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Coping with catastrophe

Rural health post in Nepal

Since the earthquake struck in April 2015, German Development Cooperation has focused on helping Nepal build a more resilient health system that will be better able to deal with future disasters.

When the earthquake struck, German Development Cooperation in Nepal reacted immediately, redirecting project resources to meet basic needs. But as the weeks wore on, Nepal’s longer term challenges became apparent: how to build a more resilient health system better able to withstand disaster.

It was a Saturday like any other.

On 25 April 2015, most people were home, schools were closed and the streets uncrowded. Spring was in the air.

Suddenly, for a minute that felt like an hour, the ground shook. The 7.8-magnitude earthquake turned out to be Nepal’s deadliest in 80 years, killing thousands and leaving many more homeless in the 14 hardest hit rural districts.

Destroyed health camp at Dharkha
Destroyed health camp at Dharkha

“We had to react quickly,” said Paul Rueckert, Chief Technical Advisor of the Nepali-German Health Sector Support Programme (HSSP), which is implemented by the technical cooperation agency GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ).

GIZ had been active in Nepal’s health sector since 1994, so it was able to move rapidly and adjust existing activities for a rapid response. As part of special funding made available in the aftermath of the earthquake, BMZ has allocated an additional €3 million for transition and recovery in the health sector in Bhaktapur, Dhading, Nuwakot and Rasuwa districts 

“We were lucky. We were already working in Dhading, one of the earthquake districts, so we were able to mobilize our staff immediately “Our team was impressive,” Dr Rueckert added, “even though many of their own homes had been affected.”

Everyone rallied to rebuild: the earthquake had damaged electrical plants, destroyed hospitals and health centers, ravaged roads and levelled homes.

The return road to normalcy would be a long one.

First, the emergency

GIZ staff reach Dhading Hospital with drugs and supplies
GIZ staff reach Dhading Hospital with drugs and supplies

The partly mountainous Central Region has Nepal’s highest population density so deaths and injuries were heartbreakingly high.

In the hectic post-earthquake period Nepal’s Ministry of Health and Population, working in partnership with international organizations, set about treating the injured and providing essential services: “We immediately concentrated on the most damaged 14 districts but so many other districts were hit,” said Sagar Dahal, the Public Health Administrator responsible for the emergency response within the Ministry of Health and Population (MoHP).

Germany threw the full capacity of its HSSP behind Nepal: the programme contributed to treating the injured and rehabilitating essential birthing centers in the hard-hit districts of Dhading and Nuwakot, built temporary tent stations with generators for three district hospitals, assisted in preventing infection and disease by distributing 2500 personal hygiene kits and helped coordinate the work of the many humanitarian agencies on the ground.

Facing the challenges of recovery

Dhading District Hospital
Dhading District Hospital

Nepal, a poor country, was already facing development challenges before the earthquake. Now it faces additional ones:

  • Rebuilding a more resilient health system that can cater to the needs of the people, especially in hard-to-reach areas.
  • The imminent arrival of winter: in some districts women are still recovering from childbirth in tents because there are no hospital wards (erecting a new building can take 2-3 years).
  • Lack of concrete information or evidence about what is actually happening on the ground.
  • Provision of basic services beyond emergency treatment: birthing centers, distribution of medication, or providing psychosocial support.
  • Finding the human resources now that foreign relief staff has gone: not everyone wants to work in a remote region that may be a two days’ uphill walk away (although the MoHP says finding staff has not been a problem).
  • Working beyond the hardest-hit 14 districts: in the 17 less affected districts 1,739 public health facilities were destroyed.
  • Funding: while donors have demonstrated generosity there is still a lack of funds and of capacity to absorb those funds.
  • Getting back to normal now that most of the 140 or so international humanitarian organizations have completed their mission and left the country.

The greatest challenge remains how to help the 2.8 million Nepalese who still need assistance, rebuild the 600,000 destroyed houses, strengthen the 280,000 damaged houses and feed more than a million people who still can’t meet their daily dietary requirements.

A ray of hope

Reaching damaged mountainous areas can take days
Reaching damaged mountainous areas can take days

Despite the desolation there are some positive signs.

The MoHP is acutely conscious of the long-term need to strengthen its health system and is making sure reconstruction and rehabilitation is reflected in its annual budget and work plan.

“Both the public and the private sector responses have been very good,” said Mr Dahal, “especially in the more remote areas where there are so many problems. But we could have done much better if we had invested more in preparedness.”

Meantime, reconstruction continues.

“Of course the short-term was important, but it takes a lot to build up a good health system. Despite the devastation, the earthquake has provided us with an opportunity to rebuild a better health system than before and we can contribute to improving services,” said Dr Rueckert.

In the districts, GIZ is supporting the rebuilding of 40 prefab health posts in Dhading and Nuwakot over the next 12 months, almost half of the fully damaged facilities. This will reinstate medical care for more than 250,000 people.

At the central level, GIZ, in partnership with the UK’s Department for International Development, has helped assess 446 completely and 701 partially destroyed health facilities. It also supported Nepal’s approval of a master plan and compulsory reconstruction guidelines for health facilities, developed by technical staff seconded to the MoHP by GIZ.

In the area of maternal and newborn health, four transition homes for pregnant women are planned in cooperation with UNFPA to give women a safe place in which to deliver.

“While our main goal is the overall response, our support for transition and recovery is focused on maternal and newborn health services delivery,” said Sanjeev Pokharel, HSSP’s Deputy Chief Technical Advisor responsible for post-earthquake rehabilitation measures. “This includes such things as temporary birthing centers, distribution of reproductive health kits and provision of delivery beds.”

GIZ staff facing a second earthquake while distributing hygiene kits
GIZ staff facing a second earthquake while distributing hygiene kits

On behalf of BMZ, GIZ is also supporting Nepal’s response to the shelter and livelihood needs of local communities: some 4500 households in three districts have received basic materials to build temporary shelters, and assistance is being provided to help preserve historical heritage in the Bhaktapur districts which were damaged by the earthquake. Furthermore the recovery programmes are supporting district-level Disaster Response Committees, which coordinate the disaster response, in three mountainous districts.

The trauma brought out the best in many who provided support, altruism and camaraderie in the face of disaster.

It also provided some lessons.

“We learned so much about information gathering and dissemination, the importance of coordination, of protocols, of working together. We were prepared in some ways, perhaps, but not in others,” said the health ministry’s Mr Dahal.

Two weeks after the tremors subsided, just as Nepal was beginning to cope, another, smaller earthquake hit, reminding everyone that potential disaster always lurks.

Should it happen again, Nepal may be better prepared, but nothing will erase April 25th, the day life changed irrevocably.

by Leyla Alyanak

August 2015

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