Deja 2

The more confounded the situation becomes, the more difficult it is to capture it in a blog. Today I write you regarding a new chapter in the reform of the Nepal healthcare system.  Today I write you without concern for reprisal or retribution. Today I write the truth - unplugged and hope that it stirs something in you to welcome a new level of understanding, to accept that things are not always what they appear and to contemplate the 'good' that donors do around the world with the hope that you will also consider the role of international aid - particularly as it pertains to the health of the poor, the underprivileged and the marginalized.
In prior entries, I wrote about how Nepal as a post-conflict country under Maoist rule is endeavoring to create a constitution focused on the peace process; how it should be building a constitutional assembly that rules by consensus and how the various parties and castes in the country harbor ideologies so disparate that coming together seems impossible.  In many ways, the needs of a government body are much like a marriage - and, at the risk of taking too many liberties, there are two things that can make it work - (1) Stakeholders must want the same things in the end - i.e. a healthy population, a productive population, a population driven to innovate, to build infrastructure, to spread equality, etc., and (2) Stakeholders must be at the same intellectual level in order to facilitate communications that are clearly understood and respected.
When there is a clear gap in 'wants' and 'intellectual capacity' (in my opinion), reaching common ground is akin to traversing a chasm without the appropriate equipment.  This, ladies and gentlemen, appears to be the situation in which the government of Nepal finds itself.
In August, after considerable strife, internal conflict and public squabbling, Prime Minister Khanal resigned.  Within a week, a new prime minister was selected.  This was initially viewed as a 'must happen' event - albeit tragic since it appeared to result in a vacuum in leadership.  When Prime Minister Bhattarai was elected, however, there was a renewed sense of hope as his academic credentials and personal image was one of a thoughtful leader despite being known as the architect of the Maoist insurgency that led to a war in which more than 12,000 were killed, shifting the course of history in Nepal.
I do not write this to offer a history lesson of which I know very little, only as background to what I see as a potential miscarriage of justice to the Nepali people and potentially a mechanism to hoodwink donor organizations around the globe. (Keep in mind that Bhattarai is the 4th Prime Minister in Nepal in 5 years).

Shortly after his election, Bhattarai, like those before him, shuffled the political deck by replacing many of the Ministerial posts, creating yet another leadership team.  And with new ministers - including a Minister of Health (Nepal's 4th since the start of calendar year 2011) who would be soon under suspicion for bribery - a host of department leaders were appointed including Directors of many health ministry posts thereby bringing to a halt much of the progress our team had been making by establishing new systems, procedures and guidelines to bring transparency to governance structures in the health sector.

This, my friends, caused me to reconsider my role as a reform agent in Nepal.  But before making any rash decisions, I met with a local supplier who claimed to have something to say regarding corrupt practices within the healthcare sector's procurement practices.  In this session, I was able to confirm leaks to 'preferred suppliers' and practices that led to bribery and unfair influence of government officials.  And while such activities have been going on for quite some time, the network of activities that underpinned this was broad and complex.  A colleague of mine and I shared this with the donor organizations who seem interested in leveraging these findings to affect change, however, a perverse incentive arrangement between country leaders and their donor organizations suggests that success is measured in money spent, not in averting funds distribution.  Alas, the challenge reaches a new level of complexity.  Now, we not only need  to manage national governance within a fluid and feckless government system, but the trigger to affect change - donor organizations and their power base - the ability to disperse donor funds - hangs like a piece of rotten fruit before a hungry mob.  You want to get the mob to eat it before someone smells the stench on your hands.  This was an alarming epiphany.

A few months ago, I was informed by a contact at one of the world's largest consulting companies of a book called Megacommunities and the concept of leveraging key stakeholders to get things done.  In his book, Reggie Van Lee describes how the engagement of stakeholders in key sectors is important in affecting long term change with a focused mission.  His conclusions could have a profound affect on the way that donor funds are managed if implemented properly.

Back to what makes a marriage work: (1) Wanting the same things out of life.  If the government of Nepal is truly vested in outcomes for the country, it should engage in honest dialog not only with donors who are making care and infrastructure possible, but the advocacy groups (another key stakeholder) should have a seat at the table.  This makes a lot of sense given that when civil society groups in Nepal would rise up and let their voices be heard - typically in protest - the government would respond - with a 'too little' too late response, but it would create some form of action.  And (2) suggests that these groups should be allowed to offer their insights and experience to affect change and to balance the power base - in the process this brings transparency to the table.

I conclude this blog today by removing myself from the madness that has become the reform of Nepal's healthcare system. Sadly, it is my opinion, that the government is not ready for reform that utilizes resources that have become increasingly scarce from developed countries like ours.  Not only should the government set metrics for how it will utilize donor funds, it should - in good faith, and with the engagement of civil society - establish SMART objectives [Specific, Measurable, Achievable, Realistic and Time focused] as do the world's most successful private sector organizations.

Deja vu 2 is no longer a suitable endpoint. Donor governments need to act swiftly and with authority before the source of funds - people like you and I, stand up and interrupt the budgeting process.

It has been a pleasure to share my experience with you. Thank you for your interest.

The Fog Lifts

When you're in the eye of the storm things look peaceful and the pace of what is happening in the hinterland may be deceptive.  From the eye, it's easy to believe that not much is happening and so too is the life of a consultant working with the Health Ministry in the Federal Democratic Republic of Nepal.

Despite all the games of musical chairs, dodge ball and other political shenanigans, we've set out to affect substantive change to the healthcare system in this country.  There are days that I think that this is not possible, not much is happening and long term change cannot be affected.  But, as I move from the eye to the balcony (a term served up by Ron Heifetz who offers new ways of looking at leadership), I can see that the swirl of activity that we have put into motion is beginning to have an impact.

On some days it's the simple things - ensuring that key personnel are equipped with the tools that they need to operate more efficiently - like computers.  Believe it or not, I've been working with a team of locals who have shared a computer among 6 people in one segment of the department - just imagine the bottleneck that this has caused - little wonder the procurement plan for essential drugs and medicines is late every year.  Well, last week the team finally received computers!  Can they use them? Well, that's another story, but I am confident that our 'capacity enhancement' efforts will make considerable progress in this area soon.

More than 50 suppliers submitted bids and showed up for the bid opening for medical equipment this month.

The drug supply that comes into Nepal through central procurement has lacked quality systems - little wonder there are so many concerns about feckless pharmaceuticals and medical products that fail to meet basic standards.  And when it comes to medical equipment, department directors (Family Health, Child Health, Maternal Health, Epidemiology and Disease Control, National AIDS Center, etc) have been requesting and seeking equipment from specifications that were developed twenty, fifty and in some cases a century ago.  It is hard to imagine - but now I know why when I step into a public health facility, it is like stepping back in time.  Why would a country do this? For one reason, those responsible for requesting equipment have not been aware that technology has evolved in nearly every aspect of medicine - anesthesia equipment, x-ray, ultrasound, beds have evolved from manual crank to hydraulic (a term that terrifies those in rural settings), imaging equipment has evolved from film-based to digital based and diagnostic testing has evolved from reagent based single test to multi-test, throughput based.  We have now implemented a system where a sustainable update of medical technology specifications can be built into the procurement process.

Archaic equipment in a rural hospital O.R.

A Quality Specialist will be coming to devise a plan where pharmaceutical testing - including chemical composition - will occur not only pre-shipment into the country, but at various points in the 5 regions and potentially a sample of the 75 districts.  There have been reports of cartels interfering with the supply chain and replacing free drugs purchased by the government and donors with sub-standard items and then selling the 'free drugs' on the open market.  Other corrupt practices have interrupted the drug supply and caused many to go without essential medicines.

Nepal is fortunate that the HIV/AIDS population is small - under 10,000 affected people in a country of 30million, however, the supply of medicines and services was interrupted as a result of a failure to act among government officials.  Essential services to provide care and medicine to many of the disadvantaged groups around the country - migrants and families, sex workers, prisoners, intravenous drug users - will be affected putting greater populations at risk.  The management of the supply of medicines will be moving to the Logistics Management Division where capacity is still being developed to include - basic forecasting skills, accessing global reference pricing, updated specifications and quality medicines.

In addition, the base of suppliers who will consider competing for the government's business are beginning to return after turning their backs on a government that proved to be too corrupt and undeserving of their time and attention.  Local and international suppliers are once again beginning to show up to bid in a more transparent process for Nepal's business.  They appreciate that fact that we now have a formal Complaint Handling and Dispute Resolution procedure and a Code of Ethics that will guide (if not ensure) the process.  This is encouraging despite the seemingly slow progress.

The data that is obtained from health facilities and districts that indicates consumption and usage patterns around the country offers little insight on what is actually happening.  The analysis of this data will provide further insight to the nature of the problems and the interventions that must be implemented to improve forecasting, planning, budgeting, etc.

When I step back and consider where change has been affected. I am pleased with the progress, the transparency and the loopholes for potential untoward actions that have been closed.  The fog is lifting off the mountains now, monsoon season is passing and with each day it appears that we can see with greater clarity and chart a more direct course toward an effective healthcare system with an improved access to essential medicines and services.

From Kindergarden to Death & Taxes

If you've followed this blog at all, you may now appreciate that August is neigh and in Nepali terms, that doesn't mean the end of summer vacation, start thinking about closing down the pool or that you should write your congressman about the importance of balancing the budget.  It means there's less than 30 days before the new constitution is due from the incumbent Maoist party.  Now I know, we've heard it all before, much like the looming deadlines facing the USA on the federal debt ceiling crisis, Nepal is struggling to pull together its various political factions in order to establish a new constitution.  August 30th marks yet another extension deadline that was set on 30 May.  And since the new deadline was set, things in Kathmandu have been relatively calm - no serious protests, no bandhs (strikes) and few public threats against public officials.  There is, however, another type of upheaval going on - we call it political jockeying.

It's no secret that Nepal is comprised of a variety of political parties and that the country is made up of people who come from various castes - much like you learned about in your 4th grade geography class, these castes establish the worth of the people and their proverbial lot in life.  The GESI component of the reform project that I am working on is dedicated to improving Gender Equality and Social Inclusion and intends to minimize the attention that is given to the caste system, yet the concept of individual value consumes considerable share of mind among the Nepali people.  Little wonder, therefore, that the government is equally obsessed with social structure and caste. (What came first, the chicken or the egg?)
In an effort to satisfy the various political factions within the country, leadership has embraced the childhood game of Musical Chairs (and although Nepal has already elevated other childhood games such as Chicken, the Hoki-Poki and Shoots & Ladders to national pastimes, it's latest obsession with the kindergarten game of Musical Chairs seems to have consumed the attention of Nepal's government officials).  
Since our team began its work on healthcare reform last October, there have been dozens of changes of high level government officials at the whim of the national leadership.  When one group is dissatisfied that the Minister of the Interior is not of a particular cast or party affiliation, a change is made and a new minister is appointed.  When, after months without a Minister of Health, a high cast Chettra is appointed, we learn that he has been replaced.  This is very unfortunate given that the recent Health Minister was engaged enough to admonish the Secretary of Health for her excessive travel schedule to luxury destinations while coyly evading critical duties such as signing contracts for NGOs who deliver critical healthcare services and completing the national healthcare budget.  Finally, it felt as if we were moving in the right direction....until 10 days ago when news broke in the Himalayan Times that the Health Minister (along with other officialss) was replaced by someone of a 'lower caste'.  No real explanation was made as to why this was so important after the new Minister was less than 60 days in the job.
Musical Chairs has become a government obsession and a real distraction for Nepal's leaders.  As new Ministers and division heads are appointed, (and I can speak from experience with my current government counterpart,) they almost seem paralyzed with fear to make decisions.  If s/he cannot satisfy one of his/her 'masters', it is possible that his/her service will be short lived and a replacement will be found.  And what do leaders do when they are afraid to make a decision? They go AWOL.  That's right, they hide, become evasive, defer, delay and obfuscate reality.  It's an interesting game of cat and mouse where no one wins and the cheese gets stale before anyone gets to taste it.
I received an interesting book from my section head that was intended to help me acclimate to the Nepali culture.  Please indulge me as I share a brief segment with you that I found truly enlightening on the Nepali mindset.  The source, a book titled, "Fatalism and Development" written by Dor Bahadur Bista, includes a passage that speaks about Achievement Motivation in Nepal;
         "As a career objective in modern Nepal, every Nepali tries to have a Jagir, 
          a salaried job where one does not have to work but will receive a pay cheque
          at the end of each month.  Candidates still show their zeal and enthusiasm for 
          work at the time of applying for the job, because that is the rule one has to follow.  
          But in such jobs one is not expected to actually work."  
Regrettably, this seems to reveal some fatalistic realities that undermine societal advancement in this country.  Reading it was an 'a-ha' moment for me and something I began to suspect when I would observe staff members sitting at clean desks with blank looks upon their faces when asked to attend to a task that had been assigned for completion days prior.
The fatalistic attitude that seems to penetrate the lives and minds of the Nepali people is perhaps the only reason that we have not yet seen the violent uprisings that have been observed in Tunisia, Libya, Egypt and elsewhere throughout the Middle East and North Africa.  Will such uprisings occur at the end of August? We'll have to wait and see, but the rumors flying about more changes to government posts within the healthcare ministry are paralyzing its leadership and delaying the critical change that is needed in order to meet the deadlines and objectives of this program as well as for the country to further benefit from the generosity of various donor organizations.
And as the life of a government employee goes, so too does the life and death of a Nepali citizen.  Last week I took the opportunity to visit Pashupatinath with my wife who came to see first hand what life in Nepal is really like.  Pashupatinath is Nepal's most important Hindu temple located along the banks of the Bagmati River.  Many choose to be cremated here in a ceremony that is  steeped in custom, ritual and tradition.  Even in death, castes are separated by a bridge.  Lower castes can cremate their dead on the lower side of the bridge, while higher castes and royalty can conduct their cremation ceremony along the upper banks of the river on the other side of the bridge.  The dead are prepared by cleansing their bodies in the river and then laid on the pier and in a combination of ritual and custom, they are fed fire to begin the cremation - as life (like death) is taken in the mouth.  The burning of bodies and prayers as well as other sacrifices ensures that the Gods will receive them and that the dead will receive the intended blessings as provided by friends and family in the tradition of a burning sacrifice.
While it's been said that the only certainties are death and taxes, in Nepal we can only hope to add change to that list.

Demands of the Job

Every day is an adventure.  It's not always the kind of adventure we are hoping for or the kind of adventure we were anticipating.  But we learn a lot along the way and try to steer the ship despite the ever shifting current and the occasional tsunami.
If you've ever been a part of international development programs - often called "projects",  you know how they work....donor organizations make contributions with the expectation that the teams they appoint to do the work will make them proud and create a story that allows them to promote (if not merely share) the outcome of their generosity.  This is a wonderful thing when it works well.  Such "Projects", however, have become known as sources of 'easy money' to government officials in 3rd world countries - not because the administrators hand out gobs of cash, but because the projects themselves are able to allocate funds as they deem appropriate - buying vehicles, hiring support staff for government officials and paying for trips under the guise of 'capacity enhancement' (aka training and education).  One such project, I have learned has paid for my government counterpart's education at Johns Hopkins University - (and, yes, I too would like to have ridden that train!)
Nonetheless, I share this with you only because I want to differentiate the kind of work that I am engaged with from a "project".  We are a team of government advisors.  Our role is to develop plans that aim to put the healthcare system on a path toward increased access, improved quality and affordability.  We collaborate with the government to devise these plans, although sometimes (more often than not) we generate the ideas, plans and do the analysis to justify the recommendations and then work to gain the support of the government in moving forward.  It's a seemingly noble, lofty and daunting initiative that we signed up for with the intention of working collaboratively with government, EDPs (External Development Partners, aka donors), NGOs and a variety of other stakeholders depending on one's area of focus - in my case; suppliers, regional and community healthcare leaders and other members of the Nepal medical and drug supply chain.
As mentioned earlier, donors are well intentioned, and their intentions are as formidable as they are well-directed.  This, of course, presumes that they are directed at all.  You need only walk the streets of Kathmandu to realize just how many NGOs have penetrated Nepal - each with the goal of providing a service or program that is intended to improve some aspect of the lives of the people of Nepal - be it their roads, water supply, energy, education or healthcare delivery.  Strangely, but not surprisingly, there is no regulation or true coordination of such activities.  This creates a problem for anyone trying to see what is truly going on here.  Here's an example;

As we all know, HIV/AIDS is a pandemic which spans the globe - some countries hit harder than others and none have had it as hard as South Africa.  Fortunately for Nepal, HIV/AIDS affects less than 1% of the population of the country, but unless managed carefully, the downward trend, resulting from a strong supply of ARVs (drugs to manage the disease) and other commodities for infections, could quickly reverse and spiral out of control.
Over the last month, Nepal has been teetering on the edge of disaster with respect to the mismanagement of supply to the population struggling with this disease.  How can this happen? Glad you asked (but in a minute you may not be).  In most countries, there is an established body known as the CCM or country coordinating mechanism.  This body is tasked with coordinating the efforts of the many NGOs (non-government organizations) - that work to fill the void in services that the government cannot provide due to lack of funds, personnel, skills, etc.  They can also help to identify areas of risk prior to outbreaks of disease, famine, conflict, etc and then marshal the resources where they are needed.

In Nepal, the CCM responsible for coordination of HIV/AIDS commodities seems to have had a lapse in control and consequently the supply of the drugs and service providers for people living with HIV/AIDS are on the verge of being interrupted.  For an AIDS patient, this can be devastating.  Even a brief interruption of essential medicines to manage this disease can result in new strains of the disease that cannot be managed by conventional drugs, necessitating the development of new clinical cocktails and much experimentation.  It is a truly precarious and difficult situation.
To address this situation, the Global Fund has agreed to provide an uninterrupted supply of HIV/AIDS products to Nepal.  But before they do, they are asking that we define and implement the logistics and supply chain that will ensure for quality control and efficient distribution of these items.  This is an essential component of my work here - and they want to see this achieved over a remarkably compressed time frame.
Without boring you with the details, this equates to much more than sweating the small stuff.  This will be an all out race to the finish.  Deep breath! More later.

Reading Between the Lines

Whenever in a different country where your mother tongue is not the native language there are many things that are subject to interpretation - the turn of the head, the wave of the hand, shuffling of papers, a bare foot pointed in the direction of the host, etc., so knowing the meaning of these subtle gestures can only help to assess a situation that can be somewhat tenuous.
Government politics is a lot like the interpretation of subtle gestures...but on steroids.  Every nation is built on a history of actions and reactions to events and while people form their opinions, cultures formulate their mores or, what is culturally acceptable.  Take the custom of bakshish, for example.  Who said it's wrong to pay off an official because he was kind enough to award you with a lucrative contract? It is after all, just a gesture of appreciation, is it not?  When do acceptable cultural norms become inappropriate, distracting and potentially dangerous? Who's to say?
One's frame of reference underlies the decisions s/he makes and influences what s/he tolerates from others, so when a government is comprised of an interconnected network of cultures, castes and political ideologies, it's little wonder that the tension behind the decision making process is so strong it leads to deadlock.

This is, in essence, what has happened in Nepal in the post conflict error.  It's a contradiction in a way; the country claims that it is working hard to bring gender equality and social inclusion to its operations, yet people are careful to point out when they have been raised Brahmin (the top echelon of the caste system) or when they disapprove of someone who accepted an inter-caste marriage between say a Dalite and a member of a higher order caste.
Nepal has established a minimal healthcare package for its public health facilities - an honorable and rather difficult task whereby the health ministry must consider the greater good.  In the process of weighing the economic situation, burden of disease and potential health risks of the population, it determines what it can (and must) provide as basic services.  Once defined, all other goods and services are incremental to the basic plan.
In addition to the basic plan of essential drugs and medical services offered by the government, the health ministry, comprised of a number of divisions run by physicians who lead different healthcare programs, offers a variety of goods and services on a national basis.  These divisions include; maternal health and safe motherhood, family health division, child health division, emergency and disaster relief, national center for aids control services, the leprosy unit, etc.
Historically, each of these programs defined, forecasted and procured medicines and services for their own health initiatives - sometimes (quite often in fact) with the support of various donor agencies, they determine what they can offer and they make arrangements to deliver these items nationally with the support of the logistics management division which does general forecasting, planning and procurement for the bulk of the public goods for health.
What goes on behind closed doors of division leaders and those who work directly with suppliers outside of the logistics management division (and even within the LMD), has been the subject of ample controversy over the years.  Some say that because procurement of goods can be so lucrative (for those of a particular moral persuasion), that centralized procurement under the careful watch of international consultants with the interest of the donors in mind, must replace all decentralized efforts.
If you read between the lines, this means that someone needs to aggregate and harmonize the national need and foster transparent practices that lead to more efficient, cost effective and streamlined outcomes.
If you were asked to step in to change such practices in a culture on the other side of the globe, would you accept?  

Making a Plan

It's been nearly two months now since I arrived in Nepal, and the fascination with what is different is beginning to take a back seat to the focus on what needs to be done.  Much of what needs to be done is the creation of systems and processes that can be followed and used to guide good businesses practices - and when even the term "good business practices" is foreign to your audience, you can imagine the challenge in helping them to embrace concepts like transparency, accountability, data management, meeting discipline, etc.

Pharmaceutical Suppliers meet at the Ministry for a 'Bid Opening'

The Nepal healthcare system services the healthcare needs of 30million people - it's not a huge country - so on the one hand it seems manageable, but the flip side, its relatively small size makes it more challenging to attract suppliers to provide products and services to satisfy the needs of this small developing country.  When you couple the size with the geographic challenges and limited economic and natural resources it's a perfect recipe for being overlooked as a market for the private sector.  Add to this the potential for leaders who could potentially be in 'rent-seeking' positions and suppliers really need to think twice about doing business in Nepal - or similarly challenged nations.

The concept of 'rent-seeking' is used to describe a practice whereby political appointees pay their superiors for the 'honor' of serving in a government post.  To earn the funds to pay the rent (so to speak) they often engage in practices that enable generation of funds outside of traditional (or acceptable) or "good business practices".  Now I don't want to implicate Nepal by suggesting that this kind of behavior takes place here - but just wanted to share an example of what happens in some developing countries to cast suspicion on government officials and causes private sector organizations to be wary of doing business in such settings.

Little wonder that the survival of such nations is so dependent on the generosity of donor organizations who seek to improve the lives of the poor and marginalized by creating programs that build infrastructure and systems that aim to build a foundation for growth.

One such program was introduced by KfW - a German organization that has generously underwritten a program to record, track and maintain medical equipment in the two most geographically remote regions of the country.  Leaders within the Ministry of Health participated as the contracted organization shared their plan for service and maintenance.  This is a great step forward, but it will be months before we know how effective this pilot program will be in improving functionality and the overall life of medical equipment.

To strengthen the skills of those entrusted with managing donor and government resources, we are holding regular meetings on a variety of topics that 'enhance the capacity' of political leaders and their delegates.  These range from reporting systems, accountability, working with suppliers, creating and managing budgets, using data to make informed business decisions and general analytical skills.

In the next few weeks we will be coordinating efforts to create a complaint and dispute resolution system; demonstrating how international supply partnerships can reduce costs and improve efficiencies; harmonizing division needs for essential medicines and healthcare products and building the skills of biomedical engineers to provide global insights to medical technology innovations designed specifically to address the needs of developing countries and their healthcare systems.

Every day there are more needs and more gaps that need to be addressed and, while daunting, it's exciting to help people find a way forward.  On the surface the obstacles seem insurmountable, but in reality it can be managed by coming together and Making a Plan.

If  your plan includes going out for a nice glass of Cabernet and a taste of Stilton cheese or perhaps a fine Sauvignon Blanc with a side order of mussels poached to perfection, ....by all means, plan on having a glass for me!  Enjoy the day!

Hard-working Nepali's use their heads when it comes to tackling particularly difficult problems.

It's a Long, Long Road

The adage is as old as time - 'hit the road', 'get on the road', 'move on down the road' - there are a thousand variations on the theme, and no matter which one sings to you today, it's inevitable that some version of this theme will resurface for you tomorrow with yet another twist.  And so twisted the road as we made our way past the landslide over mountain, through valley, past river, shack, yak, goat and bull. 

We moved more swiftly at times than I was comfortable, but we were men on a mission.  Word had it that a bandh (national strike of transport services except airports) was in progress for the next day meaning if we did not complete our journey back to Napalgunj by tonight, there would be no travel by motorized vehicle the next day and we'd miss our flight back to Kathmandu (or K-du as I like to call it).

The road back was as beautiful as the road out, and along the way, we met a number of road warriors out to fulfill their own life's purpose.  Shepherds tended to their flocks, milkmen delivered their goods, the tupperware salesman made the rounds and the produce specialists loaded their goods for sale on their bikes.   Some transported their goods atop the old noggin and some - like this feisty little guy took the goat by the horns and muscled it from one point to another.  Every site was a feast - a reminder that it's a different life here.  It's a tough life no matter how you slice it, and the only way to make it through is to live unaware of how the other half lives.

It was the scenery that made our 15 hour journey back possible.  And since the visuals can speak more eloquently than any text, I will leave you with a series of photos that tell the story.  Enjoy!

This little guy could be the poster child for why we do this kind of work! His mom made the best meal I'd had since landing in Nepal - homemade noodles with local spices, tomato and garlic (sure beats dahl bat!)

 When you look up 'multi-tasking' in the Nepali dictionary, you are likely to find a picture of this woman.  She's got one child on the breast and she's playing Rock-A-Bye baby with another in the sack.

Bicycle produce salesmen load their vehicles for a days work.

We made it back in one day, but the strike necessitated that we take bicycle rickshaws back to the airport.

 The hotel we stayed at during our last night - Traveler's Village in Nepalgunj, is owned by an American woman who has now been in Nepal for 37 years.  She specializes in 'American comfort food' (and talking your ear off) - I had waffles for breakfast with homemade sausage.  (Don't ask what was in the sausage - I didn't want to know!)  Talk to you next from K-du!

Accept it and Move on

As I write this, a terrific thunderstorm is rolling over Kathmandu.  The sound and feel of it brings me back to the night the rains precipitated the landslide which sealed the road into the remote village of Manma.

Well, on the 3rd day after the 'slide, we could hear the sound of horns echoing through the valley - a sure sign that there was movement of vehicles.  Drivers blare their horns as they approach hairpin turns on roads barely wide enough for one.  The horns had stopped and now resumed, although without the passion or intensity that came with aggressive movement.

With a bit of confidence that we could pass through the blockage, we decided to make our move - so at roughly 6:30 in the morning we packed up and headed down the mountain.  It took 2 hours before we reached the obstructed area only to find that  movement was at a dead stop.  While the obstruction was largely cleared, the traffic on both sides was competing for right of passage.  Dozens of tractor-lorries and assorted vehicles jockied for position.  As each approached the focal point of the obstruction, the reason for the lack of movement became clear - rocks, combined with water, a naturally tight land formation and growing anxiety from the crowd that loomed eagerly along the rocks created the kind of drama that is legendary on Survivor.

Three hours later, our driver made it through and we began our journey back to the terai region.  After 5 hours we had not yet covered 1/10th of the distance we needed to cover by the end of the day in order to catch our flight the next morning back to K-du.  Our sense of urgency to get back in one day was exacerbated by the fact that there would be demonstrations in Nepalganj and throughout the Katmandu Valley that would prevent travel by vehicle.  These demonstrations will continue until Nepal passes it's long-awaited constitution.

The trip back, much like the trip out was riddled with difficult terrain including heavy dust, mud, river crossings and rock.  In the few paved areas it was even more terrifying as the driver felt a need to make up for lost time by accelerating along steep and narrow mountain roads.  At one point we rounded a bend to find a bus in the middle of the road and 20 or so of its passengers standing along the road looking into the crevice below.  A tractor lorry had gone over with two men on board.  Everyone knew they were dead.

Death in Nepal is a fact of life - if you don't die of dysentery, starvation, a road accident, obstructed labor or some not so exotic tropical disease, you are one of the lucky ones.  People have come to accept that if they get ill, death is the easy way out.  There is a fatalistic attitude among the Nepalis.  Your destiny is pre-determined, and there is little you can do to affect it.  I hope to learn more about this view as I get to know more about the Nepali people.

So what do people look forward to?  A night out? A movie? A local sporting event? Not exactly.
A treat to the Nepalis - especially to the peasants in the countryside might be to add something to their monotonous diet.  A typical (and when I say typical, I mean 3x/day) meal for a Nepali peasant is dahl baht - lentils and rice.  If fortunate enough to have access to a local butcher - or shepherd who has sacrificed one of his flock for a couple thousand Rupees (~$25US), s/he may be able to add some goat, pig or chicken to his/her dahl baht.  In this photo, a man has slaughtered a goat and is now harvesting its remaining delicacies - the head and feet - for sale.  The final photo shows two men - on the side of a village road preparing a pig for sale after removing its head.  

While at first shocking, slaughtering animals in a public setting is part of the culture of living in an uncivilized place.  So too is living without the luxury of running water, power, Internet, trash pick-up, a sewage system, extensive dinner menu or access to healthcare.  Vehicles that lose their footing and tumble off mountain roads are just another part of that very same same culture - you can read about such accidents in the local papers every day.  There is little that one can do without a fully accountable government and without people who are willing to take a stand and challenge the status quo. Is it the fatalistic attitude of the people or is it something more? Until they know how to affect change there appears to be little to do but Accept it and Move on.  

Waiting it Out

The morning we learned of a landslide that had closed the road, it hardly registered with me.  I mean, could some dirt and a few boulders across an already dirt and boulder road really be that big of a deal?  So, I did what any other western-thinking person would do - put it out of my head because, clearly that was someone else's job and surely 'those people' would get on it lickety split so that by the time we needed to go anywhere, of course the road would be cleared.  We were planning to say 3 days in Kalikot district to provide capacity development for local governance councils, healthcare leaders and district health personnel.  We would be much too busy to concern ourselves with the landslide.

The meeting facility where the training workshop took place was donated some time ago by DFID (Dept for International Development) - a British organization that has generously contributed on numerous levels to develop Nepal's infrastructure.  The generosity of DFID to the Kalikot district alone is acknowledged on a large poster in the center of the village just outside the meeting facility.  In addition to DFID's generosity, USAID has contributed significantly to the supply chain and logistics for the drug supply.  And GIZ, a German donor organization has also made significant contributions to the health system infrastructure in Nepal.  A key component of my work in Nepal will be to evaluate the procurement practices, distribution and logistics of the drug and medical products that feed every institution from sub-health post to district stores to tertiary care center throughout the country and to identify gaps and opportunities for improvement from working with the private sector suppliers to the people who forecast the needs within the villages, districts and regions.  My findings will be used as evidence to support recommendations for policy change and to work with my government counterparts and the donor organizations to implement these recommendations.

On my 2nd day in Kalikot, I arranged to meet the district storekeeper at "the dungeon" and to go with him to the hospital to begin my work.  To get there involved a 40 minute downhill trek.  In this picture, you can see the blue roof of the hospital from the hillside where we began our hike.  By the time we got to the facility, I was in a pool of sweat.  The sun was beating down and the trek was as rigorous as any hike I'd taken in the mountains of North America.  While there was a road, we took the short route that took us through yards, down paths, over rock, ledge, etc. Not only do these people do this EVERY DAY- many do the trek in flip-flops at breakneck speed.  And some make the trek while carrying loved ones on their backs in a basket! (This may be the origination of the term, "basket case", but the real genesis of the term eludes me.)


So we reach the facility and our first stop is the hospital pharmacy. Local practices demonstrate non-adherence to procedures for logging what has been dispensed, estimating demand or managing supply.  The rest of the tour was no more encouraging causing me to succumb to the reality that there is much to do in terms of developing and reinforcing systems that will lead to improvements in operations at the district level.  With 75 districts and the rigorous terrain that defines Nepal,  an approach must be designed that can be replicated without relying exclusively on on-site educational initiatives.  

As it turns out, politics plays a heavy hand in personnel appointments despite the civil service exams as an initial step for assessing talent for positions in the healthcare sector.  When appointed by a government official, individuals often believe they are protected and consequently do not feel obligated to report to work or extend themselves to meet even basic job requirements.

Finding and retaining physicians is another challenge.  Trained healthcare workers quickly become frustrated with facilities that have old, outdated and non-working equipment.  And as if that is not enough, the remote areas where they are asked to practice are difficult to access, offer little in terms of intellectual stimulation and do not allow them to routinely practice the skills that they were trained to do. It was discouraging to see the condition of the hospital - beds without bed sheets, an O.R. that had not been used in nearly 2 years.  Lack of supplies. A birthing room with the tell-tale signs of a birth that took place days before.  A clinical laboratory which relies on reagents and microscopes rather than state-of-the-art diagnostic tools.  Reporting systems and communications infrastructure that lag behind advances that the civilized western world witnessed nearly a century ago.

I left the hospital and district stores compound feeling a burden of responsibility to the people of this village yet not quite knowing where to begin.  Upon returning to the workshop that was in process, I cast a hopeful eye toward the bottom of the valley realizing I had not heard or seen a single vehicle moving up the hill all day.  Indeed, the road was still obstructed. 

Getting there.

As you probably know, by mere virtue of the fact that the Himalayan Mountains dominate the northern border of Nepal- this is a country with a diverse and rugged landscape.  The lower plains of Nepal along the Indian boarder are referred to as the "Terai"- it ranges from flat to rolling hills and it's climate is hot, humid and at times quite wet.  As you head north toward the Chinese border, the topography becomes increasingly rugged - from the "Lower Hills" to the "High Hills" to the "Mountain" areas.  And while man has conquered Mountains by skiing down them, boring thru them and climbing up them, the mountains and hills of Nepal are anything but tame.

Despite all this 'hoopla' about tough geography, remote villages, lack of this or that, blah, blah, blah... a team of eight of us (plus drivers) was setting off in three vehicles to a remote area of the country that would take us from the terai through the hills to the edge of the Himalayas with the intention of answering a host of questions that would inform our approach to improving access, managing cost and enhancing the quality of healthcare in the remote areas of this mysterious, yet captivating country.

In this rigorous landscape, the word 'remote' takes on new meaning.  It means you get your water from the rain, the river or the melting snow-capped mountains.  It means you get your electricity from power that is generated from harnessed water that rushes through channels in the mountains or from solar panels atop your south-facing, mud-hut roof.  It means that when kids head off to school it's a 4 hour trek before school and another 4 hours after.  'Remote' also means that if you want to ... make that NEED to see a doctor, you can walk up to 3 days (yes, DAYS) to get to a health post and then pray that the doctor showed up that day - if there is a doctor posted there at all.  It means you can't call in advance to make an appointment; you can't select your provider; you can't expect that medicine will be there when you need it and you'd better have friends or relatives with strong backs (who love you a LOT) in case you need someone to haul you up or down a mountain to a health post to see if you can find someone who might be in a position to tend to your needs.  [Never mind have the tools necessary to address them.]

Imagine for a moment there is only one road that leads to your village - it is subject to heavy rains, erosion, landslides and the stress that tractors, busses and other vehicles put on it.  Noone in your village owns a car - noone!  The road to your village is like the coronary arteries that feed the muscle that pumps life through your body and if it should suddenly close - just like your heart can arrest, this paroxysmal collapse of life-sustaining nutrients can end life as you know it as it threatened to for me and my team when we visited the remote village of Manma in Kalikot District - located in the upper hills of mid-western Nepal in early May of 2011.  The horror is still fresh in my mind and will remain there for years to come.

Our driver overlooks Kalikot district upon arrival.

It was Sunday night, we had just completed a 12 hour drive deep into what must be one of the most remote locations on the planet.  The views en route, while treacherous, were spectacular and awe-inspiring.  The last 30 or so kilometers of our trip took nearly 2 hours (on the Autobahn, 30 km would take roughly 12 minutes) - through water, over rocks, in mud requiring periodic stops to 'road repair', assess risk and slowly migrate toward our destination.  There were times we held our breath, held silent vigil and negotiated with our ultimate judge for one more kilometer.

 Just as we arrived, the rains began (although it's pre-monsoon season, when the rains hit, they hit hard).  They began slowly at first and increased in intensity as we listened to the thunderous drumming on the corrugated metal roof of what I began to refer to as the 'dungeon hotel'.  The "White Guest House" in Kalikot is no rural resort, no upgraded safari bungalow and no place for someone of your caliber to spend a single day of your blessed life.  It was...well, let me just say it was an experience I shall never forget and lest any one of us should ever complain that the thread-count in our bed sheets does not exceed 500, a visit to the White Guest House might be just the right prescription to ensure that such trivialities no longer register as we consider what really matters in life.  I'll be the first to admit that this experience was long overdue for me.

Stairway within the 'Dungeon Hotel'

We fell asleep to the sound of thunder and awoke to the news that a landslide had closed the road and might not be opened for days - or weeks.  We were literally trapped.  The only way out was to head north, deep into the Himalayan Mountains toward China where the roads are less traveled and expectedly worse than what we had already experienced.  Unimaginable at best. Downright isolating at worst.  The thought of becoming a long-term resident of Manma village was a thought I preferred not to entertain, but there I was considering the unimaginable.

But we had just arrived and fully expected that this would be open before the day was out because that's exactly what would have happened had this occurred in the civilized world that some of us can call 'home'.  Unfortunately, but not surprisingly, the road did not open that day, or the next...or the day after that. Ugh.

(To be continued.)