office and local health posts with the support from UNFPA, the Mobile Reproductive Health (RH) Outreach Services is first of its kind that came as a dividend of peace in the region. Although two-day camp estimated to check up 2000 people, the first day registration alone was much higher than expected.
The crowd of people who desperately waited to tell their health problems was so big that three doctors, dozens of local paramedical staffs and Female Community Health Volunteers had tough time to cope with the pressure. Although December 9, 2006 was Saturday or government holiday, the school premises was almost packed from 8: 30 in the morning.
“We have to check up the patients till the daylight permit us to do so. As an only lady gynecologist, many women want to share their problems with me,” said Dr. Rajni K.C of ADRA-Nepal. “Women feel easier to discuss their health problems including reproductive health with women doctors.”
The huge crowd, who came from far distance of Dadeldhura and Doti districts even by trekking fours to five hours, without any hurry lined up in a long queue without knowing how much time a couple of doctors can spend with them.
For many, just touching a doctor seems to heal their disease. “I have never seen any doctor in my life. As I felt pain in my lower parts of stomach, my son and husband brought me here. I have to see how my ailment will heal just by a touch from a doctor,” said Kumari Devi Khadka, 62 of Rajwar Village of Doti district. “My husband and son told me that doctor can heal all disease.” Like Khadka, mother of ten children, there are many women who were going to face medical doctors first time in their life.
The rush of people was so big that a patient might get in an average 2-5 minutes to consult with doctors. “We spend our time depending on the complication of a patient. If a woman has severe problem, she gets even half an hour. If people do not have major complications, it will be shorter,” said Dr. K.C.
“What I want is to tell the doctor about my problem. I have been felling pain below my stomach,” said Tikeshwor Madai, 45, mother of seven children.
Although it was a health camp, there was also an emergency service for those who needed immediate service.
“I have seen people from far away districts starting to assemble at the school from early in the morning. This kind of gathering is only possible during polling day or festival but they are not as peaceful or quiet as they are now,” said Shiva Dutta Bhatta, Public Health Administrator of Dadeldhura District. For majority of disadvantaged people particularly women of different ages this was the day when they could meet with doctors to complain their health related problems. Health camps fill gaps of inadequate health service.
Funded by ECHO and implemented by UNFPA, a mobile health camp under Mobile Reproductive Health Outreach Services to Conflict-Affected Population brought festive mood in Khara as well as other surrounding villages of Dadeldhura and Doti districts.
“This is for the first time in the last ten years when these kinds of big gathering was possible in the district,” said district health official Bhatta.
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Dr. Singh : Humanitarian task
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Initially targeting over 14,000 clients/ patients (women, men and adolescent) and local health care providers, the first phase of health camps have already been organized in Dang, Rolpa and Banke of mid-western region and Dadeldhura, Doti and Accham districts of far western region.
Not only for the patients, the camp is also training ground for health workers, “We are learning ways of pre-natal and post natal care as well as other surgery,” said Bhagirathi Pandey, 20, assistant nurse at local primary health care center. One of the aims of the camp is to train and orient local health service providers to deliver reproductive health services and surgical procedures to conflict-affected populations. Dadeldhura and Doti were two most affected districts where many sub-health posts buildings were also bombed.
Although people have been living with painful ailments for a long time, their faces are full of smiles. The camp organizer ADRA-Nepal, District Health Office and District Hospital showed documentaries in the camp to generate level of awareness. One of the aims of the program is to increase the awareness of clients/patients of RH preventative care and general RH care through dissemination of IEC materials.
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Zonal hospital : Inadeuate manpower
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For most of the people, country’s main political agenda of republic Vs monarchy or first past post system Vs proportional representation, Maoist Vs government seem to have no meaning. They know they have to cast vote when the elections is held. Despite the rampant poverty and its effect, there is smile in the faces of all.
Similar Problems
Brought to the camp by their sons, husbands and daughters, daughter in laws, the overwhelming majority of women had similar health related problems - constant pain below the stomach for several years. After reaching the health camp and expecting to see the doctors, these women looked completely satisfied.
Although Safe Motherhood Policy 1998 stresses the need to increase the accessibility, availability and utilization of maternal health care facilities and to strengthen the technical capacity of maternal health care providers at all levels of the health care system, the hospitals and health centers in far western region of Dadeldhura and Doti are yet to see it materialize.
“One of the unfortunate things is that we don’t have enough manpower at all in all levels. From doctors to other medical staffs, the Seti Zonal Hospital is running with half the staffs,” said Dr. Ganesh Bahadur Singh, acting medical superintendent of Seti Zonal Hospital .
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Women in health camp : Long suffering
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In such a situation, though it is small, health camps are only hope for people of remote parts of Nepal . The health problem of women varies from serious nature of reproductive health to general problem and the camp offers all kinds of services If there is serious case including the third degree of uterine prolapse, the doctors at the camp will refer them to the next camp for surgery.
“This project is highly relevant to ensure that preventive and corrective measures for reproductive health concerns can be provided before they severely limit livelihoods,” said Junko Sazaki, UNFPA’s Representative to Nepal .
According to the World Bank’s Country Assistance Strategy 2002-2007, with approximately 85 percent of the total population living in rural areas, the basic health care services remain limited.
Health After Conflict
For a majority of people living in rural areas, access to health care and facilities are hampered by economical and cultural barriers. At a time when 12 years long conflict had badly shaken the health care services with lack of health workers, health facilities and medical supplies, overwhelming poor people have no alternatives other than to die without basic medicines. After beginning of peace process, the health camp is only effective way out to reach to the disadvantaged population.
UNFPA estimates that the burden of most common diseases, including maternal illness, which are estimated to grow by 100,000 new cases per year remains almost attended. The Mobile health clinics provide diverse health services including diagnosis, counseling, treatment and referrals of cases to the National Health System, thus addressing potentially life threatening concerns such as safe family planning and childbirth, emergency obstetric care, gender-based violence and sexually transmitted infections and HIV/AIDS. The camp also provides vital surgical procedures such as prolapsed uterus corrections.
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doctor checking up women : Too busy
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In terms of Nepal ’s ecological regions, poverty in the mountains is significantly above the national average. The average level of poverty in remote mid-western and far western districts are much higher than the national average of 31 percent. In far west and mid-west, the people whose income is less than US$ 1 a day are significantly high.
Nepal is one of the poorest countries in the world with per capita GDP of around US$270 in fiscal year 2004. According to Nepal Living Standards Surveys (NLSS II), a study conducted by Central Bureau of Statistics under the support of the World Bank, the poverty has dramatically declined in Nepal between 1995-96 and 2003-04. In 2003-04, 31 percent of population is poor in Nepal . The mid-western and far-western regions have the highest levels of poverty, 60 and 64 percent respectively. Among development regions the proportion of women consulting for prenatal care in the far western and mid western region is still very low compared to other regions.
“I had given birth to 11 children, all the children were delivered at home. When I was last pregnant 13 years ago, I knew there was a hospital in Dadeldhura but it was economically unaffordable to us,” said Khoji Devi Oli, who was a third degree patient of Uterine Prolapse and referred for surgery in second round of health camp in March, in Gankhet Village Development committee of Doti district. “I survived all painful conditions of uterine prolapse but my family is economically in no position to spend about Rs.23,000 (US$300) operation cost,” said Oli, whose only four daughters and 3 sons survived out of 11 births.
Cases of Uterine Prolapse
According to medical research, the cases of uterine prolapse are common in Nepal and there is high concentration of women with uterine prolapse in Doti and Dadeldhura districts. Out of 4,766 patients checked up in the first heath camps conducted in Dadeldhura in November, 2408 cases were related to General Reproductive Checkup Health, Gynecological Services, Ring Pessary Insertion and 60 cases referred for Uterine Prolapse Surgery.
“All over Nepal , hundreds of thousands of women are suffering from uterine prolapse. Its prevalence among women at reproductive age exceeds 10 percent and is as high as 24 percent among women between the ages of 45 and 49 years. All together more than 600,000 women are in urgent need of medical care,” said Junko Sazaki, UNFPA’s Country Representative.
Although Prolapsed uterus is very serious and painful problem related to reproductive health, many women hid it because of social and economic reasons. For people who cannot afford to buy primary medicine like cetamol, it is virtually impossible for them to pay the cost of treating the prolapse.
“Since society is conservative and reproductive health related problems are taken as sin, no one wants to disclose it whatever the pain they have to suffer,” said Dr. Gopal Gnawli, acting district health officer of Dadeldhura District Hospital . “The women disclose the disease at the last stage when it is impossible for them to deal with.”
Although Dadeldhura-Dhangadhi Highway connects many villages of far western region with the rest of Nepal including health facilities of the country, majority of people are still isolated by the poverty and conflict. The cultural barrier is so crucial that women cannot ignore it before deciding to break tradition.
“I have been suffering from uterine prolapse for the last fifteen years but I hid it within me. Had I disclosed it then, my husband would have remarried and I would have to suffer physical as well as economic problems,” said Kosidevi Air, 55, of Doti district.
Despite efforts of several NGOs and INGOs, the access to health care and facilities are hampered by geographical, economic and cultural barriers. The twelve years long armed conflict has jeopardized the basic health care services exacerbating the lack of health workers, health facilities and medical supplies.
More than two third of health centers are now without trained health manpower in Dadeldhura and Doti districts. Even in the district hospitals, only one doctor has to perform all the roles.
“We don’t have enough health workers in the hospitals as well as in the primary health care centers and sub-health posts. I have to perform 2-3 delivery and run other general surgery and out patient department as well,” said Dr. Gnawli. “In a situation when the district health infrastructures are unable to provide the basic health service and Reproductive Health Service to disadvantaged and needy population, the UNFPA’s mobile camp is only way to cover the areas out of reach.”
Along with nearby village, most of the people visit the camp because they don’t need to pay any money for all the check up, diagnosis, treatment and vital surgical services. “The patients do not need to pay anything here. All the cost will be borne by the camp,” said Mimi Mireille Guiraud, monitoring and evaluation officer of UNFPA based in Dadeldhura. “Problems with the health systems in far western districts of Nepal are that they don’t have proper documentation.”
With a total budget of EUR 320,000, the project is a part of the US$ 6,000,000 aid package to Nepal by ECHO, which is the biggest single source of humanitarian aid in the world.
UNFPA chose ADRA-Nepal and PHECT-Nepal to run the mobile camps. The ADRA-Nepal will run all the mobile camps providing all basic health facilities and medicines and PHECT-Nepal will take up the referral case of surgery for Uterine Prolapse in second round.
“UNFPA is not a usual partner but we considered its proposal to run mobile camps in remote parts of the far-western and mid-western region as timely and appropriate. At a time when many people of far-western and mid-western region are in desperate need of basic health services, health camp is best way to meet the basic needs of people,” said Dominquez Feron, Technical Assistant for Nepal. “ Nepal is now in peace but poverty and access to health remain same.”
Published by UNDP and Ministry of Health in October, Millennium Development Goals Needs Assessment for Nepal reveals that there are huge resources gap that is hampering the implementation of program to provide basic health services to women particularly the pregnant ones. Of course, antenatal care coverage has been improving over the last decade, but the progress has been very slow. Nepal requires 26.2 million dollar in fiscal year 2010 for the maternal health intervention package.
At a time when there is a huge resource gap to introduce the package all over the country, the health camps show how a small amount of investment can bring bigger change in reproductive health to the people living in conflict-affected areas of far-west and mid-western region. .
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