Orientation

I particularly like this map because it not only highlights Kathmandu, but the red also distinguishes the boundary of the 5 districts that separate the country.  The north side of each district includes the Himalaya Mountain range along the Chinese boarder and the south side is the hilly and plains area which borders India.  

Just for orientation, I want to share a great map with you - it came to me courtesy of a former classmate of mine, Sheila Daunt, whose organization, Search for Common Ground, has done some work in Nepal.  The map highlights the districts that SCG did in Nepal for the purpose of peacekeeping.

Next weekend I will be traveling to Kalikot, a remote mountainous village in the "Mid Western" Region of Nepal to see how the villagers live and receive healthcare services.  More to follow.  Enjoy your weekend!  

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Digging In

Digging into the work for the Nepal Health Sector Support Program (NHSSP as it is known) includes getting to know how the system works on a number of different levels - the overall government (currently operating without a constitution), the health ministry and all that goes with it including the politics, how political appointments are made, the struggles over creating a new constitution, the political factions - including the communist - Maoist - incumbent party, and the challenges that a living caste system brings to the mix.

International Development programs are currently working through a transition from a programmatic approach - the funding of specific needs with focused programs (i.e. Women & Children; HIV/AIDS; Healthcare financing; or Gender Equity and Social Inclusion) to the new approach, known as the Sector Wide Approach or [SWAp] which calls for international development programs to operate broadly across government institutions (finance, health, education, etc.) rather than merely implement a specific thematic program.  This means that programs are more integrated, and must consider how each affects the whole.  This is a good thing since in the past, a Leprosy (yes it still lives) or an HIV/AIDS program could be supported by NGOs (non-government organizations) that do not typically account for their contributions to a country's overall healthcare plan making it difficult to plan funding and determine gaps in need.  This has led to problems with duplication and waste of precious resources.

So, bottom line, SWAp is good, but can be daunting to manage across a team of program-specific experts.

The NHSSP team is basically tasked with revising the healthcare system of Nepal - including financing of the public sector, defining the Human Resource needs - both on a clinical and administrative level, scoping the job descriptions of public sector employees, developing educational programs that 'build' or I should say 'enhance' capacity - that's code for teaching people how to do the jobs that they have.  [To say 'building capacity' implies that it is not there at all, so the politically correct term is 'enhancement' - suggesting that there is something there to build on - now this remains to be seen.]  And finally, the area that I am focused on is procurement and dissemination of the medical products across the public drug supply system.

In Nepal, apparently, procurement in the healthcare sector is a point of interest for donors since public procurement has historically been fraught with potential for fraud and abuse.  There are numerous stories of cartels operating within the system that have had support from various officials to interfere with the drug supply.  One of our challenges it to put an end to such practices by creating policies and procedures that raise the transparency of everything and everyone that is associated with the procurement, distribution and management of the drug supply.  Where to begin?!

This week has been focused on discovery - meeting with various government advisors who have first hand knowledge of how the system works to build a foundation of understanding so that when I travel to the rural regions I can plan my approach and consider policy options in the context of the most challenging geographic settings (my first excursion is scheduled for the week of May 7th to a remote mid-western mountain district).

Another aspect of the drug supply sector involves suppliers who have, in the past been associated with 'undue influence' on government officials.  These suppliers are periodically invited into the government logistics management facility to ask questions regarding tenders that they plan to bid on.  Because of questionable historic practices - no one can be trusted.  While it is not a pleasant way to do business, it is one of the harsh realities of this operating environment.  The photo shown here was taken during a recent inquiry of suppliers regarding an open bid. The men in the photo are all competitors so holding one's cards close to the vest is part of the game.  One could cut the tension with a knife.

Easter in Nepal

Happy Easter!

By way of orientation, Christianity is not a dominant force in the Republic of Nepal - or in much of Asia for that matter, but there are enough ex-pats around to justify a christian church or two in and around Kathmandu. Fortunately for me, the Church of the Assumption in Lalitpur is just a 10 minute walk from home.  I found this out the way we find most things out these days - the Internet.  The article that made me aware of this church was foreboding in that it actually revealed that an explosion took place at this very same church on 23 May 2009:

Church in Nepal hit by explosion

Bloodstains covered the church floor after the bomb attack Two people have been killed and at least 12 injured in an explosion at a Roman Catholic church in Nepal. The blast, south of the capital Kathmandu, comes as the country's parliament prepares to elect a new prime minister. Police cordoned off the area, which was strewn with shattered window panes. No group has said it carried out the attack but police said they suspected the involvement of a Hindu extremist group, the Nepal Defence Army. The little known organisation says it wants to restore Nepal's Hindu monarchy. Police say the explosion took place during a service at the Church of the Assumption in Lalitpur. The article was a sad reminder that this country continues to struggle with its political identity - the maoists have taken over from the monarchy but the influences from communism and struggle for democracy coupled with the disparate ethnic groups and castes represents the proverbial 'white elephant' in every room.    I arrived at Assumption a with time to snap a few pictures few minutes before the 10 am service when I was approached by a man who asked if I wouldn't mind doing the first reading.  Of course I was happy to, but I was a little intimidated since I'd never set foot in this church before, nor had I attended a Christian service in Nepal before - I was in for a bit of a surprise.  The service was half in English and half in Nepali - a bit confusing, but a real honor to be asked to participate in this beautiful church in this very unfamiliar place. The nuns in attendance were reminiscent of another life when they had a powerful presence at Catholic schools and churches around the country - given the dress of these nuns could I help but think that Mother Theresa gave her life of service just south of Nepal in Calcutta, Indai?  In this photo the nuns were pinning the greeting corsage on one another to mark Easter.  The greeters also placed this small welcome pin on each of the parishioners.   The Church does not have pews, most worshipers sat on mats on the floor (a few chairs scattered around the periphery), much like they do in a mosque, but that did not detract from the engagement of the participants whatsoever.  After listening to the Nepali version of the homily first, the English version seemed rather anticlimactic - how I do miss the eloquence of Rev. Susan Chandler at St James' Episcopal Church! Look closely and you will notice that the date of death  for the deceased is 2060!  That's not called planning ahead, that is because the Nepali calendar began in 57 BC!   2060 is actually 2003 in the rest of the world. After the service, on the walk back to my apartment, I came across the water truck and a bird salesman. Because water (like power) is in such short supply, the wealthy have water delivered to their flats and it is stored in large tanks on the rooftop.  As I was leaving this morning, the water truck was filling my tank.  More  evidence that we have so much to be thankful for. On any given day on any given street you can find vendors peddling their wares.  I've encountered the melon salesman, the potato, onion and green bean salesman, the tomato, radish and cabbage salesman - each traveling by bicycle and each with scale in tow, weighing their goods and bagging it on demand.  The cost is quite low - I got a kg of onions today (even though i only wanted one) for under a buck - roughly 60 Rupees - half a watermelon - the sweetest I've ever tasted for less than 300 Rupees and these guys go neighborhood to neighborhood (of course you cannot count on them to arrive at a specified time).  But today I was delighted to see the BIRD Salesman!  These were not for eating - songbirds for sale! And every vendor has his own call or song or chant.  It's one of the more charming things that you'll find in the streets of Katmandu and its neighboring communities.   In this picture, Raju and his younger sister proudly display their birds - who could resist?!  (Well, this time I did, but God help me if the puppy vendor comes calling!) I hope you have a very Happy Easter and that you have a chance to enjoy the company of your friends and family. All the best!  Songbirds for Sale!

Get Outta Town!

Apparently there is a code for ex-pats to connect in strange and unfamiliar places around the globe.  It is called, strangely enough, "the Hash".  The HASH is an established venue for ex-pats around the world to meet for social activities - usually including running, hiking, touring and drinking.  Nepal is no exception.  

With a lively group of ex-pats in and around Kathmandu, a group convenes on Saturday afternoons as an excuse to get out of town, see the countryside and to get to know some like-minded folk where, if you are fortunate enough you can meet and speak with someone in your native language.  Getting there, however, is half the challenge...I mean fun.  The directions to the "HASH" were as follows; 

• At the SW part of Ring Road, head out to Dakchhinkali Road straight past the University entrance.



Meeting place for the Chobhar HASH

• Up forested hill on which village of Chobhar is located, carry on around hill until you start decending to the SW.  Pass quarry buildings on left, followed by an area of pine forest. Before the next large bend in the road look for shredded paper at a dirt track going up on the right - the "on-in" is ~250m up track by a large pipal tree.

I'll admit that on the surface this sounded easy enough but we honed in on it after passing the 'shredded paper' a half dozen times.  It turned out to be well worth the effort as we had a chance to meet many local Nepalis from the province of Chobhar, to visit their temple and see village life in action.

Ladies of Leisure 

Life in the village is slow when villagers are not at work and the Nepali's could not have been more welcoming.  They invited us to stop and chat, although that was quite difficult unless the local youth were around - most of whom speak some English and were happy to practice with us.

The gentlemen of Chobhar were not so much into talking as the ladies were - they were busy playing some kind of game that included rolling rectangular dice and moving pieces on a multi-colored cloth game board.  The game appeared to be serious business with winners and losers - and judging by the looks of the men who sat around the board, I'd venture to guess there were more on the losing side of the equation.  

And then there were the boys - always ready with an easy smile and happy to interact with westerners.  

During this particular "HASH", I met people from the Netherlands, France, Canada and the UK - no Americans this week.  They were working on projects that ranged from Roads Improvement to De-mining (an initiative that was begun by Lady Dianna), Education and Health.  It was clear that the Health Ministry is not the only government body that is without leadership at the moment!  (It was great to compare notes.)

At the top of the hill was the Chobhar temple.  Rich in symbolism, the temple architecture, visitors and the offerings to the gods filled the senses with new experiences and the gave the inquisitive plenty to explore.

The symbolism of the Hindu temple eludes we Christians, but some of the things that I was able to learn during my brief visit include:

• The copper plates and bowls that are nailed to every wooden surface (save the wooden carvings) are affixed by newly wed couples who come to ask the gods for a long and happy life together (Jacqui/Josh and Jenna/Chris - be sure to come with copper plates in hand when you visit!)
• The long strands that cascade down from the top of the temple and provide access to the gods to bring their spirits to this holy place.
• The candles, rice bowls, sweets and money that is placed on the alter-like surface are offerings to the gods.

I learned from my good neighbor and friend Samaya that one should always approach such temples in a clockwise fashion so as not to upset the gods (or offend others who are in worship).  This must be why worshipers sit facing the clockwise traffic of people.  (Thanks for the tip Samaya!!)

Throughout the village we noticed additional symbolism on homes, street corners and in unsuspecting places.  The photo above shows the eyes of the Buddha, known to represent wisdom and to convey the "all knowing" nature of the Buddha.   This symbol is so prevalent throughout Nepal that they have come to symbolize the country itself.  

As our day in Chobhar came to an end, we were rewarded once again with a beautiful sunset over the foothills of Kathmandu.  It surely was a pleasure to get out of town and to experience the camaraderie of fellow ex-pats and to see the beautiful countryside.  I hope you all had a most enjoyable weekend!

Shapes in the Fog

World Bank offices in Kathmandu

On very foggy days - and this does not pertain to Nepal - it's interesting to note how as the fog lifts you begin to observe shapes that become more clear with time.  That's very much how International Development projects work.  When you begin to plow through the mountain of reports that have been written over time - months, years and sometimes a decade or so, it's easy to become bewildered.  And then, when you can't take it anymore, something magical happens - the World Bank (or another significant party) invites you to a meeting.  In this case, I was invited to a meeting with the 'pooled donor' organizations at the offices of the WB in Kathmandu shown here.

I entered the meeting not knowing who would be in attendance or what the focus of the meeting would be - in fact I did not know that this was even a meeting with the donors.  Pooled donors are those donor organizations who give money dedicated to a cause with no particular strings attached - it must be used in healthcare, but they do not, for example specify the HIV/AIDS program, TB drugs, medical infrastructure, etc...and so, recipients really like this kind of money because it gives them the flexibility to do with it what they wish (and I wish I could say .... within reason, but I do not think I can make that qualifier).  One such donor is familiar to most of you reading this - USAID - and the organization was well represented.

At any rate, it seems that one of the major frustrations with this healthcare reform initiative at this point is that the government has been under such turmoil and change that it is a moving target of policy, personnel and accountability.  This has attracted the attention of the donor organizations who recognize that accountability will be key to ensuring that their investments (aka OUR investments) are used to make a difference to the people of Nepal.  I am impressed with the resolute intent of the donor organizations to wield their collective might to seek a greater degree of accountability from the government of Nepal.

Schedule for Procurement Planning in Nepali

Unfortunately, the government is not the only moving target - so too are the regional and district healthcare leaders responsible for the implementation of many of the programs that are being created to improve access, cost and quality of healthcare services throughout the country.  In fact, because of the constant revolving door of personnel in key positions, I am beginning to consider a new kind of training program for district and regional healthcare leaders within the pharmaceutical procurement and distribution sector - potentially a day-to-day, week-to-week and month-to-month guide as to how to operate in their given position.

As the human resources program manager acclimates to his new role on this assignment, I suspect there will be many discussions around how to create and distribute training materials that will address the needs of those who manage regional and district healthcare operations throughout the country given a broad range of communications channels and technical competencies.  We will need to ensure that we capture the attention of the educated healthcare administrator with access to power, a computer and the Internet as well as the district administrator in the village who cycles or walks to work where electricity and computers are found only in the imaginations of his or her unborn children who will (if extremely fortunate) become educated and emigrate to the developed world in search of a better life.  I hope you will stay with me as the fog begins to lift and the ideas that are developed to address these seemingly daunting challenges take shape.

Under Development

They're called "Developing Countries" for a reason, but not because everything appears to be under development.  It seems to me that very few things are, in fact, under development.  In reality, most things appear as if they have been here for quite some time.  Much of the infrastructure appears to be crumbling - roads were designed for carts and cattle, they were once paved and today they appear to be in a state of perpetual deconstruction.  Sure, some things are new - there are new homes in certain places and new ideas coming in from around the world, new investments being made in people, education and healthcare, but I wish I could say that this also applied to power and energy!

Yesterday I moved into my new apartment - a four story building with a roof deck.  While it came equipped with furniture, a refrigerator, 2 bedrooms and 2 baths, a dining room, living room and kitchen, it did not have an alternative power source. Why is that so important you ask? Because the majority of Nepal's power is hydroelectric, it is most efficient (I am told) during the rainy season - summer months to we westerners - and when things dry out so too does the source of power.  And when there is no power, the government takes matters into its own hands by rationing it - otherwise known as "load shedding".  On April 8th, the latest 'load shedding' schedule was published.  It calls for 14 hours without power during the current period....and you might not mind if the power were available to you in the morning while you were getting ready for work and in the evening while you were preparing your dinner.  Unfortunately, that is not the case.

The schedule changes every day and repeats for some unknown period of weeks.  Fortunately, my water is heated with solar power and I am told that I may want to reconsider my showering habits so that I shower in the evening before the heat that was gathered from the sun dissipates otherwise by morning the water will have cooled down in time for a lukewarm shower - this will take some getting used to!  How very blessed we are!  (rather, YOU are!)  The wealthy here buy generators or inverters.  I have an inverter - basically two huge batteries that take two strong Nepali's to hoist them one at a time to a corner of my kitchen.  It cost my landlord Rs75,000 to put this in place - that's 75,000 Rupees or approximately $1,100 - that's a lot of Rupees!  My landlord, however is a terrific guy and seems committed to make me happy.  In fact, he introduced me to Jumuna - my "Didi".

Didi means "helper" in Nepali.  Jumuna will do any housekeeping that is asked of her and has committed two days a week to caring for my things - she does laundry by hand but I have insisted that my good shirts be sent out for cleaning - even if they need to go to a Chinese laundry in Shanghai!

Jumuna was here all day yesterday while I ran errands to set things up. She speaks very little English, and my Nepali is, well embarrassingly non-existant.  Did I say "Namaste" to you already?  Oh, right, I've exhausted my bag of tricks - but I am learning that a hearty, prayerfully pronounced "Namaste" will go pretty far with the natives and deliver a smile every time.

So now that I am settled in, the work begins.  And nearly every International Development project begins with a mound of background reading - one would think that this could have been provided in advance so that I would be informed before I got here - but I think that's part of the trick - very clever when you think about it - if we knew what we were in for, would we really have come?

All joking aside, while the living can be difficult, the work is fascinating - at least at this point I can say that reading about it is fascinating.  The fact that some places on this planet (and I'm not naming names) don't have policies and regulations to ensure for the safety of the national drug supply, or that the policies that are in place are not well adhered to - and knowing that the people who dispense pharmaceuticals often are uneducated or that a drug quality test could consist of evaluating the exterior of the package rather than the chemical composition of the product or even that the ability to communicate a supply shortage (aka "stock out") is obstructed because of an inferior communications infrastructure all suggest that there are some (we know who we are) who forget to stop to count our blessings and recognize that all men were not created equal.

As I move through the mountain of reports this week, my focus is to develop a plan of attack for the upcoming months and to determine how to improve access to quality medical products in a country with poor national infrastructure.  I will be counting on your prayers to guide my work.  With gratitude.

House hunting Nepali style

So today was the day I set aside to look for a place to live outside of the hotel apartment.  My agent met me on foot and suggested we walk to see the places he thought I would like.  Our foot travels took us from a busy, dusty, noisy street outside the Shaligram Hotel where I am currently staying to a quiet, scenic, beautifully cultivated oasis which I will soon call home.  There were many single family and apartment buildings typically 3-5 stories tall.  En route we met a man from Vancouver, Canada who asked if we needed assistance.  I was so delighted to meet someone who spoke perfect English that we struck up a conversation and he invited us to see the single home he was renting in a gated community of 5 homes.  Steve is a teacher at an American school in Kathmandu who is near completion of his two-year assignment.  In some ways it was like looking fast forward at my experience in that he was very comfortable in this environment whereas I am still at the point where every sight and event seems newsworthy - but clearly it is not.

This view is from Steve's upper floor - he has a 4 story home all to himself, furnished by his school!

I found a place with a private courtyard that sits atop a hill with wonderful views of the Himalaya's....BUT, because of the climate and some other weather related issues that I have yet to understand they are not always visible, but the best views are apparently in the fall.  (If you look closely you can barely make out the foothills in front of the mountains.

This is a view from the roof deck where you can see the foothills in front of the mountains but the Mountains could not be seen today for some reason.  At the end of the street lies the Greenwich Hotel - it is equipped with nearly everything the westerner could want including pool, sauna, al fresco dining, and a charming lobby with fireplace.  I can see you and I having a cocktail at the bar after your long trip to Kathmandu (I'll save you a seat.)

The street around the hotel is quiet and the flowers are beautiful - spring has had a wonderful impact on this area of the city - known as Lalitpur.  There are a number of quaint restaurants and shops as well as a new temple - if you are Hindi, this would be your local place of worship.

And while the streets around my new home are rather tame, it is just a short walk to the bustling streets of Patan where I came upon a young man sewing flowers together and a woman cooking maize.  All in all it was a great day - tomorrow is moving day, so I've got to start packing

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First Day on the Job

Much like the first day of school, my first day was spent getting acclimated - less about the pencils paper and my desk, however than it was about the logistics of Kathmandu which seems a bit daunting even to the most seasoned of travelers.  Fortunate for me, I did not need to drive!

"Bim G", the driver seems to have the logistics down pretty well keeping to the left side of the road and managing not to hit anything or anyone despite the chaos around us.

I met with the project leaders who report directly in to the World Bank and Health Ministers.  They are managing a multi-faceted project whose scope is all-encompassing in an environment with tremendous turmoil (no focal point for leadership within the ministry of health, multiple Directors recently 'sacked' and a variety of programs ranging from HIV/AIDS, Maternal Health, Gender Equality & Social Inclusion in various stages of execution) that must be harmonized in order to bring sense to resolving distributive equities in the healthcare sector.  Good stuff, but admittedly not for the weak of heart.

The Ministry of Health Facility, shown in the picture, is home to the minister of health and headquarters for those charged with impacting the health and lives of the Nepali citizens - particularly the poor and marginalized.  While the building looks rather modern (by developing country standards) on the exterior, don't be fooled, it is poorly lit and spartanly equipped, however, it does have WiFi!

Given the disparities in the healthcare sector and the multi-caste system that lingers despite efforts to minimize the focus on a particular ethnic or religious sect, the government has elected to utilize visuals whenever possible to help explain what is going on.  This schematic was designed to demonstrate how to transport the injured.  And, much to my chagrin, the Nepali language is aligned with Sanscrit with characters that look more like Arabic than Chinese or the Roman alphabet.

Rolling blackouts, or "load shedding" as it is known here, occurs on a schedule where the city experiences 14 hours without power each day based on a schedule.  The power-on hours shift among the different areas of the city so that no one area gets power at the same time for a hot shower or reading in the evening - just as I write this paragraph, the power in my hotel apartment went out, but fortunately we have a generator here so it was just a few moments before the power went back on.  The streets however are very dark at night - darkness like I've only experienced on the 'dark continent' of Africa, although it seems to get dark early as the sun sets beyond the Himalayan Mountains.

The streets are lined with power lines that are grouped in nests of wire, much like you would coil a hose or power cord.  It seems rather wasteful of wiring, but there must be a reason for it, .... right?

The cow in Nepal, because of the high Hindu population is revered and so when I exited the bank to a loud mooing sound, I should not have been surprised - but I was, given that I was in downtown Kathmandu!

I hope you have a great weekend!

April 15th 2011 - Day One

Upon arrival in Kathmandu, I was taken by driver to the Shaligram hotel which will serve as base camp for the start of my work in Nepal.  There was so much to take in in the plant life, birds, monkeys in the downtown as well as smells and colorful roadside stands.  It won't be long before the barometer of what was and what is will shift to reflect the new reality.  What was once discomfort is now luxury and what was once overlooked now demands my careful consideration.  As I blog awaiting the arrival of my driver there are many sounds outside the apartment that are strange to my ear - a cooing like some kind of bird, a croaking that combines the annoying drip of a faucet with the deep throated regularity of some kind of amphibious creature and the periodic honking reminder that civilization lies just beyond the guarded gate of the complex that I now call home.

Last night I was given a brief tour of the neighborhood and met the four brothers who own the fruit stand on the street just beyond the gate.  One hoisted a well-fed, happy little girl who must have been no older than 6 months.  Her eyes sparkled and seemed to be made-up like a young woman in her twenties.  I remember when my precious girl was this age - I reached out to hold her and, delightfully, her dad complied.  (I am sure I will become a good customer to this family if I can get one hug and squeeze a day from that little angel.)

The day awaits, but before I go, I want to share a photo from the air as I entered Nepali airspace.  The terrain of this mountainous land is striking.  I was alerted to the challenge that awaits in ensuring for equitable distribution and access to essential medical supplies throughout the country with emphasis on the rural poor and overcoming gender inequities.  Because the land is so challenging, man walk miles for access to a primary care facility.  But look for yourself - this is what we will aim to tame over the weeks and months ahead.  (More on partnerships later.)  Have a great day.