The village of Khangra lies beyond the hills in the south from the Rajpur Comprehensive Clinic on the border with India. There are about 65 families that live there. Khangra is one of the most prominent villages in the Naka Chhetra. The Naka Chhetra (translated as the “Border Region”) has a distinct geographical identity in South-Western Nepal because it is the only region in the entire country where the border with India runs through hills instead of plains. Other prominent villages in this region are Kalyanpur, Gauriya, Adabaruwa, and Gandhaila. These villages have about 30–50 households each.
Above is the map of Rajpur Rural Municipality and shows its administrative division into seven wards. The yellow line indicates the trail that is about seven hours walking distance on average from the Municipal center to Khangra.
Barriers to Health: The region is cut from the rest of the country due to an absence of roads on the Nepali side. Going to the municipal center is about seven hours walk away through steep mountain passages and river banks. Similarly, Nepalese telecommunication networks do not work, and almost everyone here uses Indian telecommunication networks. Due to the lack of connectivity, people are often not able to call for help during medical emergencies. Even the health workers of this region are not updated timely about changes in national health programs.
Locals, including an elected representative, make the journey from the village to the municipal center along the mountainous trail.
Drinking water is indeed a luxury. The few community taps in the village are supplied through narrow plastic pipes from a water source about 3 kilometers away in the mountains, and it is common that the pipes would get clogged, damaged and buried by landslides etc. There is a school that teaches its students up to the eighth standard after which they have to go to the schools in other towns in order to pursue their education. Given the fact that most parents are not willing to send their young daughters away it implies that for a lot of girls, education stops here.
Students of the fifth grade pose for a photo in their classroom in the only school of the region.
Local Health Facility: There is a Community Health Unit there and is served by an Auxiliary Health Worker and an Auxiliary Nurse Midwife. It is housed in a two-room building with a tin roof. Some drugs are supplied that cater to the commonest illness and pregnancy. The elected representatives from this region have been able to lobby a budget of about US $2000 for adding a new two-room building for this health facility.
The two-room building of the Community Health Unit in Khangra.
Two chairs, a table, and a medicine cabinet are seen in one of the rooms of the Community Health Unit. The other room designated for Antenatal Checkups is furnished with a plastic chair, a plastic tea-table, and a plastic bed.The Auxiliary Health Worker has gained a good reputation around the village and is trusted by people there. The Auxiliary Nurse Midwife, who was recently appointed, complained that the number of antenatal checkups was “almost nil.” She was in-charge of the facility when the Auxiliary Health Worker was away, as was the case when we reached there. During our short visit there, a man who looked to be in his mid-fifties showed up to refill an empty blister of anti-hypertensive medication. Sadly, those drugs were not available at that time. He was asked to get it from elsewhere until another allotment of the drugs came. But he was concerned about the newly developed swelling on his feet, something that told us his disease condition was worsening. The 11th and the 12th of every month were designated dates for vaccination camps at two different areas in the region. However, it was not difficult to understand that they were not regular or “not taking place” entirely, as one of the members of a local mother’s group would tell us. The Community Health Unit had no outreach programs.
The Female Community Health Volunteer: And there is Ms. Devkala Shrestha, a Female Community Health Volunteer. She serves the villages of Kalyanpur, Khangra and Adbaruwa. She visits homes of pregnant women during their delivery and helps them decide whether the women can deliver at home or has to be taken to an equipped health facility outside of the region. She has received training from various institutions and non-governmental organizations on how to identify risks during child delivery. “Luckily, no mother or baby has died since I started working” in her village and the neighboring ones, she proudly declared. She also provides Vitamin A supplements and Polio vaccines from her home during the designated days as per the National Immunization Schedule. A day before the vaccination, she has to hike all the way to the larger health facility located at the municipal center. When we asked her about whether or not she monitors the growth and development of the children there, she said that she was not provided with the “scales for measuring the weights of children over 35 days of age.” She told us that she also provides counseling to patients with Hypertension and Diabetes and that some patients with hypertension come to her home to get their blood pressure measured. She also facilitates the meetings of the local Mother’s Group. She informed that there were 25 mothers in the group. Generally, Female Community Health Volunteers like her are assigned the responsibility of the secretary of such groups, but since she could not read or write, one of her neighbors has assumed the role.
Healthcare Information System: The Community Health Unit and Devkala, the Female Community Health Volunteer, are provided with basic recording and reporting tools; they separately report to the higher health facility at the municipal center. Devkala expressed that she does not receive feedback from the staff of the municipal health facility. However, on probing we learnt that neither Devkala nor the Community Health Unit have a record of the pregnant women in the furthermost villages. Similarly, Devkala pointed out that there was no proper record of immunization of children in the community. As for the non-communicable diseases there is no government recording tool at the village level. It is understandable that these gaps in healthcare information hamper planning and eventual programs implementation.
Dependence on Indian Border Administration: With limited health services in the region and lack of connectivity with the rest of Nepal, going to an Indian town was the easiest way to get even basic healthcare for the people of Khangra and its neighboring Nepali border villages. Carrying stretchers across the border, or travelling during night time would require the people of Khangra to get permission from the Border Posts/Patrol of Indian Police. Even during emergencies like snake bites, fall from trees, and difficult deliveries, locals have to go through such time-consuming bureaucratic procedures, while the officials from the other side of the border remain uncooperative.
Villagers organizing themselves to form a Consumer’s Group that will build a Community Health Unit building utilizing the budget allocated by the Rural Municipality.
Health beyond hospitals: Healthcare providers and healthcare administrators, drugs, vaccines and health facilities are just one part of health. Health, as we realized again in this visit to Khangra, is determined by so many other factors. Due to the lack of connectivity with the rest of Nepal, access to health care is a major challenge of this region. As one gentleman, who came to the community gathering to form a consumer group, told us, “For the people of Khangra to receive healthcare, we need a road and a telecommunications tower so that we can call for an ambulance to come to our village if we have an emergency.”