Health & Society
No Road, No Map, But No Child Left Behind: The Five-Hour River Journey to Deliver Healthcare in Tripura
Deep inside Tripura’s Atharamura mountains, a tiny hamlet called Kalicharan Para has no road connecting it to the world. Getting there means a five-hour boat ride through rough waters and thick jungle. For the health teams who made the journey, that was exactly the point.
At dawn, the Khowai River runs quiet through dense forest and steep hills in Tripura. The water catches the early light. There are no roads here. No highway signs. No last-mile connectivity in any sense that a planner in a state capital would recognise. There is only the river, and the forest, and somewhere deep inside the Atharamura mountain range, a small hamlet called Kalicharan Para — home to families for whom this waterway is not a scenic route but the only route.
To reach Kalicharan Para, you must board a boat, navigate rough currents, pass through thick jungle and unforgiving terrain, and arrive — five hours later — at a village that exists, for most practical purposes, beyond the reach of the Indian public health system. No road means no regular ambulance. No routine immunisation visit.
That changed when the district administration and the WHO National Public Health Surveillance Network (WHO-NPSN) identified Kalicharan Para as a priority high-risk area and decided, simply, to go there.
The Team That Made the Journey
What made this outreach mission unusual was not just that it happened — it was who made it happen together. The team that arrived in Kalicharan Para was not a small squad of frontline workers sent alone into the forest. It included the Medical Officer from the Primary Health Centre, the Community Health Officer from the nearest Ayushman Arogya Mandir, the Chief Medical Officer, the Sub-Divisional Magistrate, and Primary Health Centre officials.
Critically, senior leadership made the journey too. Dr Soubhik Debbarma, Member Secretary of the National Health Mission, and Mr Rajat Pant, the District Magistrate and Collector of Khowai, travelled alongside frontline workers. They were joined by the WHO-NPSN team led by Dr Tigran Avagyan.
In public health, this matters more than it might seem. When senior officials travel to a remote village rather than receiving reports from it, the message to both their teams and to the community is unmistakable: this place is worth the effort. These people are worth the journey.
What the Team Brought — and What It Found
The outreach camp brought together multiple health services under one roof — something that is easy to take for granted in a city and extraordinary in a village with no road. Services included:
- Immunisation — scheduled childhood vaccines delivered directly to families
- Screening for non-communicable diseases — hypertension, diabetes, and other conditions that often go undetected in remote areas
- Malaria awareness activities — critical in a forested, river-adjacent region
- Antenatal care — check-ups and guidance for pregnant women
- Village Health and Nutrition Day services
- Deworming
What the team also found, and what no health camp checklist could have prepared them for, was the conversation. Sitting with villagers and listening to their daily realities — the difficulty of accessing even basic communication, the long distances to any government facility, the quiet weight of living beyond reach — transformed what could have been a logistical exercise into something more human. Statistics became people. Data became stories.
A Remarkable Finding: No Home Deliveries
One of the most significant things the team discovered was something that wasn’t a problem. Despite the extreme isolation of Kalicharan Para, the village has recorded no home deliveries. Every expectant mother has gone to a government-run health facility for an institutional delivery.
This is not something that happens automatically in remote communities. It reflects sustained effort, trust built over time between the community and health workers, and a commitment on the part of families to make extraordinarily difficult journeys — the same five-hour river route — for the sake of a safe birth. In public health terms, it is a significant achievement, and one that deserved to be recognised and strengthened rather than simply noted.
What Happens After the Visit
The value of a single outreach camp is real but limited. What makes the Kalicharan Para visit matter beyond the day itself is what was set in motion because of it.
Mr Pant directed the District Health Department to make regular visits to the village — not one-off events, but a sustained schedule of outreach. He also asked the Engineering Department to explore developing an alternative road. A physical connection to the rest of the district would change not just healthcare access but the entire texture of daily life for Kalicharan Para’s families.
The lessons from the visit also travelled back to the State Headquarters. WHO-NPSN convened a high-level meeting with senior officials to discuss building a sustainable, scalable framework for immunisation and primary healthcare delivery in hard-to-reach areas — so that what was done once in Kalicharan Para could become a repeatable system rather than a one-time effort.
What “Last-Mile Healthcare” Actually Means
“Last mile” is a term borrowed from logistics — it describes the final, hardest leg of a delivery, when a package has to get from a regional hub to an individual door. In healthcare, it refers to the challenge of reaching people who are geographically, economically, or socially the furthest from health services.
In India, last-mile healthcare is not a metaphor. It is a five-hour boat ride. It is a forest trail that becomes impassable in monsoon. It is a family that knows a government health facility exists somewhere, but has no practical way to reach it. Solving the last-mile problem requires more than good intentions — it requires systems, transport, trained workers, and the institutional will to keep showing up even when showing up is genuinely hard.
At dawn, the Khowai River is quiet again. The health team has gone back. The children who were vaccinated will not remember the day. The mothers whose blood pressure was checked will carry the results for a while, and then — as all of us do — file the paper somewhere and return to the business of living.
But something has shifted in Kalicharan Para. A place that was, for the purposes of the health system, effectively invisible is now visible. It has been visited by senior officials who will not forget having made the journey.
It has been entered into plans and directives and meeting agendas in Khowai and Agartala. The five-hour river route has been travelled once — which means it can be travelled again, and eventually, perhaps, it will not need to be travelled at all.
No child should be left behind, no matter how distant the destination. That sentence, spoken into the forested silence of the Atharamura hills, is the entire point. And in Kalicharan Para, someone finally came far enough to say it in person.
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The United Nations has shaped so much of global co-operation and regulation that we wouldn’t recognise our world today without the UN’s pervasive role in it. So many small details of our lives – such as postage and copyright laws – are subject to international co-operation nurtured by the UN.
In its 75th year, however, the UN is in a difficult moment as the world faces climate crisis, a global pandemic, great power competition, trade wars, economic depression and a wider breakdown in international co-operation.
Still, the UN has faced tough times before – over many decades during the Cold War, the Security Council was crippled by deep tensions between the US and the Soviet Union. The UN is not as sidelined or divided today as it was then. However, as the relationship between China and the US sours, the achievements of global co-operation are being eroded.
The way in which people speak about the UN often implies a level of coherence and bureaucratic independence that the UN rarely possesses. A failure of the UN is normally better understood as a failure of international co-operation.
We see this recently in the UN’s inability to deal with crises from the ethnic cleansing of the Rohingya Muslims in Myanmar, to civil conflict in Syria, and the failure of the Security Council to adopt a COVID-19 resolution calling for ceasefires in conflict zones and a co-operative international response to the pandemic.
The UN administration is not primarily to blame for these failures; rather, the problem is the great powers – in the case of COVID-19, China and the US – refusing to co-operate.
Where states fail to agree, the UN is powerless to act.
Marking the 75th anniversary of the official formation of the UN, when 50 founding nations signed the UN Charter on June 26, 1945, we look at some of its key triumphs and resounding failures.
Five successes
1. Peacekeeping
The United Nations was created with the goal of being a collective security organisation. The UN Charter establishes that the use of force is only lawful either in self-defence or if authorised by the UN Security Council. The Security Council’s five permanent members, being China, US, UK, Russia and France, can veto any such resolution.
The UN’s consistent role in seeking to manage conflict is one of its greatest successes.
A key component of this role is peacekeeping. The UN under its second secretary-general, the Swedish statesman Dag Hammarskjöld – who was posthumously awarded the Nobel Peace prize after he died in a suspicious plane crash – created the concept of peacekeeping. Hammarskjöld was responding to the 1956 Suez Crisis, in which the US opposed the invasion of Egypt by its allies Israel, France and the UK.
UN peacekeeping missions involve the use of impartial and armed UN forces, drawn from member states, to stabilise fragile situations. “The essence of peacekeeping is the use of soldiers as a catalyst for peace rather than as the instruments of war,” said then UN Secretary-General Javier Pérez de Cuéllar, when the forces won the 1988 Nobel Peace Prize following missions in conflict zones in the Middle East, Africa, Asia, Central America and Europe.
However, peacekeeping also counts among the UN’s major failures.
2. Law of the Sea
Negotiated between 1973 and 1982, the UN Convention on the Law of the Sea (UNCLOS) set up the current international law of the seas. It defines states’ rights and creates concepts such as exclusive economic zones, as well as procedures for the settling of disputes, new arrangements for governing deep sea bed mining, and importantly, new provisions for the protection of marine resources and ocean conservation.
Mostly, countries have abided by the convention. There are various disputes that China has over the East and South China Seas which present a conflict between power and law, in that although UNCLOS creates mechanisms for resolving disputes, a powerful state isn’t necessarily going to submit to those mechanisms.
Secondly, on the conservation front, although UNCLOS is a huge step forward, it has failed to adequately protect oceans that are outside any state’s control. Ocean ecosystems have been dramatically transformed through overfishing. This is an ecological catastrophe that UNCLOS has slowed, but failed to address comprehensively.
3. Decolonisation
The idea of racial equality and of a people’s right to self-determination was discussed in the wake of World War I and rejected. After World War II, however, those principles were endorsed within the UN system, and the Trusteeship Council, which monitored the process of decolonisation, was one of the initial bodies of the UN.
Although many national independence movements only won liberation through bloody conflicts, the UN has overseen a process of decolonisation that has transformed international politics. In 1945, around one third of the world’s population lived under colonial rule. Today, there are less than 2 million people living in colonies.
When it comes to the world’s First Nations, however, the UN generally has done little to address their concerns, aside from the non-binding UN Declaration on the Rights of Indigenous Peoples of 2007.
4. Human rights
The Human Rights Declaration of 1948 for the first time set out fundamental human rights to be universally protected, recognising that the “inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world”.
Since 1948, 10 human rights treaties have been adopted – including conventions on the rights of children and migrant workers, and against torture and discrimination based on gender and race – each monitored by its own committee of independent experts.
The language of human rights has created a new framework for thinking about the relationship between the individual, the state and the international system. Although some people would prefer that political movements focus on ‘liberation’ rather than ‘rights’, the idea of human rights has made the individual person a focus of national and international attention.
5. Free trade
Depending on your politics, you might view the World Trade Organisation as a huge success, or a huge failure.
The WTO creates a near-binding system of international trade law with a clear and efficient dispute resolution process.
The majority Australian consensus is that the WTO is a success because it has been good for Australian famers especially, through its winding back of subsidies and tariffs.
However, the WTO enabled an era of globalisation which is now politically controversial.
Recently, the US has sought to disrupt the system. In addition to the trade war with China, the Trump Administration has also refused to appoint tribunal members to the WTO’s Appellate Body, so it has crippled the dispute resolution process. Of course, the Trump Administration is not the first to take issue with China’s trade strategies, which include subsidises for ‘State Owned Enterprises’ and demands that foreign firms transfer intellectual property in exchange for market access.
The existence of the UN has created a forum where nations can discuss new problems, and climate change is one of them. The Intergovernmental Panel on Climate Change (IPCC) was set up in 1988 to assess climate science and provide policymakers with assessments and options. In 1992, the UN Framework Convention on Climate Change created a permanent forum for negotiations.
However, despite an international scientific body in the IPCC, and 165 signatory nations to the climate treaty, global greenhouse gas emissions have continued to increase.
Under the Paris Agreement, even if every country meets its greenhouse gas emission targets we are still on track for ‘dangerous warming’. Yet, no major country is even on track to meet its targets; while emissions will probably decline this year as a result of COVID-19, atmospheric concentrations of greenhouse gases will still increase.
This illustrates a core conundrum of the UN in that it opens the possibility of global cooperation, but is unable to constrain states from pursuing their narrowly conceived self-interests. Deep co-operation remains challenging.
Five failures of the UN
1. Peacekeeping
During the Bosnian War, Dutch peacekeeping forces stationed in the town of Srebrenica, declared a ‘safe area’ by the UN in 1993, failed in 1995 to stop the massacre of more than 8000 Muslim men and boys by Bosnian Serb forces. This is one of the most widely discussed examples of the failures of international peacekeeping operations.
On the massacre’s 10th anniversary, then UN Secretary General Kofi Annan wrote that the UN had “made serious errors of judgement, rooted in a philosophy of impartiality”, contributing to a mass murder that would “haunt our history forever”.
If you look at some of the other infamous failures of peacekeeping missions – in places such as Rwanda, Somalia and Angola – it is the limited powers given to peacekeeping operations that have resulted in those failures.
2. The invasion of Iraq
The invasion of Iraq by the US in 2003, which was unlawful and without Security Council authorisation, reflects the fact that the UN is has very limited capacity to constrain the actions of great powers.
The Security Council designers created the veto power so that any of the five permanent members could reject a Council resolution, so in that way it is programmed to fail when a great power really wants to do something that the international community generally condemns.
In the case of the Iraq invasion, the US didn’t veto a resolution, but rather sought authorisation that it did not get. The UN, if you go by the idea of collective security, should have responded by defending Iraq against this unlawful use of force.
The invasion proved a humanitarian disaster with the loss of more than 400,000 lives, and many believe that it led to the emergence of the terrorist Islamic State.
3. Refugee crises
The UN brokered the 1951 Refugee Convention to address the plight of people displaced in Europe due to World War II; years later, the 1967 Protocol removed time and geographical restrictions so that the Convention can now apply universally (although many countries in Asia have refused to sign it, owing in part to its Eurocentric origins).
Despite these treaties, and the work of the UN High Commission for Refugees, there is somewhere between 30 and 40 million refugees, many of them, such as many Palestinians, living for decades outside their homelands. This is in addition to more than 40 million people displaced within their own countries.
While for a long time refugee numbers were reducing, in recent years, particularly driven by the Syrian conflict, there have been increases in the number of people being displaced.
During the COVID-19 crisis, boatloads of Rohingya refugees were turned away by port after port. This tragedy has echoes of pre-World War II when ships of Jewish refugees fleeing Nazi Germany were refused entry by multiple countries.
And as a catastrophe of a different kind looms, there is no international framework in place for responding to people who will be displaced by rising seas and other effects of climate change.
4. Conflicts without end
Across the world, there is a shopping list of unresolved civil conflicts and disputed territories.
Palestine and Kashmir are two of the longest-running failures of the UN to resolve disputed lands. More recent, ongoing conflicts include the civil wars in Syria and Yemen.
The common denominator of unresolved conflicts is either division among the great powers, or a lack of international interest due to the geopolitical stakes not being sufficiently high. For instance, the inaction during the Rwandan civil war in the 1990s was not due to a division among great powers, but rather a lack of political will to engage.
In Syria, by contrast, Russia and the US have opposing interests and back opposing sides: Russia backs the government of the Syrian dictator Bashar al-Assad, whereas the US does not.
5. Acting like it’s 1945
The UN is increasingly out of step with the reality of geopolitics today.
The permanent members of the Security Council reflect the division of power internationally at the end of World War II. The continuing exclusion of Germany, Japan, and rising powers such as India and Indonesia, reflects the failure to reflect the changing balance of power.
Also, bodies such as the IMF and the World Bank, which are part of the UN system, continue to be dominated by the West. In response, China has created potential rival institutions such as the Asian Infrastructure Investment Bank.
Western domination of UN institutions undermines their credibility. However, a more fundamental problem is that institutions designed in 1945 are a poor fit with the systemic global challenges – of which climate change is foremost – that we face today.