Report on the findings in Chyangmityang 

September/October 2011 Lichtenstein

In the last week of September and the first days of October 2011 S. Schwarzer and
W. J. Lehner tried to analyze the situation in Chyangmityang / Solukhumbu / Nepal.In this village quite far away from all tourist tracks MountainSpirit Germany – mostly in cooperation with MountainSpirit Nepal – has set up and operates a village clinic and other charity projects. The MSD Team have given two times (in October 2010 and in April/May 2011) basic trainings in health care, hygiene, family planning and other topics to the villagers. A third training is planned for April 2012.

During the last visit to Chyangmityang the Team met members of Maya Sherpa Foundation and talked about the possibility of a mutually structured support for the village. It seems to MountainSpirit that the intention of Maya Sherpa Foundation is quite similar to that of MountainSpirit. To avoid double input in one part and leaving other parts without attention the activities of both organizations should at least be coordinated and if possible forces should be joined.

Objective of this visit was to introduce from the Team to the village and to MountainSpirit's activities in Nepal as well as analyzing the situation – especially the financial situation and the long-term future prospects – in Chyangmityang.

History of the activities in Chyangmityang

From 2003 on, MountainSpirit Nepal developed the plan to establish a village clinic similar to the village clinic project in Shermatang/Helambu which had started operation successfully at that time. MountainSpirit Germany had arranged the funding of the Shermatang project and was willing to establish and fund a similar project in a different region. The evaluation by MountainSpirit Nepal and the feasibility studies showed that the Chiangmityang village clinic project should be implemented by MountainSpirit Nepal together with MountainSpirit Germany and would have a positive future.

The project was planned in close cooperation with the villagers using the AI 4-D-model approach. Construction material was provided by MountainSpirit while the work for erecting the village clinic building was done by the villagers. Volunteers from Germany supported the erection. MountainSpirit arranged the education of the first health worker and paid for that.

During the “anniversary tour” - i.e. a visiting and trekking tour by members of MountainSpirit Germany around the 10th anniversary of the founding of MountainSpirit Germany in November 2009 – some members felt that the situation in the village clinic of Chyangmityang needed improvements. Additionally the visit to the primary school led to further private donations especially for the necessary school building renovation.

After the anniversary tour MountainSpirit Germany indicated to MountainSpirit Nepal that the
Chyangmityang project is not running smooth and needs further attention which MountainSpirit
Germany is willing to give. Especially MountainSpirit Germany intended to show more activity e.g. by sending doctors for direct medical basic training and possibly other experts.

For MountainSpirit Germany the project in Chyangmityang is highly important as this project is
intensively communicated in the regional media in Germany and is an object to identify
MountainSpirit's charity work and success in public. Thus, Chyangmityang has to be seen a symbol needed to generate donations.

By coincidence the five years period stipulated in the basic contract for erecting and operating the  Chyangmityang Village Clinic between the villagers and MountainSpirit ran out at the same time and MountainSpirit Nepal decided to hand over the project completely to the responsibility of the villagers. On the other hand MountainSpirit Germany prepared the grassroot level trainings and further support at the same time. Today, two trainings have been held and further financial support has been given to the village. Some arrangements have been made with the villagers and the monastery directly between the Team Members in direct cooperation with Phuri Lama Sherpa (MSN member from Changmityang) as well as members of Maya Sherpa Foundation. Some conflicts between MountainSpirit Nepal, MountainSpirit Germany and the situation in the village had to be resolved during the visit.

The village – access, economy and geology

Chyangmityang is situated about three hours walk (measured in the speed of the locals) from Phaplu. Phaplu (together with Saleri) is a district centre with a small airport, district clinic and shopping possibilities. Internet access is available in Phaplu.

The road coming up the valley to Phaplu was during our visit – partly because of the monsoon (?) – in very poor condition and could in no case be used by cars. It must be doubted if anyone – private investors, government, … – will be capable of repairing this road within the next few years. (In Phaplu an ambulance car is parked some 50 m away from the main road.)

Right next to the district clinic a narrow mountain path is climbing up to the hilltop (about 3000 m above sea level) and then descending into the valley of Chyangmityang (about 2600 m above sea level).

The villagers financed the building of a road from somewhere between Phaplu and Saleri over the hill and into the village, leading along most of the scattered houses and ending high up at the monastery. The road was built in the late spring time (dry season) this year in a very simple way. During our visit – in the monsoon season – the road was no longer usable as it was washed away in some parts and hill slides blocked the track in others. The villagers explained to us that there was no more money than for building such a simple track and that there is no more money for repairing it.

This example clearly shows the conflict in a remote village: the villagers want to have access to the outside world. But there is a lack of economic and engineering knowledge. No one in the village could or would explain to us what the villagers where dreaming about when ordering the road to be built. To know these objectives would be helpful for further supporting the village. Seen from outside, such road would never be able to attract tourists. Chyangmityang is situated too far away from the places of interest (Mt Everest, Sagarmatha National Park, …) and has very little to offer.

The economy in Chyangmityang is based on barter transactions inside the village and with
neighbouring villages. All products of the daily life are sufficiently available in the village. Signs of malnutrition could not be found. Most (agricultural) products exceeding the own demand are bartered within the distances reachable by foot within four to fife hours. Money is generated by selling products mainly in Phaplu and Saleri. This situation could be improved by a usable road – but the small amount of sellable products would never compensate for the cost of maintaining such road. Another source for money is the support from relatives who have left the village and who are sending back some money or investing it in the village.

The road would only make sense with an entire change in the economy away from the existing barterbased economy towards a “modern” monetarian society. But that also would mean to step away from the concept of self supply to the principle of division of labour. New (agricultural) products would have to be produced and refined in the village. But for all these steps most of the basic knowledge is missing – we made a visit to a village in mediaeval times.

The hills (mountains) are formed of different metamorphic rock, most with high density, very low permeability and extremely low porosity. Through this the water supply in the village depends on surface water and small wells out of rubble. The water supply is instable over the year – high amounts in the monsoon season sufficient to run the water mills and the small (5 kW) hydroelectric power station against little drinking water in the dry season.

The cutting of the road into the steep slopes activated the rock above in several areas. Some soft layers between the hard rock form good sliding surfaces. After this first monsoon season only small landslides could be observed – but enough to block the road completely. It has to be expected that the landslides will increase in size and intensity. It will be rarely possible to stop the now activated rock and if tried it will create enormous cost.

The village – households and farmland

The village consists of about 50 houses scattered around the steep basin formed by the mountains in the West, the North and the East.
The villagers call the village themselves Chyangmityang. They see it divided into four or five
settlements, i.e. Mera, Bilikhu, Khuchi-La and Gomne (where the village clinic and monastery is
situated). (All names according to the writing of the villagers) People outside the village tend to use the name Mera for the whole settlement.

Most people in Changmityang belong to the group of the Sherpa and are Buddhists. A minority – most of them settling at the southern end of the village – belong to the Rai and other Hindu groups. It was clearly expressed that all groups live together very peacefully and cooperate in the different committees governing the fate of the village i.e. the village committee, clinic committee, school committee, monastery comity and probably some more. How far – beside this structural influence – the influence of the communism from the capital of Kathmandu and the district capitals really is could not be found out. But it seems that the villagers kept a critical distance to everything going on outside their village.

The houses are normally situated in the centre of the corresponding fields. The fields can be assumed in a radius between 30 and 200 m around the houses.

The farmland is of good quality. The people grow a wide variety of products such as barley, wheat,millet, maize, beans, cauliflower, lettuce, potatoes and others. Potatoes form one basis of the nutrition.

Most households have one or more cows and some chicken.

Most houses are connected to the local island power supply network. Further down the valley the villagers operate a micro-hydroelectric power station. The power is not available during daytime (as it might be too dangerous with non-insolated power cables hanging freely over the fields and paths) and will be switched on regularly around 5:00 PM for about five hours. We got told that the community has a major problem because of the wooden poles (through which in some cases the power cables run open in drilled holes). The poles are rotting in the wet ground and breaking. Sometimes the power cables are not higher than 1 m above ground. And in the height of Chyangmityang (~ 2600 m MSL) the threes are no longer growing in a form that allows using them as poles.

Primary school

In the village the Shree Buddy Primary School is operated as a governmental school. The number of students mentioned to us varied between 9 and 17. After the age of 10 or 11 the students have to leave for secondary schools. For the first part of the secondary education the students normally go to Salieri staying there during the week and returning for the weekend and school holidays. Further education can only be obtained in Kathmandu.

We met the schoolteacher Bal Bahadur Basnet in Saleri on his way into Dashain vacation which
started the day when we arrived. He expressed his thanks for the support of the renovation.
The villagers are responsible for the maintenance of the school building. The poor condition of the building and especially of the floor, roof and drainage situation of the back wall existed already during the anniversary tour and led to a direct donation by Eckhard Rouff for the materials needed for the repair.

The school building was visited together with the school committee. A repair of the wooden floor is desperately needed but makes only sense if combined with making the roof watertight and draining the backside of the building. Rainwater collects behind the building and seeps into the back wall and the soil below the wooden floor planks. The situation was discussed with the school committee.

Additionally further problems were mentioned. Since the renovation of the school toilets the rainwater no longer washes the toilet bowls. Additionally, the same problem as with the back wall of the school building exists. A simple solution was discussed and scribbled on a piece of paper: two half-pipes shall be mounted as gutter and the rainwater shall be led down to the toilets in two spouts.


As per proforma invoice from the school committee, 65,400 NRS where handed over to the head of the school committee, Mr Dhandi Sherpa. The protocol about the handing over was signed and pictures were taken. The money will be used for buying the corresponding materials for the renovation. The situation will be checked byMSD Team during their next visit.

Village clinic


On September 29 an extensive meeting was held with the clinic/village committee and the health worker, Mr Dinesh Rai, in the village clinic. In addition on the following day the same topics were discussed in the presence of the head of the village committee with the monastery.

The situation in the village clinic can be described as follows:
We found the village clinic absolutely clean and tidy. Although designed as a waiting room the
patients normally go straight through to the treatment room and wait there until the previous treatment is finished.

Consultations are held every day except on Saturdays. In one book the health worker notes down the starting and end time of his presence in the village clinic and signs every line. Photos were taken from this book.

The shelves in the treatment room are well filled with medicine for the common diseases. Per day about 3 to 4 patients ask for treatment with most diagnosis being gastritis, diarrhoea, otitis, joint pain, asthma, scabies, headache, cold and flu, burns, different types of wounds. During the about 12 treatments S.Schwarzer observed we found a very high accuracy of diagnosis and treatment by the health worker although he has to work without all the laboratory support Western doctors are used to. We are sure that the health worker is capable of selecting the few severe cases and sending them further or to the district clinic in Phaplu with sufficient accuracy and treating all other cases in a very good way compared to the possibilities in such a remote place. The health worker mentioned to us that there are only very few severe cases coming to the village clinic per year.

The patients receive a paper how the handed out medicine has to be taken. It is at the same time a receipt for the low fee the patient has to pay. Every patient is also registered in the treatment book. Photos were taken.

In case of need the health worker also visits the patients at home. He also pays visit to the monastery if needed while mostly the monks come down the few steps to the village clinic.
For simple treatment, all necessary instruments are available. The sterilization of the instruments is a problem because the steam sterilizer is completely defect and electrical equipment cannot be used due to the lack of electric power during daytime. So sterilization has to be done by washing the instruments and sterilizing them with alcohol. We watched this accurately being done.
The amount of contraceptives of different types surprised us. We were informed that the government supplies the contraceptives free of charge (most probably out of the WHO program). Even long-term contraceptive injections are available and are – as far as we can understand – regularly applied.

Beside the contraceptives the government supplies different vaccines (also most probably out of the WHO program) free of charge to be applied by the health worker.

The furniture in the treatment room is in a suitable condition. Not untypical for the country the benches and tables in the waiting room are only painted on the most needed surfaces.

The heater for heating the treatment room is completely corroded and deposited in the so-called living room for a health worker not having a house in the village. (In this room also the batteries and other installations of the solar system are installed – the room is in quite good condition but today not in regular use) The health worker complained that it is too cold in winter for treatment. A solution could not be found in the discussions. Heater pipe and most probably the heater itself has to be replaced.

The four panel solar power installation installed by MountainSpirit Germany/P. Avramidis is
working correctly. The batteries seem still to be in good condition. Regular readings of the power inand output are no longer noted down.

General treatment situation

Prior to the visit to Chyangmityang MSD Team spoke to Dr Mingmar
Sherpa in Kathmandu and to Mrs Pema Sherpa in Phaplu.

In the – slightly idealistic – view the situation in Chyangmityang has to be regarded even without the now existing village clinic as quite good. It is situated only 3 to 4 hours walk (for a healthy person) from the district clinic in Phaplu. And according to the governmental rules there must be another village clinic in one of the nine VDC’s to which Chyangmityang belongs – but no one could indicate if it exists and where it should be. But it must be at least more than four hours walk away.

Because of that for the two persons we talked to Chyangmityang was not the best possible place for setting up a private run village clinic.

For MountainSpirit and seen as a model project Chyangmityang is definitely the right place because the village had the demand for better health service (e.g. to avoid more migration to Kathmandu) and is relatively easy to reach for evaluation, support, supervision and direct trainings. So Chyangmityang can act as the needed model for learning how to establish further village clinic projects in more remote places.

It has to be considered that the medical treatment and the medicine – again slightly idealistic –is given free of charge in the district clinics because they are operated by the government (as long as the government cares at all). A private run village clinic like Chyangmityang has to pay the wages of the health worker and buy the medicine privately. Normally such (private) village clinic has to charge even small amounts for the treatment. In Chyangmityang it is arranged that the villagers pay according to their financial capacity. The deficit has to be covered by a donator as long as the clinic is operating.
Nevertheless it has to be seen that such village clinic in a place without a monetarian economy will depend on foreign funds for paying the wages of the health worker and buying the medicine forever. If no action is taken to develop the economic basis paralleled to establishing a village clinic any village clinic project will be a “barrel without bottom”.

Furthermore, this situation clearly shows the importance of giving grassroot level trainings in all
relevant fields for the villagers to improve their knowledge, abilities and skills allowing them to modify their living conditions gently on the basis of their existing culture.

Health worker

The health worker, Mr Dinesh Rai, was educated at the Himalayan Paramedical Institute at
Okhaldhunga in the Nepali year 2066/67. He successfully completed a 15 months CMA course.
Today he lives near the village clinic. Originally he comes from Basa village.
During the visit in springtime 2011, Dr. med. Rainer and Anne Claußnitzer decided together with the village committee to select two young woman to be sent for education as health worker.

Five persons from the village were interested and two persons were finally selected after some tests: Mrs Dali Sherpa and Mrs Sakini Sherpa. They have already started their education.

As said before we received valuable information from Dr Mingmar Sherpa in Kathmandu and Mrs
Pema Sherpa in Phaplu. They draw our attention to the situation of the health worker: there are two different types of education available in Nepal.
· a 15 months training as Country Medical Assistant (CMA)
· a 18 months training as Auxiliary Nurse Midwife (ANM)
It has to be expected that a village like Chyangmityang needs a (female) ANM to keep the young pregnant woman in the village instead of making them start their migration out of the village.

Furthermore we should expect that the woman in a village dislike to be treated by a male health worker.

In all talks in Chyangmityang village we found between the lines the above information confirmed although the male health worker is highly accepted and supported.

In the talks in Chyangmityang village the second question was not mentioned at all although we feel it is a pending question: what happens in case of holiday or illness of the one health worker?
Mr Dinesh Rai typed and printed – with the help of the monastery – a letter to MountainSpirit saying that he will serve in the village clinic ‘until the clinic is ruined’.

Summarising the situation it has to be said that it is a good decision to educate another health worker.
It has to be considered that after the education more hands demand payment. Furthermore the education as ANM would be much better than a CMA. And the villagers understood Dr Rainer's selection as the promise to pay for the education. So we are bound to arrange the education cost.
We received the following education cost for the full CMA education per person:
food 40,000; uniform 3000; monthly fee 15,000; admission 17,210; books and copies 5300; form 310 NRS. Total: 103,500 (in reality total = 80,820 NRS). To include unforeseeable cost we should calculate per person for the complete education with the total cost of per person NRS 120,000 = €1200 = US$1680 (plus 10% handling charge (to MSN))
A quick decision and the quick action on this matter is needed.

Supply of medicine

We found sufficient medicine of all necessary types in the shelves of the village clinic.

In the talks with the village committee, the health worker and the monastery the following situation seems to be existing: the village comity arranged not long ago a close corporation allowing the monks and students in the monastery to have health treatment in the village clinic and on the other hand funding the village clinic including the health worker and buying the medicine (in Kathmandu (?)). The cost seems to be covered out of donations to the monastery from Taiwan and maybe USA/Maya Sherpa foundation. (But in the end the second donator is to be a future dream by the villagers.)

Maya Sherpa foundation confirmed recently not to have sponsored such activities so far and said not to intend that in the future.
In the above-mentioned talks with Mrs Pema Sherpa of Phaplu Hospital we tried to arrange any
possibility of supplying medicine free of charge to the village clinic in Chyangmityang. Mrs Pema
Sherpa agreed to visit Chyangmityang towards the end of 2011 to see what can be done. We asked and maybe urged to take Chyangmityang Village Clinic as a sub health post of the Phaplu Hospital. She promised to check this possibility. From our perception such a construction would enable a medical supply free of charge. But we found strong resistance in Dr Mingmar about that topic after our return to Kathmandu.

It must be mentioned that contraceptives and vaccines are supplied free of charge out of
governmental programs.

Village committee meeting

In the village committee meeting in the rooms of the village clinic and in presence of the health worker on September 29 we asked the first question: “what would be good for the village clinic?”
The answer from the village committee was the wish to be equipped similar to Phaplu Hospital with doctors and financial resources. We got told that the funds flowing into the monastery are getting shorter and that the monastery intends to withdraw from funding the village clinic because of the shortage of finances.

We explained that it is economically not feasible to have a doctor in such a village clinic for only 3 to 4 easy treatments per day and that the existing health worker performs as good as most doctors.
The village committee asked the question if not a doctor could come regularly – every 2 to 3 weeks – to the village and we explained that we just talked this topic with Mrs. Pema Sherpa of Phaplu Hospital who promised to us to check this situation. But we also expressed our concern that this will not be possible due to the shortage of doctors in Phaplu Hospital.

The village committee asked if we – MountainSpirit – would take over the cost for the education of the two girls and we confirmed that we will check the situation finally after the results of this evaluation. Until the years end we will confirm our decision through MountainSpirit Nepal. Furthermore we said that most probably we will take over the cost for the education and asked the villagers to check the possibility to change the education from CMA to ANM or to find a possibility to add an additional course on top of the CMA education.

In addition the village committee explained to us that it is even more important for them to keep the health worker Dinesh Rai here in the village and to pay his wages. Our question for the actual wages was answered by the committee with the figure of NRS 1,200 per months although we have clear doubts if this figure represents the actual payments through the monastery. During all further talks the village committee insisted on this figure and confirmed that this is the payment made by the monastery.

We explained that we can't confirm any further actions before having talked to the monastery
concerning the payments.

We asked if the village committee has already tried to order medicine free of charge from Phaplu Hospital. We got the answer that it might have been tried or not. But maybe we initiated an attempt to do so?

We came back to the education of the two girls. We agreed with the village committee that a contract has to be made that the two girls stay as CMA/ANM for at least five years in the village clinic. Under these conditions we see it as feasible that MountainSpirit Germany takes over the education cost and transfer them through MountainSpirit Nepal.

The draft contract is attached to this report.
Again we came back to the wages of Mr Dinesh Rai and confirmed that we will check this situation as well before the years end.

Monastery meeting

With the help of the English teacher at the monastery - Mr Namgial Sherpa - a meeting was held in the dining room and the yard of the monastery with leading monks, the health worker in the head of the village committee.
It was again confirmed that the donations to the monastery don't come in that generously as they used to do in the past and that the monastery would like to withdraw from the obligation to fund the village clinic.
The monastery would be prepared to supervise the activities of the village clinic and the village committee.
Again the question of the salary of the health worker was put on top of the agenda by the Nepali side. And again the same figure mentioned by the village committee was given to us although some indications were given that this is a future salary.

For compensating for the input of the monastery we suggested to check if both sides would not have the chance to cover some educational cost of some students in the monastery e.g. by taking these students into MountainSpirit's child sponsorship program. We explained that we might be in the position to find donators willing to cover the education cost of children when the parents could not take over such education fees. The monastery will check if such children could be sponsored and send us pictures and CV’s of such children.

Feeling that the amount of NRS 1200 as salary (as demanded by the village committee) for the health worker is too high the discussion circled around the future situation when the two girls enter into the village clinic as additional CMA/ANM. We made clear that the amount of NRS 1200 has to be seen – if given at all - as a pot out of which all CMA/ANM have to be paid. The amount of work – i.e. 3 to 4 treatments per day – would not increase and so the workload will be shared and distributed on more shoulders. Consequently also the salary has to be shared between the persons involved. Finally this idea was accepted although there is a clear desire to be felt to get more money out of MountainSpirit.

A decision on the height of the salary for Mr Dinesh Rai and the time for taking over part of the salary or the whole could not be reached. We promised to check the situation carefully and indicated that a possible approach could be seen in a step-by-step taking over parts of the salary from the monastery.


The village clinic is well-equipped and operated today. MSD Team trainings have left deep and positive traces in the awareness of the villagers and should be continued.

Financially MountainSpirit was partly seen a little bit as a milking cow by the villagers. This was
rejected but our realistic input for the development of the health situation in the future of the village was confirmed by us.
A village clinic without economic development of the village will be a “barrel without bottom” forever and a realistic exit strategy has to be found. Leaving the village five years after the start of the erection of a clinic building even if stipulated in a contract leads to a ruin and a loss of reputation and will be in no way a help for remote villages. A suitable balance has to be found. This should be seen as the central learning from the model Changmityang.

The model Changmityang is suitable for “export” into other villages in remote areas in case of minor adjustments and in case of a long-term strategy.

Besides the fundraising MountainSpirit Germany should concentrate on coordinating the activities with other charity organisations active in the same region and on grassroot level trainings in different topics given by senior experts. These experts have to be prepared in cross-cultural matters prior to their work for MountainSpirit in Nepal. Any negative interfering with the existing and hundreds of years old culture has to be avoided. The villagers should be put in the position to select themselves which part of their culture shall be changed in which way to find their position in the modern world.


  • - 1. MountainSpirit Germany/MountainSpirit Nepal has to check the financing of the education  of the two girls as CMA/ANM. In case of our financial contribution the contract with the girls has to be made out.  see draft
  • - 2. MountainSpirit Nepal has to find out if there is a possibility to extend the started CMA
  • education to ANM
  • - 3. MountainSpirit Germany/MountainSpirit Nepal has to check the financing of the health worker see promises for the time after the 2 girls finish education
  • - 4. MountainSpirit Nepal should name the appropriate salary
  • - 5. MountainSpirit Germany/MountainSpirit Nepal have to decide on the long-term funding and
  • the way to transfer the salaries to the group of health workers
  • - 6. MSD Team next grassroot level training has to be prepared for spring 2012
  • - 7. A suitable location for the next village clinic project shall be suggested by MountainSpirit Nepal

W. J. Lehner
S. Schwarzer

Draft contract / memorandum of understandingbetween MountainSpirit Germany/MountainSpirit Nepal and Dali Sherpa ………….Sakini Sherpa
1. Dali Sherpa is prepared to attend the education to become CMA/ANM. She will try to change the started education program to ANM or alternatively try to find a possibility to extend the CMA training to become ANM. She will do her utmost to finish her exam in 15/18 months after education starts. The education will be held at …………
2. MountainSpirit takes over the education cost of up to NRS 120,000 upon prove.
3. Dali Sherpa will enter into a contract to work as part-time health worker in Changmityang
Village Clinic after finishing the education. The amount of working hours will be arranged
according to the demand and times of the possibly other health workers working in
Changmityang village clinic.
4. Dali Sherpa will make herself available to work as health worker in Changmityang Village
Clinic for at least five years from the date of finishing her exams.
5. Dali Sherpa is prepared to share the working time with other CMA/ANM. The salary is
adjusted according to the shared number of working hours.
6. The salary is taken over by MountainSpirit for a period of five years after the exam. It is
adjusted in a height according to the comparable average salary of a health worker in
comparable situations. The partial working hours are taken into consideration.
7. In case Dali Sherpa will not be available for fulfilling the contract to work as CMA/ANM for a
five years period in Changmityang Village Clinic she will pay back of the education cost
not starting work or up to one year after finishing education = 100%
between one and two years after finishing education = 80%
between two and three years after finishing education = 60%
between three and four years after finishing education = 40%
between four and five years after finishing education = 20%
With the support of MountainSpirit Nepal this contract should be made out and signed with the two candidates in case MountainSpirit Germany – maybe in cooperation with other charity organizations - agrees finally to finance the education and the salaries of the health Worker.



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