Health Center
Keemalung, Nepal

The health situation in Nepal has improved significantly in the past years, but there are still significant differences between the poor and the wealthy as well as urban and rural areas. Especially in the high mountain regions in the north and east of the country, the healthcare provision remains very inadequate. The consequence: sick individuals and pregnant women often travel for several days on foot to reach a hospital, often on steep and poorly developed roads.

Even for people who have no health limitations, these paths are already very arduous and it is understandable that for the people who live in remote mountain regions, medical treatment is associated with great physical strains. And aside from these strains, it is also true that the long distances cost people a lot of time and the stays in the cities cost a lot of money.

For the people these circumstances have partly tragic consequences when, for example, pregnant women can no longer reach a hospital in time for childbirth, open wounds and fractures go untreated and life-saving medications are not available to the people. Changing this has been and still is the common goal of DESWOS, Gecotec, and their Nepalese project partner “Nepal Helping.” All three partners are therefore committed to expanding basic medical care in remote mountain regions of Nepal: good basic care is an important contribution to the improvement of the living and health situation of the population there, mostly poor people.

Since 2019, DESWOS, Gecotec, and “Nepal Helping” have planned, financed, and realized the construction of three health stations in the mountain villages of Bohrle, Gope, and Keemalung, in the northeastern part of the country. But what does it mean to build in these remote mountain regions? What are the biggest challenges? What are important success factors? And what characterizes a building constructed to be earthquake-resistant? What does it actually consist of? The answers to these questions will be examined in detail below.

Two major challenges that arise when building in the mountain regions of Nepal: the transportation of building materials and the limited time window in which construction can take place. Materials that are available locally such as stones, timber, and sand are used whenever possible, however, the vast majority of materials had to be transported by trucks and pick-ups from far away, mainly from the capital Kathmandu or the city of Dharan, which required a lot of patience from the drivers, as waiting for a crossing over a river could take several days, since the old, slow-moving ferry could only take one or two vehicles, depending on their size, to the other side of the river.

The roads in the high mountains of Nepal do not go simply up or down the mountain: they are steep, winding, and especially in the remote regions, unpaved. This not only puts the drivers, but also the vehicles to the test. Another challenge and limitation for building in the Nepalese high mountains is the seasonal change between dry and rainy seasons, which is primarily determined by the monsoon. During the monsoon season, which lasts from May to October, the rainfall is usually so heavy, that roads can no longer be used.

Material transport and construction activities are not possible during this time. Conversely, this means, that all essential construction activities should be completed in the short time window between November and April. Therefore, in order to make the most out of the short time window for the construction of the health station, the local project partner “Nepal Helping” has already before the rainy season, and about 3/4 of a year before the beginning of the construction, started preparing and transporting the construction materials for the respective project to the sites. These had to be, of course, stored securely on site.

But what were the key factors responsible for the success of the three previous construction projects? Without a competent, experienced, committed partner who is familiar with the local conditions, nothing can be done. And with ‘Nepal Helping’, we are fortunate to have exactly such a partner, who meets these requirements and is capable of independently planning a construction project and reliably executing it. The craftsmanship skills of the core team and their willingness to be permanently on-site for the construction management throughout the entire construction phase and to work and live together with the villagers have certainly also helped to ensure that the construction projects proceeded quickly and with quality.

Another success factor was certainly the involvement of the local population in the construction projects. This created a win-win situation for everyone. “Nepal Helping” was able to utilize the knowledge and commitment of the people on-site. Be it through local carpenters, who carried out the carpentry work. Be it through the many helping hands, who assisted the transport of building materials. Or be it through the women, who provided food to all the workers on the construction site.

And on the other hand, the people on site had the opportunity to earn money from the construction site and to improve themselves professionally through their work in various trades. It was also important for success, that all relevant stakeholders for the approval and implementation of the construction project were involved in the initiative at an early stage such as the mayor, the local clinic committee, as well as those responsible at the district level.

Because one thing was clear: construction could only begin when a plot of land was found on-site, the responsible district administration approved the construction plan, and the coverage of ongoing costs, such as the salaries of the medical staff, was assured. At this point, it should also be mentioned, that the constitutional reform in Nepal from 2015 and the decentralization process initiated by it has simplified the approval process for such construction projects.

However, districts generally still lack the knowledge and money to carry out such a construction project themselves. As with all buildings, in Nepal, the initial step based on the construction plan is the surveying of the land and building. This is followed by the excavation of the site, especially in sloped areas, and this is almost unavoidable in mountainous regions, it is important to find a balance between the excavation into the mountain and the retaining walls on the valley side.

The health station has a total of five rooms, which are arranged around the entrance area. Upon coming in the entrance area, on the left side there is an examination room, as well as the staff’s lounge or sleeping area. On the front side is the kitchen and on the right side are the delivery room, including a toilet and shower, and another room, which can be used for treatments and for resting patients. Additionally, there is another toilet with integrated shower facilities in the outdoor area of the health station.

The next steps include the construction of the foundation. The foundation is important, as it distributes the loads of the building onto the ground. Depending on the strength of the ground and the the loads that occur, it will appear narrower or wider. Supports that place more weight on the foundation, are designed with a single foundation and then incorporated into the strip foundation. It was and still is important, that between the foundation and the structures built on it there is a good mechanical connection, such as through reinforcement steel or a rough surface of the foundation.

But what are the central elements for a earthquake-resistant construction? It is essential for an earthquake-resistant construction, that the reinforced concrete structure is integrated into the masonry. It is important that the walls are built first and then the supports are poured, because only then does a mechanical connection between the walls and supports ensure that the horizontal vibrations, which are mostly generated during earthquakes, are absorbed.

Other important building elements for the earthquake safety of a building are the vertical and horizontal concrete elements, which also include the upper ring beam, that essentially wraps the building and prevents or reduces horizontal movements of the building. Finally, for the earthquake safety of the building, the concrete ceiling must also be directly connected with steel to the vertical structures, because only then is the building tightly bundled – like a package – on all sides. And the result? In the mountain village of Keemalung, “Nepal Helping” has succeeded as hoped in just six months, from November 2023 to April 2024, to build the health and maternity station. Without the active support of the local population and their craftsmanship, this would certainly not have been possible.

And just a month later in May, the health facility could be ceremoniously opened in the presence of the villagers and all project participants. The health center covers 100 square meters, with six rooms, two treatment rooms, a delivery room, a sleeping room, a waiting room and a kitchen. All rooms are equipped with the necessary equipment such as a couch, a birthing chair, beds, an ultrasound and ventilator, a computer or a stove. Additionally, the center has two toilets and a shower and has electricity and water connections.

Two medical professionals, an assistant doctor and a trained midwife are permanently on site, to take care of the health concerns of the people from the surroundings of Keemalung. For about 6000 people, this means a significant improvement in healthcare. What were the total costs of the project? The total costs for the project amounted to around 105,000 euros. This means the costs were about 15,000 euros above the original plan. The main reasons for the cost increase were, on one hand, the transport costs, which turned out to be higher than initially assumed, and, on the other hand, the earthworks were more complex than expected, as a large boulder, which the workers encountered while preparing the site in the subsoil, made it necessary to shift the construction site by about 30 meters.

How did the design process go, and who was responsible for it? The health station is, compared to the buildings that are usually found in the high mountains of Nepal, anything but simple. Because the building overall features a good to very good construction standard. This applies both to the solidly built foundation and to the earthquake-resistant construction of the building, support pillars and the roof, the water and electricity connection, as well as the proper interior finishing.

The four health stations that our local project partner “Nepal Helping” has built so far, certainly resemble each other. Thus, aspects that have proven effective have been retained. The external appearance with the red and white facade paint has also been deliberately maintained, to create a kind of recognition value. And yet there are differences between each health station, which is why it is not a simple copy-paste design. The respective terrain situation and Land size made it necessary to adapt the building to the respective location.

Experiences gained from the health stations built so far have also led to adjustments in the design. to adjust the design. For example, in the first health station in the village of Betang, which was built, the kitchen is in Nurse’s sleeping room, which has proven to be impractical. In Keemalung, unlike the first health station, the toilet – including a shower for patients and/or visitors – has been moved outside.

Is the price lower or higher than for comparable projects? What a normal construction price per square meter is in Nepal, is certainly hard to answer. What we can say, however, is that the total costs for the health station built in Keemalung compared to the second health station, that we supported in the mountain village of Bohrle in 2020 have almost doubled. Two reasons are likely primarily responsible for this. On one hand, the transportation costs in Keemalung were significantly higher, as the project site is located in a much more remote region.

On the other hand, in Nepal, the Construction costs have risen significantly, also due to increased costs for wages, building materials, and transportation. It should be noted that the total costs also include expenses for the interior furnishings of the health station, such as the medical equipment and its installation also include the costs for personnel- administrative costs of the local project partner, as well as expenses for the insurance of the construction workers and the ceremonial opening of the health station. The pure construction costs are thus in the range of around 80,000 euros.

Are there plans to use the roof as a terrace or to build another floor? The building is designed so that a further floor, planned in the future, could be added, which is very unlikely to happen in the next few years. A possible staircase was then constructed in the outdoor area. To reduce the risk of possible break-ins, a fence has been erected around the health station. In addition, the property is guarded by a night watchman.

What is the situation with water supply and toilets? The water supply for the health station is provided by a nearby spring. Because there is no public water network in the Keemalung mountain village, the area is too remote and mountainous. The health station has two flush toilets, with the wastewater flowing into a underground soak pit.

What about wheelchair access? In the entrance area of the health station, there is a ramp. The construction of such a ramp was a government requirement. Certainly, the question can be raised, to what extent a ramp in a mountainous area, where no one moves around outside their home in a wheelchair on the unpaved and steep paths, is necessary. In everyday life it is usually the case that people who can no longer walk by themselves, are carried by their relatives or friends, even to the toilet. And yet, the ramp is likely to be important for older people, who may no longer be able to manage steps, to access the health station. However, within the health station, there is a wheelchair to transport patients from one room to the other, if needed.

We, DESWOS, Gecotec, and “Nepal Helping,” are convinced that this commitment has been worthwhile and helps to improve the lives of people in the remote high mountain areas of Nepal. Therefore, we are firmly determined, to continue our commitment in the future without wavering and to further support the people on site. From the successfully implemented projects so far and the fact that the building type we developed is now to become the standard for all other local health stations, we definitely draw the necessary motivation for this. We are therefore optimistic that the health- and maternity station in Keemalung was not the last one we built in the mountains of Nepal. Therefore, we look forward to everything that is yet to come.