For about a year now, the Government of Nepal has been undergoing a decentralization of power. The country has been divided in to five provinces and outfitted with new government employees at the state level. It’s an exciting moment for a project like ours, which is aimed at capacity building in the government health system. Right now entire tier of government in Nepal is literally undergoing construction for the first time.
In the mean time, a large number of essential items are not yet decided even as the new government is deploying its duties. The desks are purchased and people have been assigned to sit behind them – literally – but exactly what these people are responsible for and how their responsibilities are to be executed is still a work in progress. Many operational policies are still not in place, and decision-making power isn’t yet clearly defined between different levels of government. Basically, we are in a car that is being built while rolling down the highway. You’ve probably been there too, right? And I accept that many people would find this alarming.
These people, however, find it AWESOME.
This a great time to be a grassroots organization in Nepal that has been working on health care with previously less-empowered leaders in villages. Oddly enough, Jevaia Foundation now has a lot of specialized knowledge on a key primary health issue that few if any other organizations are working on in Nepal. We have policy ideas that we’ve already modeled in multiple health posts, and there are elected officials in lower levels of government with an interest in getting this model supported by the ministry of health. And right around the corner from us in the capital of Province #4, the policies, budgetary headings, and guidelines that will decide these matters are currently being created.
Our hope is that in coming months, we’ll be able to play a role in influencing some of the new health policy. Currently oral health care in Nepal is available almost exclusively in private practice. The ministry of health doesn’t even have a budget heading for oral health at the primary care level, and in the villages where we work leaders have cobbled funds from other budget categories to run dental clinics in their Health Posts. In the new provincial system, we’re hoping to organize local officials and communities to demand the creation of oral health budgets from the Ministry of Health at the province level. Cool, right?
So even though everything’s a bit weird here at the moment, a time of change and uncertainty is of course always, potentially, a time of heightened opportunity. It is certainly a million times better than an unyielding stasis, as anyone who has been in one of those surely knows.
Now let’s bring this all back down to the ground for a second, in my home village of Kaskikot, where newly elected village leaders reopened the dental clinic we started…which had been closed for SIX YEARS. (Read the Washington Post story about our handover of the Kaskikot clinic in 2013). The new Kaskikot clinic is fully integrated in to the Health Post and financed by the village government. Patients register in the main building and then take a registration ticket to the dental room. Data on patient flow and treatments provided is maintained just like all other primary care services delivered in the Government Health Post. Our job is now confined to monitoring quality of care and providing technical support. It’s AMAZING.
In order to garner backing for this example and its variations in other villages, we’ve been hard at work over the last few weeks meeting people behind desks in the new province government, and then meeting with other people they suggest we meet with. It’s so refreshing to talk with these newly appointed officials and to brainstorm with folks outside government who, like us, have been chipping away at difficult issues for a long time and are trying to sort out what the new system means for these bigger goals. The confusion of the moment is offset by what feels to us like a sense of possibility and movement. By extension, it’s important that everyone carry on with a grand performance of confidence, even though nobody is sure what is going on. So we’re right in there keeping up.
For example, recently I thought to invite a couple folks we’d met up to Kaskikot to see the dental clinic one Sunday. They agreed to come. I immediately began worrying over how to make sure that they’d be there on a busy day. The Kaskikot clinic is generally seeing about 8-15 patients a day, which is close to full capacity…but it’s also the busy planting season, and it’s raining, and….and anyway it would just be a bummer if we invited Important People to our clinic and there were not a lot of patients when they arrived. Maintaining confidence under construction means pulling out all the stops.
Fortunately, the Kaskikot clinic runs on Sundays, and I spend Saturdays at home in Kaskikot. I decided to invest in some advertising. Here’s where we move this story from Important Offices to Aamaa’s Kitchen.
“We’re going to the clinic tomorrow morning,” I informed Didi and Aidan and Pascal over dinner. They were in Kaski for last week for school vacation. Didi protested that she needed to leave early morning to cut grass for the buffalo because Aamaa’s leg has been sore. Also, she pointed out, what if it rains later in the day? I answered that I was 100% certain that it never rains on Sundays and that we were all to leave for dental exams at 9:30am.
On Sunday morning I started my rounds early, at Saano Didi and Saraswoti’s houses. Nobody looked like they’d been planning on a dental checkup after breakfast. “C’mon guys, we’ll go together, it will be fun. Malika Didi is coming,” I begged. With dignity, of course. For the greater good. Then, walking down the ridge toward Deurali, I ran in to Mahendra sauntering home.
“I need you to come to get a dental checkup today,” I said.
“A dental checkup?”
“At the health post. There are some important people coming to see it.”
“Ok Laura didi.”
Mahendra and Saila
“Really? You wouldn’t lie to me.”
“I wouldn’t lie to you Laura didi.”
“Hey and bring some of your friends,” I added, testing my luck. Mahendra has a posse of bros that move as a pack.
“Ok Laura didi.”
“Really?” It seemed suspicious.
“I’ll be there Laura didi.”
“Around 11,“ I said, and continued down the ridge.
I came to the yard of Saili Bouju, who is married to our local shaman Bauta dai. Since I pass their front yard every time I walk home from the main road, we check in pretty regularly. When I’d arrived on Friday, we had already made a plan to go to the dental clinic on Sunday morning.
“Saili Bouju, we’re going for a dental checkup today, right?”
“Yes, yes Laura,” she assured me in her deep raspy voice.
“I’ll be by at 9:45,” I said. “With Malika didi.”
I continued up the walk to the the next two houses, where I made my pitch to Barat’s two sisters-in-law and their families over over tea. Ambika Bouju happened to stop by as I was rinsing my teacup.
“Ambika Bouju, come for a dental checkup today.”
“Hey, I’ve been meaning to do that,” she replied, to my great happiness. “I need to take my son in.”
“Today’s the day! There are some Important People coming from Pokhara to see it. We need a crowd.”
“Ok, I’ll be there,” Ambika Bouju agreed.
Out at the main road I came upon Amadev bouju on her yard. She can’t hear very well. “Bouju, let’s go to the health post today,” I said. She smiled and nodded and said, “Sure, Laura.” She’s an overall positive person.
“Ok, ok,” Amadev Bouju said.
“To get your teeth checked.”
I had a feeling we might not be talking about the same thing, so I hopped down in to the yard to discuss the matter at a shorter distance. “COME TO THE HEALTH POST TODAY WITH ME TO GET A DENTAL EXAM,” I repeated.
“Oh! Dental exam? My teeth don’t hurt.”
“A checkup is important!” I proclaimed. Amadev Bouju rolled over fairly easily. She said she’d meet us at the clinic.
I made my way toward Butu bouju’s house. Back in the day, when her daughters were younger, we used to have sleepovers and make chocolate chip pancakes over the fire. Butu bouju was out in the yard and tried to impose more tea upon my already full-of-tea stomach. I was delighted to find out at she’d been thinking to bring her grandkids to the Health POst for a checkup at some point. Like today. “I’ll be by with Malika didi to pick you up,” I said, making sure that Didi would have no out now that I’d advertised her all over the village, and headed home.
“I’ve rounded up most of the people in Deurali,” I announced over breakfast. Didi replied that she was going to cut grass. I reminded her of the importance of oral hygeine, and of my schemes, and how she loves me. And so on.
We set off mid-morning. Narayan and Amrit, who were over to play with Aidan and Pascal, were rounded up and I shuttled the whole gaggle along the edge of the cornfield. They disappeared in to the tall stalks and I turn around to make sure that Didi is following close behind.
Somehow, by the time we got to Govinda Dai’s house, I was already alone again. Didi had peeled off to go retrieve Butu Bouju. Saili Bouju said she had a headache and would go another time, and only after much cajoling said that she’d meet us there in a little while, which I was pretty sure was a way of pacifying me and sending me on my way. When I passed Ambika Bouju’s house she was nowhere to be found, and even though her daughter said she’d be up the road shortly, it seemed improbable. All four boys—Pascal, Aidan, Narayan and Amrit—had taken off ahead of me down the road while I was trying to recapture our patients, and by the time I reached Govinda’s house in Dophare, all the kids were nowhere in sight. I walked in to Govinda’s yard alone.
“Ok Dai, let’s go,” I resigned. I’d been in this moment at least a thousand times before. Everything looks static and bleak. There are no people. It is foggy or rainy or dark or something else that generally conveys that you are all alone. All is lost. You just have to wait. If none of our neighbors came, some other people would come, surely. Or in the worst case scenario it would be a quiet day, and our visitors would certainly understand that this is the busiest time of the year for rural communities.
As Govinda dai readied his umbrella, I looked in the road and saw that Mahendra had appeared out of thin air, with a friend. They were carelessly posted by the side of the road, sullen and awesome as usual.
“I told you I was coming, Laura didi,” Mahendra said with casual authority. “You guys go ahead. We’ll be along.”
Near Maula, we caught up with Aidan and Narayan. “Where are Pascal and Amrit?” I asked. “THEY WENT HOME,” Aidan declared triumphantly. I sighed. Oh well. “I’m going to call your mom,” I said, and took out my phone to dial Didi, who was missing in action. “I HAVE MOMMY’S PHONE,” Aidan declared triumphantly again. “IF YOU CALL MOMMY IT WILL RING RIGHT HERE!”
I pondered Aidan, his ecstatic domination of my communication with Didi, and the treacherous cell phone he was holding. I thought morosely that Didi and Butu Bouju most likely got to chatting and weren’t coming along.
We arrived at the Health Post in a thick fog. The previous night’s rain had left everything squishy and slick. Durga, the clinic assistant, was just getting through the morning disinfection and setup process. The technician Dipendra was nowhere to be found. It was 10:40 and our visitors where scheduled to arrive at 11.
10:50. Dipendra rolled up on his bike.
10:53. Pascal and Amrit came tumbling out of the fog through the gate to the Health Post complex. They tore across the lawn, jumped over the wall, and went back out in to the road to play by the pond until called for their exams.
10:57. I saw Didi materializing in the fog at the gate. Behind her, Butu Bouju was walking and chatting with her grandkids, like a band of spirits walking out of a cloud. I blinked. There was Saili Bouju behind them.
11:10. A line of non-recruited patients had taken tickets and were awaiting treatment. The bench outside was full, not just with my neighbors, but with the natural flow of weekly patients.
11:15. Ambika Bouju arrived with her son.
11:20. Mahendra and his bros sauntered in to the yard.
11:30. Our two visitors showed up to find a full clinic with a long line of adults, children and elderly patients sitting out a 40 minute or so wait. Inside the clinic room, Dipendra demonstrated the treatment planning form that was developed during our last professional development in December. I pointed out our infection control protocol on the wall and other features of the clinic protocol that we’ve added to the Health Post setting, like floor coverings, dress, tray numbers and documentation.
We retreated to the local government building next door to talk about our next steps at the province level. By the time we came back outside to get in a car back to Pokhara, it was about 12:00, and the line outside the clinic had grown even further.
“Saili Bouju!” I call across the lawn.
“I told you I was coming,” Saili Bouju said.
(p.s. I have no idea what’s going on with my weird knome-hairdo in this photo)