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.