DOLPA, NEPAL — Ramkarni Lama has spent the last six years suppressing a severe toothache with just painkillers. Dolpa, the district where she lives, doesn’t have a single private or public dental clinic. The closest functional dental facilities are in neighboring districts, far from Lama’s home. An agricultural laborer, Lama earns very little and can’t afford to travel outside her district to get treated by a dentist.

With a population of over 42,000, Dolpa has one government hospital that is equipped with the infrastructure needed for a dental facility, but authorities have not been able to recruit even a single dentist over the past two years.

For residents of Karnali, the province where Dolpa is located and the largest of the seven that constitute Nepal, the idea that a patient might have to travel more than 100 kilometers (62 miles) for a simple tooth procedure isn’t surprising. The province stretches across the Himalayas in Nepal, with a sizable section of it situated on the Greater Himalayas, the highest section of the Himalayan mountain ranges.

Krishna Bahadur Rokaya, who heads the disaster management wing of Karnali’s Ministry of Internal Affairs and Law, says that 57% of Karnali’s terrain is considered steep.

For decades, people have refused to work in the province despite the government offering varied benefits, including increasing pay by up to 135%. As a result, crucial infrastructure projects have been delayed, patients have to travel hundreds of kilometers to get critical care treatments, and children are losing out on quality education, among other things.

‘There are no doctors’

Akhanda Upadhyay, head of Dolpa District Hospital, says the hospital has 42 employees, including support staff. Of them, only two are specialist doctors — one general physician, one obstetrician and gynecologist — while the other four doctors don’t have specializations. The hospital’s functioning rests primarily on doctors working temporary contracts and medical graduates sent to Karnali to complete their mandatory residencies. “Once these contract doctors leave after completing the mandatory service to find jobs in urban areas, the sting of staff shortage will be felt more,” Upadhyay says.

In Mugu, another Karnali district, Anka Bahadur BK visited the nearby Mugum Karmarong Community Health Center with acute chest pain last year. There was no doctor available, so BK had to leave with medication prescribed by a midwife on duty at the health center. When his pain worsened, BK’s family had to take him to Nepalgunj in Lumbini province, 200 kilometers (124 miles) away from his home. There, he was diagnosed with lung damage. “What is the point of having a hospital here? There are no doctors,” BK says. “The government is deceiving us by constructing hospitals without doctors. There is a so-called hospital, but when we get sick we have to travel far away.”

Chhiring Kyapne Lama, the chairperson of the rural municipality where the Mugum Karmarong Community Health Center is located, says that the 10-bed hospital has not had a single doctor in the past six months. Equipped with ultrasound machines and a laboratory for pathological tests, among other facilities, the municipality floated several advertisements to recruit doctors but did not receive a single application.

Mugu and Dolpa are located in the northern fringe of Karnali, where some of the highest mountains of the Himalayan range are found. It costs up to 2.7 million Nepali rupees (20,300 United States dollars) per year “to keep any doctor in an area like ours,” Lama says. “Even getting to headquarters [the capital] of the Karnali district in Birendranagar takes two to three days by car.”

At the same time, the difficult topography of Karnali magnifies the impact of any disaster incident. In the last decade, police estimate at least 503 people have died and 203 gone missing during natural disasters, primarily landslides — a persistent threat in the mountain-covered state.

The impact is felt most in sectors like health care. Karnali has the fewest health institutions of any province in Nepal. There are just 15 hospitals spread across Karnali's 10 districts, according to the province’s Ministry of Social Development.

Bonuses offer short-term fixes

In Jajarkot, another Karnali district, the health services office advertises for vacant positions every year. And every year, they fail to receive even a single application from specialist doctors, says Navaraj Kandel, a health education officer at the provincial Health Service Directorate who used to head the Jajarkot office. All the posts in the district’s hospital for specialist doctors are vacant.

To counter this, the Karnali government in 2020 decided to provide doctors who work in the province with annual bonuses ranging from 75% to 135% of their salaries, depending on the district and grade levels.

Yet, many of the officials who manage health facilities across Karnali say that the incentives do not improve the long-term outlook. Doctors who do apply typically stay just long enough to include working in difficult terrain as an addition to their resumes.

As a result, only 314 of 895 health personnel positions in Karnali are filled, according to records at the province’s Health Service Directorate. For example, the province has 79 posts for specialist doctors but only 10 are filled, and the government has managed to recruit for only 33 of the 157 medical officer positions, says Basantaman Shrestha, the directorate’s health education officer.

Hiring challenges are widespread

Health care isn’t the only sector to struggle for workers. When Nepal switched in 2018 to its new federal system — which established the federal, provincial and local levels of government — Karnali was chosen by the fewest number of employees. Even government employees who had homes in Karnali chose to work at the federal level, which would most likely place them in another state. With so few applications, the province had to provide incentives to attract employees and keep them, says Mahendra Bahadur Shahi, former chief minister of the Karnali provincial government.

But even with incentives, the geography of Karnali, riddled with deep canyons and ridges, weighs down the offers. An estimated 35,333 people will be affected by natural disasters in Karnali province this year, says Rokaya, from the disaster management department. More than 8,000 households are at risk of floods and landslides, he adds. For almost half the year, continuous snowfall made it impossible to carry out construction work in the Humla, Mugu, Jumla, Kalikot and Dolpa districts. And during monsoons, the Karnali highway, which connects parts of several districts, remains shut.

Dipendra Bahadur Bista, chief of the Road Division Office at Jumla, says that work in Karnali's Himalayan districts can only be done for three or four months out of the year. During the rains and snowfall, even 5-meter-wide (16 feet) roads get completely blocked due to landslides. Tricky access also inhibits road work, he says, with some areas accessible only by motorbike and hiking.

Bista’s office has 17 vacancies for engineers and sub-engineers but only four employees. "A sub-engineer came to Karnali for the first time a few weeks ago, and during the first week of his stay he told other employees that it was better to die than work in such a place," Bista says. Bista and his colleagues have been trying to comfort him and help him settle down.

Keeping employees in Karnali depends on personal efforts like Bista’s, in part because Karnali is the only province that has not yet passed the Provincial Civil Services Act, a law drafted to provide better benefits to workers in remote locations.

'I will leave’

Medical students who receive government scholarships have mandatory service requirements, and often end up serving in Karnali. This also helps them earn “points” in the government’s employment incentive program, which can later translate into financial assistance while pursuing higher studies and also promotions to jobs with higher pay.

Dr. Kavir Poudel, who hails from Bagmati province, is doing his mandatory service in a hospital in the Jumla district of Karnali. Prior to this, he had worked in a similar capacity in the inhospitable Mugu district. Poudel says he intends to leave Karnali as soon as his contract ends. “The government gives us allowances, but it costs a lot to return home in Bagmati from Jumla," Poudel says. He has to take two flights across two provinces and then travel by road to get home to Makwanpur. Often the flights don’t take off for days due to bad weather, so Poudel stays back without being able to visit family and home.

Humla, Mugu and Dolpa form the crown of Karnali, lodged into the high Himalayan peaks. Except Humla, nine districts of the province are now connected to the national road network. However, several of the newly constructed roads are unpaved and difficult to travel on.

Bir Bahadur Thapa, an employment coordinator in Humla's Adanchuli rural municipality, says that a five-hour journey on a dirt road costs him between 2,000 and 3,000 rupees (15 -23 U.S. dollars). “The road is rough, and buses aren’t always available, so I have to often travel in crowded and uncomfortable goods vehicles.” Even those, Thapa says, aren’t always available. So sometimes he's had to walk six to seven hours to reach a destination in the Karnali province. “I stay and work here only out of necessity. I will leave once public service commission posts open up and I get work in another district,” he says.

More must be done

The government’s policies, several people complain, are not enough to keep them in Karnali.

While a “points” system was created to attract more workers to Karnali, Dipendra Rokaya, a former member of the province’s planning commission, says it has only encouraged short-term commitments. Employees come to Karnali just to increase their points so that they can be promoted later, he says. "Employees can only be promoted after working in remote areas for at least two years. Therefore, they come with no sense of service.”

However, Dr. Bhagawan Koirala, president of the Nepal Medical Council, says that the reason most doctors do not want to come to remote areas like Karnali is because of the government's poor policies. For example, government employees in remote and difficult parts of Karnali are not provided government housing, and due to a lack of development they can’t find good housing to rent either, he says.

Kanchhi, who asked to be identified only by her nickname for fear of retaliation at her job, passed the auxiliary nurse midwife exam and was assigned to Mugum Karmarong rural municipality in Mugu in January. Less than a month after she started work, her 2-year-old daughter fell ill. “There was no meat, fruits, milk, biscuits, etcetera available easily that I could feed my daughter,” she says. The girl’s condition worsened and no local medical facilities were available to treat her.

Cars are rare to find and expensive in the district that has only unpaved roads. So Kanchhi walked five hours to the Talcha airport, cradling her toddler to take a flight to Nepalgunj. Scared for her daughter’s well-being, she returned to her home in Lumbini province’s Banke district, but had to return to Mugu after she couldn’t find a job there. “I booked a flight, but the flight was canceled five times because of strong winds at Mugu airport,” she says. “Who can stay for a long time working in Karnali like this?"