Opportunity To Rebuild Resilient, Equitable Health Systems : Dr. Poonam Khetrapal Singh

More than one month ago when the first earthquake tore across the Himalayan country of Nepal, it caused injury, death and destruction. The fact that this earthquake was anticipated for some time now failed to dim the shock and sorrow it caused. Images of grief-stricken Nepali citizens – from the mountains to the plains – became the clarion call of a global outpouring of solidarity and aid. The May 12 aftershock, read as a footnote to the original quake by much of the media, compounded the tragedy that Nepal’s people suffered.


As with all disasters, the extent of the carnage was dependent on the preparedness, resilience and accessibility of the country’s health care system and its ability to deal with the flood of patients requiring urgent, life-saving treatment. In this regard, the Government of Nepal must be given credit.

Since the 2004 tsunami, disaster preparedness in the countries that fall within the World Health Organisation’s South-East Asia Region has been measured by the lessons learned from the shortcomings of the response to that unprecedented crisis. Within living memory, no comparable calamity had occurred, meaning little planning had gone into preparing and responding to its eventuality. Health care systems were caught off guard and rendered largely dysfunctional.

Nepal’s recent tragedy, however, had long been foreseen. Nepal is located on a tremulous fault line that experts say is disturbed approximately once every 80 years. Though no quake of a similar magnitude had ravaged the country within the living memory of most of its citizens, the 1934 Nepal-Bihar quake left its mark on the national psyche: Each year on January 15, an estimated 8,500 Nepali victims of the tragedy are mourned.

This awareness was translated into hard policy in areas of critical importance. While the scattershot urbanisation of the Kathmandu Valley was always going to be difficult to temper, major public hospitals were retrofitted to withstand powerful quakes, ensuring that a coordinated health response, when required, would be effective. Essential services such as emergency rooms, operating theatres and maternity wards were prioritised for fortification, while emergency medical supplies were strategically located.

Though over 90% of the country’s health infrastructure was destroyed by the quakes, including four district-level hospitals outside Kathmandu, the retention of key health care facilities throughout the country prevented a disaster of much greater magnitude.  

Of equal importance is the fact that health workers had been given the basic skills to deal with the unprecedented influx of patients. Educational programmes in mass-casualty management ensured that amid the chaos there was reason and efficiency. As Nepal’s health workers performed round the clock, often under torchlight, patients were triaged and resources allocated where they could be most effective. Nepal’s first responders provided critical care when it mattered most, and were later supported by foreign medical teams that provided surge capacity in a coordinated, largely orderly manner. 

Still, as the monsoon nears and the provision of immediate relief cedes to long-term planning and reconstruction, the challenges to providing equitable access to quality health care are acute. With approximately 2.8 million people displaced, many of whom live in remote areas, priority must be given to reaching the most vulnerable.

Along with temporary health care facilities being rolled out to replace those that have been rendered unserviceable, disease surveillance is currently being conducted in the 14 most-affected districts so as to enable a rapid response if an outbreak occurs. Messaging, meanwhile, is being deployed to far-flung regions of the country to enhance preventative measures.

In the coming months, priority areas of concern include the continuation of maternal and child health care services; the provision of culturally appropriate, evidence-based mental health care for those that have ongoing trauma as a result of the disaster; and access to rehabilitation for the almost 17, 000 people injured in the tragedy. 

Perhaps the greatest challenge of all, however, will be rebuilding Nepal’s health system to ensure equitable access in a country with multiple topographic zones and varying degrees of urbanisation. Though it may seem trite, the opportunities that the crisis presents are significant, and must be taken advantage of.

Equitable access

Health services must be rebuilt and distributed according to the needs with respect for equitable access and the public nature of the endeavour, while risk-reduction programmes must be disseminated and implemented at the sub-national level. Soil testing, the enforcement of health facility-related building codes, and investment in design for seismic-proof facilities and homes must be encouraged and enacted across the country. At the regional level, neighbours must continue to coordinate closely to enhance the effectiveness of their responses.

While much of this discussion will take place on a policy level and will be the subject of lengthy revision, the key point to be held sacrosanct by those facilitating Nepal’s health system response and its long-term recovery is remarkably straightforward: It’s about the people. As we mark the one-month anniversary of the 25 April quake, for Nepal’s 5.6 million affected citizens, the health-related challenges are ongoing and demand the unflagging solidarity of those with the capacity to help.   

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