Shutting down hospitals and Professor Govinda KC

The medical society is in a phase of huge anger now. I would not say it to be in a phase of revolution because things/system is probably not going to change. I wish I am wrong.

An Imagination
Let me share a story with some undercover facts that is widely known and published in media but could hardly be proved.

A businessman is in a search of place to invest. He comes to know that opening a medical college would be good investment. The procedure starts with getting “letter of intent” from ministry of education. It’s hard to get that but not so hard if you are ready to spend around 20-25 millions of rupees. Then he needs to build infrastructures. This would take plenty of time. So he opts to buy a ready-made apartment, obviously which is not suitable to make a medical school or hospital. Then the universities disagree to affiliate stating that colleges already running are more than they can manage. The businessman again spends few more millions of rupees under the table and gets the affiliation. Now, number of students is to be set by the medical council. Let us suppose you want to teach around 100 students per year. For which you need to have a hospital with about 600 or so beds. More than 70% of the beds should be occupied. There are rules for the number of faculties/doctors as well. But his hospital has less then required number of beds. Patients are not there so beds are empty. Numbers of faculties and doctors are not even half of required. He again spends few millions of rupees to the medical council members for less number of beds. Council leaks the date of inspection. He brings the villagers by paying them, for sleeping in hospital beds, to show the bed occupancy to the members of inspection committee. He pays around 100,000 rupees per day and brings faculties/doctors from neighboring country to show the people in inspection. The faculties too come since 1 lakh rupees a day for just being there and doing nothing is too much. In addition they also get a chance to visit a beautiful country.

In this way, the businessman starts medical college investing around 100 to 1000 million of rupees. Is this amount not too much? Probably not. The charge of study is around 3-5 million for the national students. The students from neighboring country who are in majority, pays around 6-7 millions. Students from other international countries pay around 9-10 millions. Since this huge amount is collected every year, the investment of 1000 million in starting is not too much. In addition, the medical college starts PG (Post Graduate) training as well. The charge for PG training is up to 15 million (1.5 Crore). PG trainees are not charged internationally, they are paid instead. But not in this country.

Is the condition same in Nepal? Probably yes. Can’t be sure. But such businessmen do exist here. Our system as well is equally corrupt. 

The current Condition
A medical college operating for more than 10 years is stopped to take any new admission this year because of inadequate infrastructure and other requirements. I wonder, what was the “Nepal Medical Council” doing for this number of years?
Dr. Sasanka Koirala from IOM who is also a leader of Nepali Congress has recently reviled that bribe of 600 millon (60 crore) rupees happened in current dean appointment by the four medical collage in pipeline (Source: Kantipur Dainik, 21 Jan 2014). Probably he is true as well.  

The experts have understood that such system will ruin us. Only rich people could be doctors. The produced doctors probably won’t be technically competent. Thus the service for the common people will get expensive and the quality will be substandard. So this is to be stopped. They are fighting against such sick system. The sequel of this has recently started in Institute of Medicine (IOM), Maharajgunj. A reputed and well respected personality, Prof. Dr. Govinda KC is in “Hunger strike till death” after a doctor with controversial background was made the dean of IOM. Supporting him, all the doctors have stopped working after 6 days of hunger strike since no step is taken yet to address his demands. The professor’s health is degrading. Anything can happen any time. If he dies, this would be a huge loss. This would also be news of our national embarrassment worldwide.

The new dean is accused of corruption during his inspection in some private medical college as a member of Nepal Medical Council. He is arguing that he has not paid even a penny to become the dean. The fact is he needn’t pay to become dean. I guess he could have instead received some amount, in fact huge amount for the agreement of giving affiliation to new medical college in pipeline. Different medias claim that owner of medical college at Birgunj and Biratnagar are ready to pay any amount to get affiliation for their new medical colleges in the capital city.

Today at our hospital: Patan Hospital

Queue of patients in emergency after OPD shut down

Since government has not taken any step yet, Nepal Medical Association has decided to close all the hospital in the country.

A public hospital like ours has huge number of patients. To get the ticket early, people come early in the morning and stay in queue. Today as well, counter opened at regular time, 8 am. People waiting from hours started to buy OPD tickets. After about half an hour, hospital was informed to be closed. The counter was shut down. Most of the people coming to such public hospital are poor and can’t afford the costly private clinics. The cost of lodging and food is also very very expensive in Kathmandu for patients from out of valley. Thus they got furious. Finally patients were seen in emergency. Patient’s queue in emergency seen there is a rare scene.

The point is, would a socially responsible doctor like Govinda KC who goes to remote areas in his own expenses to serve the needy for free, would like the public hospital to be closed? How can one take such a step to support him? I am pretty sure this is wrong decision by Resident Doctors Association, Nepal Medical Association and other stake holders. A doctor takes many oaths like student oath, Hippocratic oath etc during and after his medical school. This step is against all our oaths as well. The punishment of deeds of corrupts medical mafias and TU leadership should not be given to poor patients. We can’t make them innocent victims. The intention is definitely good but we should instead search other ways to pressurize the government and TU officials.

The solution
Changing the dean alone won’t solve the issue. Professor KC has done hunger strike previously as well. The noble issue was temporarily solved and again become same. We know that we need medical colleges, so a full stop to the affiliation would also be wrong decision. The government should make a strict protocol about numbers and places for a medical collage to be established. The policy should be made such that the number of government medical collage should be more than private one in specified time period. We need to learn from the disarray at Patan Academy of Health Sciences (Patan hospital) last year as well. 

In my view, the problem is solely due to the political appointment. The VC of TU, whom we can consider the root cause of current situation at IOM, is appointed by the political party. A Vice Chancellor (VC), rector or Registrar appointed by the political party will be faithful to the political parties and not to the university. The appointment should be based on open competition. A proposal for what they will be doing as a VC, their Vision, goals should be asked to submit for assessment. A team of experts should be appointed to access the proposal and also their hierarchy, background, capability, contribution etc. A public defense by them at the university could also be done etc. this could be a way select a VC.

There can be different models for selection of deserving VC. A team of experts should be created to make one, so that the most deserving person will get the leadership, and not the one selected by politicians.

At the end
we are with you Prof. Govinda.

Prof. Dr. Govinda KC in hunger strike. Photo:Facebook page of Milan Malla

Medical students in community

Today I am talking about need of sending medical students in rural community during their study in medical school.

It was believed in the past that health problems could be solved by advancement in medical technology and by production of smart and competent doctors. It was true few decades ago, when medicine was not this developed. Identification and management of health problems was mostly not easy and sometimes not possible. Now, medicine is very much developed. There is tremendous improvement in technology and knowledge of health issues and disease. We can treat/manage most of the health problems. But still there are people who are dyeing prematurely and untimely in many parts of world due to insignificant and minor problems. The major reason of this is inaccessibility of the medical service. In rural parts of our nation, there is absence of proper health services and qualified health professionals. Even simple and easily manageable health problems are killing people in those areas. The life expectancy of one district of our country is two decades less than other district (Mugu and Kathmandu). Just imagine the disparity… A baby born today will live about 20 years less just because of being born in Mugu, not in Kathmandu. What is its fault for this punishment? If there had been availability of the health services and health professionals, the disparity had not been this large in our country and around the globe. Newly graduated doctors and other health professionals don’t understand there need in those areas thus are concentrated in big cities. This was realized by WHO and medical universities worldwide and they concluded that, medical students should be trained to work in community as a part of medical education which will make them well aware about the ground reality and also make them compassionate enough with desire to contribute in service of rural areas. They can be advocates of disadvantaged and underserved ones and also provide service to these underprivileged people.

Knowing such need in current generation of doctors, many medical universities around the globe have implemented community based curriculum in their medical schools. Our medical school PAHS (Patan Academy of Health Science) as well has opted Community Based Learning and Education (CBLE) as a strategic approach to make its graduates community oriented and to make them advocates of disadvantaged. Such community based educations are experience based learning that gives students an opportunity to understand the problem at the ground level. It enables the graduates to understand ‘social, economic and cultural aspects of people’s life and their relationships with health & disease and problems of the community’ in real life setting. Community Postings make the graduates gain confidence to adjust and efficiently carry out their duties when posted in such a setting. Thus it motivates them to develop an enthusiasm to serve the underprivileged areas of the country. Please don’t forget, taking the students in community for 1 day as a trip or picnic because of mandatory rules of community posting by the affiliating university won’t help at all. I have heard some medical collage do so.

I know going to rural forever is not practical for any health professional. But going there for few years immediately after graduation is achievable. Before he leaves the place for higher education or anything, fresh graduate will take his place. And I am pretty sure, the strategies like CBLE will encourage graduates to work in rural for at least few initial years of their professional life.

Thank you.

PHCC posting…

Our medical school has opted CBLE (Community Based Learning and Education) as a strategic approach to make its medical graduates ‘community oriented and advocates of disadvantaged’. (Why so? I will talk about that in my next blog). Recently we 4^th year students were posted in different PHCC (Primary Health Care Centre) of Makwanpur and Lalitpur district for our 6^th CBLE. I am sharing few of interesting experiences during my posting at Chhatiwan PHCC, Makwanpur.

First of all, villagers had wrongly received message that some senior doctors from Patan Hospital are visiting them. Thus we put on our card indicating “MEDICAL STUDENTS” and we introduced our self as same wherever required.

Government of Nepal doesn’t have adequate human resources. This was true in our PHCC too. A medical doctor with MBBS degree was supposed to be there but not even an HA(Health Assistant) was present. The PHCC was run by a team of motivated staffs leaded by a senior AHW (CMA).

There were some admirable tasks done by community. HFOMC (Health Facility Operation Management Committee) had established a laboratory where some basic investigations could be done. This helps up to some extent for right diagnosis and management. DPHO(District Public Health Office) had managed an extra ANM (Auxillary Nursing Midwife) as well. The 3 ANM is still not enough for PHCC services and 24 hour maternity service. Yet they are doing it. I highly admire their job.

Our PHCC was doing somehow fine(?) job for Family planning, Safe motherhood, Immunization, Reproductive health, Curative services etc. But a health facility with limited medications, inadequate lab, no basic facilities like ECG, X-Ray, USG (Video X-Ray) could hardy give proper care to its patients. There were many things unacceptable for me.

I found that patient safety was not cared at all. In the dressing room, the used instruments should be well sterilized. Do you know how is that done there? The instruments were washed with soap and tooth-brush, and rubbed with spirit before use. Amazing!! Isn’t it? An autoclave is not that expensive machine and is easy to use too. Unless it is managed, the instrumented can be boiled in water. But who cares?

Let me tell you, any patient visiting the facility with fever due to systemic illness were given treatment of malaria and typhoid both. Though it was an endemic reasion of these diseases, one of the diagnoses was compulsorily wrong and both might be wrong for some patients. They are receiving over treatment. People are receiving antibiotics not needed to them. Such practice will make organisms resistant to antibiotics we have, and we won’t be able to manage those disease because of unavailability of new antibiotics in future. I was not satisfied, but nothing could be done. This is how these health facilities run. And I was just a trainee there to understand how things are.

I also noticed that such centers are acting like non referral center. They refer very very few patients. Even patients with significant problem requiring visit to higher center were managed haphazardly. I feel that there is serious need to train these health professionals to identify RED FLAG SIGNS and get patients with those signs referred to higher centers.

I remember a patient of mine. An 18 year old unmarried lady visited me with some problem. Her problems were suggestive of Sexually Transmitted Infection (STI). But she denied having a boyfriend or any unsafe sexual activity. Urinary Tract Infection (UTI) was another differential diagnosis, but it was less possible and urine microscopy as well was not suggestive of it. Other investigations were not available. I got confused and consulted my supervisor, the AHW of PHCC. Do you know what he did? He gave medications for both the disease. This lady too got overtreatment.

You have to make a record of every patient, diagnosis and treatment in specified registers of HMIS (Health Management Information System). In the chart provided, COPD (Chronic Obstructive Pulmonary Disease), a respiratory problem, was kept under cardio vascular disease. I wonder how did the experts in ministry made such blunder and distributed all over the country.

During my posting at ANC (Anti Natal Checkup i.e. Medical and nursing care of women during pregnancy) I found that most of the women being pregnant for 1^st time were 15-17 years of age. It clearly shows early marriage in our communities. I asked the age of marriage to those mothers. Most of them answered 14 or 15. Along with smoking, alcohol and drug abuse, we are also worried about problems of premature sex in big cities of our country. But this is socially rampant in rural too. This is definitely going to adversely affect the heath of these mothers and their children too. I asked to all the mothers visiting me in ANC care room about their contraceptive use as well. Almost half of them replied that they didn’t use any, other half said that they didn’t need it because their husbands were in foreign. These examples clarify why our CPR (Contraceptive Prevalence Rate) is stagnant in below 50 % (Source: DHS 2011).

A really nice calendar like pamphlet is designed for pregnant mothers. Danger signs during pregnancy, delivery, peurperium, infancy and Maternal and new born care is well explained there. See  photo below. Since most of the patients are illiterate, PHCC staffs suggest those mothers ask someone to read it for them in home. I don’t think this is going to help. I suggest: the health facility staff should themselves read and explain it to the mothers.

Army officers, coming there for the security of different programs related to upcoming election were staying in new maternity building of the PHCC (not used yet). I remember our last evening there. We went to canteen for our dinner. Different varieties of alcohol are available even in canteen of the PHCC. Some army officers were drinking there and the whole canteen smelled really very bad. We waited outside for long, until they left. Smoking, drinking etc. is banned by Government of Nepal in public places like hospital. As always we have made admirable rules and regulations but failed implement it. I was many times disturbed by bad smell of cigarette as well, by local people (mostly female) even inside emergency of PHC.

Chhatiwan is large VDC. Providing health service to entire VDC is not possible by single health facility. Thus the PHCC runs other SHP in parallel. This is good step for public welfare. The government doesn’t has the provision of keeping two health facility in one VDC. Thus they have divided the human resource in PHCC for two facilities. Single health facility is enough in VDCs of hill with population of less than 5000 population or so. The VDCs in terai are comparatively larger with more than 10,000 population each. I think, running parallel institution, as done by Chhatiwan PHCC could be an option to solve such problem in large VDCs with comparatively more number of population. 

Thank You