A few days ago, I talked to a young doctor working in a primary health care center located just two hours' drive away from Kathmandu. She shared her frustration and asked if we could help by donating a heater for the delivery room at their health center. She had a point; a heater was important to protect newborns from hypothermia. Hypothermia, a condition in which the body temperature drops to a dangerous level due to prolonged exposure to cold, is one of the leading causes of deaths among newborns.
She claimed that it had been three months since they ordered heaters along with other essential equipment for the delivery room. Although the district health office responded positively, the process had taken too long: While the temperature was dropping with each passing day, there was no sign of the heaters and equipment.
For a health center located at high altitude, right beneath the shades of a forest, and where you need to wear extra clothes just to enter the building, it is difficult to imagine a mother delivering a baby during winter.
I once happened to be at that health center on an immunization day. As I walked around observing the place, I had a chance to talk to a group of young mothers. They were waiting for their turns to vaccinate their babies. I asked them if they had delivered their babies in the same health center. To my surprise, all of them shook their heads and said, “No!”
Some told me that they travelled for two hours to Kathmandu to deliver their babies while others replied that they chose to deliver at home. “Why didn't you come to a health center that is located in your own town?” They told me that it would have been inconvenient.
If they had chosen to deliver at that health center, they could have received free maternity care as part of “Aama Program”, a national initiative to promote institutional delivery. In addition, as they belong to hilly region, they would've received additional incentive of Rs.1000 for travel cost. They wouldn’t have to worry much about arranging clothes for mother and newborn because the health care centre would've provided them with “Nyano jhola” (warm bag) consisting of a pair of bhoto and trousers, gloves, socks, cap and diaper for the newborn, and a mother’s gown for breastfeeding. Despite the government efforts, and despite being aware of the benefits, these mothers had refused to deliver at that health center.
As I looked around, I realized I couldn’t blame them. Although the town had access to proper road and public transportation, the health center was built carelessly on a hilltop that was not accessible to ambulance. It was impossible to imagine a woman in her labor pain climbing up the steep stairs for ten minutes just to reach that health center. To make it worse, even if the woman managed to get there, the delivery room was too dark and too cold to give birth. Even though the health center had well trained health workers on duty 24 hours, the building and the delivery room weren't ready to receive the mothers in labor!
Unfortunately, this isn’t a reality of just one rural health facility in Nepal. Over the past one year, I have had the chance to travel extensively to different districts and visit over 30 health centers belonging to different tiers of health system. Irrespective of their remoteness, almost every third health centers that I visited shared the same problem. There was a road access nearby but the health center itself was located in some isolated or inaccessible place.
I have visited most of these places with my colleagues as part of facilitating the medical students on their exposure to the health system. I was representing neither the government, nor was I a part of any million-dollar project. I was there as a teacher, a researcher, and a listener who couldn’t offer much to the health facility directly. Thus, there were not much of expectations involved in most of my casual conversation with the health workers. However, the health workers needed someone to genuinely listen to them and look deeper into the challenges they face every day. The pattern of the rular health workers' frustrations was apparently similar. “We are committed to work, but what can we do when we don’t even have basic facilities to provide quality care?” was a question they all asked.
As a teacher, I work in an institution that is preparing future doctors to work in rural areas and resource-constraint places. The students, who are being trained to think critically, too reflect back on issues like this. You can understand their anxiety and nervousness when they ask you whether they will also become frustrated like the current health workers. You encourage and train them to become an agent of change, but at times, you too are worried about how long will it take for the change to manifest.
There is no doubt that all the efforts and progress made to promote institutional delivery over the last decade are truly remarkable. It is also understandable that it will take time to amend existing infrastructures of the health facilities. Perhaps there isn’t any easy and immediate solution to these problems.
But we can’t deny the fact that there are some gaps in our understanding. In an era when we intensively promote delivery in the health facilities, how can we pay so little attention to issues of resources and accessibility? Lack of awareness is an important factor behind vacant delivery rooms. But we should realize that it is not the only reason.
If we want to provide quality health care, significant importance should also be given to accessibility of health centers and availability of adequate basic resources. Perhaps sensitizing everyone about such issue could be an initial step for a better rural healthcare.
Dhital is a Lecturer at Patan Academy of Health Sciences
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