Beauty and Barriers: What Nepal’s Landscapes Teach Us About Healthcare Inequity

By Kedar K. V. Mate

Nepal is one of the most beautiful countries in the world with hilly terrain, untouched natural beauty, and some of the most wonderful people on earth. Just outside the capital, Kathmandu, huge, towering mountains can be seen overlooking the city. For someone who has never seen the Himalayan range, all mountains appear big enough to be considered the Himalayas. However, one day, when the weather cleared, and several white peaks appeared in the distance, I finally understood what set the Himalayan range apart—their snow-covered summits rose so high they seemed to touch the sky, an awe-inspiring sight that no other mountain could match. While I imagined what it would be like living amidst such pristine beauty, I was reminded of the challenges one would experience in case of emergencies, natural disasters, or access to healthcare. This landscape underscored the stark reality of remoteness. For those living amongst the landscape, the nearest healthcare facility could be hours or even days away with non-existent roads, heavy rains, and landslides. I couldn’t help but feel that here, accessing healthcare would be a feat of success, not guaranteed or a right. 

My project in Nepal investigated the current prehospital system at the Dhulikhel Hospital in the Kavre district. The World Health Organization defines the prehospital system as one that encompasses all aspects of care provided before a patient arrives at a healthcare facility, including recognising an emergency, activating emergency services, on-scene care, and transport to definitive care. The study found that most of the population surveyed in the emergency department of the Dhulikhel Hospital reported using private vehicles to reach the hospital. Ambulance response times were often delayed, and in many cases, patients had to find their own means of transportation to reach the hospital. Even when ambulances did arrive, patients and their families frequently declined the service due to the high cost, opting instead for private or informal transport options. Many contributing factors were identified, with lack of ambulances and cost being the most important ones, especially as ambulances were used merely as transport, a role that private cars could also fulfil. The study revealed that while ambulances were available in the region, their distribution and capacities varied significantly. The hospital operates three types of ambulances (shown below). The Type A ambulance is the most advanced, equipped with oxygen, a pulse oximeter, an AED, and IV access capability, and is staffed by a driver and a healthcare professional. Type B ambulances have moderate equipment, including a spinal board, stretcher, and oxygen. The most common are Type C ambulances, which are basic transport vehicles with just a stretcher. The Nepali Red Cross has provided valuable training to drivers in basic life support and first aid. 

From left ro right: Ambulances Types A, B, and C

The challenges observed during my visit such as long distances, poor roads, limited ambulance availability, high transportation costs, and uncertain weather conditions, can be understood through the lens of Penchansky and Thomas’s (1981) framework, which outlines five dimensions of healthcare access: availability, accessibility, affordability, accommodation, and acceptability. In this context, limited numbers of equipped ambulances and uneven service distribution reflect issues of availability; geographic remoteness and road conditions directly affect accessibility; high out-of-pocket costs for transport impact affordability; and the inconsistent organisation and quality of care offered by the emergency response service speaks to gaps in accommodation. 

Addressing health inequities in geographically challenging regions like Nepal requires much more than clinical resources alone. Any solution will have to adapt to geography, climate, and economic realities. My time at Dhulikhel Hospital revealed that access to care should not be a privilege shaped by terrain but a right protected by systems that reach even the most remote peaks. 

Kedar K. V. Mate, BSc. MSc. PhD

is a third-year medical student in the Faculty of Medicine and Health Sciences at McGill University and a Senior Research Fellow at Exeter University, UK. He is a health outcomes scientist with a Ph.D. from McGill University and has completed two post-doctoral fellowships. Before medical school, he worked as the Director of Outcomes Research at the Cleveland Clinic. His research program focuses on measuring patient-centered outcomes by employing innovative research methods and developing and validating outcome measures using modern psychometric approaches.