BMJ 2014;349:g4913 doi: 10.1136/bmj.g4913 (Published 14 August 2014)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Nepal may have enough doctors but they’re in the wrong place The vast majority of Nepalese people struggle to access even basic medical care, says Pranita Ghimire, because it is focused in cities rather than where the need is greatest and where most opportunities exist for doctors Pranita Ghimire medical officer, general practice, Manmohan Memorial Eastern Regional Community Hospital and Research Centre, Birtamode, Jhapa 00977, Nepal Low-income countries have two parts. One is rich. Children go to decent schools, get a good education, grow up watching Star Wars and Disney, play the same video games as children from rich countries, read Harry Potter and Lord of the Rings, eat at KFC and Pizza Hut, and live as globally as the internet permits.
The other part is chaotic and underdeveloped, where the country is so mismanaged that nothing makes sense—wealth inequality, a never rising gross domestic product, an unmanaged health system, a lack of governance and education, and the list goes on. But how does the rest of the world see Nepal? The stereotypical image is of political crises, including monarchical massacres, strikes and hunger. Statistically, we must be a 10-90 country, with a wealthy 10% and the remaining majority struggling to survive. A brain drain is a contributing factor—that is, migration to foreign countries or nearer to home to the urban centres of Kathmandu, Pokhara and Dharan. A local newspaper in Rajbiraj reported a recent telling example. A woman had died of postpartum haemorrhage because she did not have the 20 Nepalese rupees (£0.12; €0.15) to enter the emergency room of the local hospital. Her crying husband had gone to beg for the money with her newborn infant while she bled to death. I was recently part of a countrywide assessment of Nepal’s surgical needs. The tool we used, the Surgeons OverSeas’ (SOS) assessment of surgical need (SOSAS), was first used in Sierra Leone and Rwanda. As expected, it found a severe shortage of surgeons in these countries.1 2 Huge deficiencies in personnel, equipment and supplies were already apparent in Nepal, but our survey showed a discrepancy between the total number of doctors and the actual services available to rural patients.3 4
Nepal has a population of 27.47 million people and has more than 15 medical colleges, producing more than 2000 physicians and 500 postgraduates a year. Additionally, about 1500 medical
students graduate abroad, mainly from schools in China, India, Bangladesh, Pakistan, and the Philippines. And about 500 Nepalese students get postgraduate qualifications abroad each year.5
Out of all these graduates, perhaps 50 a year become surgeons. If we focus only on unmet surgical need in rural areas, where qualified personnel are lacking, this number might be enough, given that Nepal already has many established surgeons. But those in rural settings are limited by poor infrastructure and likely have less chance to develop professionally. Most aspire to work in urban hospitals, with better tools and experienced seniors.
So the problem is in distribution, and the reason may come down to governance. Perhaps the lack of proper systems, protocols and vision has handicapped us. Irrespective of the number of medical graduates and postgraduates, most doctors settle in urban hubs catering to urban needs and where they can earn more money. Sadly it seems that medicine has become a business. Most people in Nepal lack health insurance. They have to pay for everything out of their own pocket, however dire the situation. There might soon come a day where triage is done on this basis.
Students pay a handsome sum, of US$40 000 to 50 000, for their medical tuition, and similar amounts for postgraduate degrees. Afterwards, the only thing on their minds is to make money. They think they deserve personal comforts after all the years of hard grind and investment.
And the government does not adequately provide. So, is it wrong if 50% of graduating medical students want to emigrate to continue their education? Is it wrong if most graduates amass in urban centres so they can make a decent living? But rural Nepal cries out for help. A newborn baby is given cow’s urine instead of colostrum while his mother is pale from blood loss and starts seizing for an unknown reason. This is
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BMJ 2014;349:g4913 doi: 10.1136/bmj.g4913 (Published 14 August 2014)
Page 2 of 2
VIEWS & REVIEWS
treated as an act of God. As is cancer, HIV and leprosy. One of the villages we visited had a health worker who was pale from iron deficiency anaemia. The sad thing was this government health worker did not know that iron tablets are provided free in our country. What care can we expect in rural Nepal if even health workers do not know what is available?
must be offered to all healthcare workers. Also, patients need good health records so that they do not get repetitive and expensive workups and batteries of tests just because they were not educated about the importance of carrying around the results of their previous interactions with health services. Not missing patients through flaws in the system should be a priority.
One of the villages we visited had a private clinic with a full appointment diary. And who was the doctor? The man in charge did not have a valid degree to work as a health assistant, yet he was the “dactar-sahib” of the village. The same story can be found throughout rural Nepal.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
We saw a case of a child with autism, unattended and uncared for. We saw a case of elephantiasis, many cases of intellectual disability, and even more cases of lipomas, sebaceous cysts, keloids, urinary obstruction, and many other minor non-debilitating yet uncared for surgical problems.
We saw a signboard outside one residence that said “Aurthopedic surgeon.” The man in charge was not even a health assistant. He reduced fractures, did minor procedures, and had performed countless septic abortions, and three of his patients had recently died. Popular opinion was that those who had died had deserved to, as some sort of divine punishment. We have to think of solutions. Foreign aid is a good start. A large chunk of our national budget has to be reserved for health reforms that focus on creating tertiary care centres in each region. We need to limit the number of medical college springing up as businesses. We need universal health insurance, with free care for the people in most need. With better planning, it may be possible to improve the geographical distribution of doctors, nurses, health assistants, and all other paramedics to align with need. Attractive salaries
For personal use only: See rights and reprints http://www.bmj.com/permissions
We need more studies like SOSAS in Nepal. They show the world the true nature of the country and how much attention our pitiful healthcare system needs. But they also make young doctors like me think about the future. Do I want to be selfless, and practice in rural Nepal catering to unmet medical needs, or do I want a decent urban living for me and my family?
Provenance and peer review: Not commissioned; not externally peer reviewed. 1 2 3 4 5
Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB, Yambasu SE, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 2012;380:1082-87. Petroze RT, Groen RS, Niyonkuru F, Mallory M, Ntaganda E, Joharifard S, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery 2013;153:457-64. Groen RS, Kamara TB, Dixon-Cole R, Kwon S, Kingham TP, Kushner AL. A tool and index to assess surgical capacity in low income countries: an initial implementation in Sierra Leone. World J Surg 2012;36:1970-7. Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 2012;99:436-43. Public Health Perspective Nepal. Annual Report 2068/69 (2011/2012) of Department of Health Services, Ministry of Health and Population, Nepal. http://phpnepal.org/index.php? listId=453#.U6R7iJSSy2E.
Cite this as: BMJ 2014;349:g4913 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Nepal may have enough doctors but they’re in the wrong place The vast majority of Nepalese people struggle to access even basic medical care, says Pranita Ghimire, because it is focused in cities rather than where the need is greatest and where most opportunities exist for doctors Pranita Ghimire medical officer, general practice, Manmohan Memorial Eastern Regional Community Hospital and Research Centre, Birtamode, Jhapa 00977, Nepal Low-income countries have two parts. One is rich. Children go to decent schools, get a good education, grow up watching Star Wars and Disney, play the same video games as children from rich countries, read Harry Potter and Lord of the Rings, eat at KFC and Pizza Hut, and live as globally as the internet permits.
The other part is chaotic and underdeveloped, where the country is so mismanaged that nothing makes sense—wealth inequality, a never rising gross domestic product, an unmanaged health system, a lack of governance and education, and the list goes on. But how does the rest of the world see Nepal? The stereotypical image is of political crises, including monarchical massacres, strikes and hunger. Statistically, we must be a 10-90 country, with a wealthy 10% and the remaining majority struggling to survive. A brain drain is a contributing factor—that is, migration to foreign countries or nearer to home to the urban centres of Kathmandu, Pokhara and Dharan. A local newspaper in Rajbiraj reported a recent telling example. A woman had died of postpartum haemorrhage because she did not have the 20 Nepalese rupees (£0.12; €0.15) to enter the emergency room of the local hospital. Her crying husband had gone to beg for the money with her newborn infant while she bled to death. I was recently part of a countrywide assessment of Nepal’s surgical needs. The tool we used, the Surgeons OverSeas’ (SOS) assessment of surgical need (SOSAS), was first used in Sierra Leone and Rwanda. As expected, it found a severe shortage of surgeons in these countries.1 2 Huge deficiencies in personnel, equipment and supplies were already apparent in Nepal, but our survey showed a discrepancy between the total number of doctors and the actual services available to rural patients.3 4
Nepal has a population of 27.47 million people and has more than 15 medical colleges, producing more than 2000 physicians and 500 postgraduates a year. Additionally, about 1500 medical
students graduate abroad, mainly from schools in China, India, Bangladesh, Pakistan, and the Philippines. And about 500 Nepalese students get postgraduate qualifications abroad each year.5
Out of all these graduates, perhaps 50 a year become surgeons. If we focus only on unmet surgical need in rural areas, where qualified personnel are lacking, this number might be enough, given that Nepal already has many established surgeons. But those in rural settings are limited by poor infrastructure and likely have less chance to develop professionally. Most aspire to work in urban hospitals, with better tools and experienced seniors.
So the problem is in distribution, and the reason may come down to governance. Perhaps the lack of proper systems, protocols and vision has handicapped us. Irrespective of the number of medical graduates and postgraduates, most doctors settle in urban hubs catering to urban needs and where they can earn more money. Sadly it seems that medicine has become a business. Most people in Nepal lack health insurance. They have to pay for everything out of their own pocket, however dire the situation. There might soon come a day where triage is done on this basis.
Students pay a handsome sum, of US$40 000 to 50 000, for their medical tuition, and similar amounts for postgraduate degrees. Afterwards, the only thing on their minds is to make money. They think they deserve personal comforts after all the years of hard grind and investment.
And the government does not adequately provide. So, is it wrong if 50% of graduating medical students want to emigrate to continue their education? Is it wrong if most graduates amass in urban centres so they can make a decent living? But rural Nepal cries out for help. A newborn baby is given cow’s urine instead of colostrum while his mother is pale from blood loss and starts seizing for an unknown reason. This is
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g4913 doi: 10.1136/bmj.g4913 (Published 14 August 2014)
Page 2 of 2
VIEWS & REVIEWS
treated as an act of God. As is cancer, HIV and leprosy. One of the villages we visited had a health worker who was pale from iron deficiency anaemia. The sad thing was this government health worker did not know that iron tablets are provided free in our country. What care can we expect in rural Nepal if even health workers do not know what is available?
must be offered to all healthcare workers. Also, patients need good health records so that they do not get repetitive and expensive workups and batteries of tests just because they were not educated about the importance of carrying around the results of their previous interactions with health services. Not missing patients through flaws in the system should be a priority.
One of the villages we visited had a private clinic with a full appointment diary. And who was the doctor? The man in charge did not have a valid degree to work as a health assistant, yet he was the “dactar-sahib” of the village. The same story can be found throughout rural Nepal.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
We saw a case of a child with autism, unattended and uncared for. We saw a case of elephantiasis, many cases of intellectual disability, and even more cases of lipomas, sebaceous cysts, keloids, urinary obstruction, and many other minor non-debilitating yet uncared for surgical problems.
We saw a signboard outside one residence that said “Aurthopedic surgeon.” The man in charge was not even a health assistant. He reduced fractures, did minor procedures, and had performed countless septic abortions, and three of his patients had recently died. Popular opinion was that those who had died had deserved to, as some sort of divine punishment. We have to think of solutions. Foreign aid is a good start. A large chunk of our national budget has to be reserved for health reforms that focus on creating tertiary care centres in each region. We need to limit the number of medical college springing up as businesses. We need universal health insurance, with free care for the people in most need. With better planning, it may be possible to improve the geographical distribution of doctors, nurses, health assistants, and all other paramedics to align with need. Attractive salaries
For personal use only: See rights and reprints http://www.bmj.com/permissions
We need more studies like SOSAS in Nepal. They show the world the true nature of the country and how much attention our pitiful healthcare system needs. But they also make young doctors like me think about the future. Do I want to be selfless, and practice in rural Nepal catering to unmet medical needs, or do I want a decent urban living for me and my family?
Provenance and peer review: Not commissioned; not externally peer reviewed. 1 2 3 4 5
Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB, Yambasu SE, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 2012;380:1082-87. Petroze RT, Groen RS, Niyonkuru F, Mallory M, Ntaganda E, Joharifard S, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery 2013;153:457-64. Groen RS, Kamara TB, Dixon-Cole R, Kwon S, Kingham TP, Kushner AL. A tool and index to assess surgical capacity in low income countries: an initial implementation in Sierra Leone. World J Surg 2012;36:1970-7. Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 2012;99:436-43. Public Health Perspective Nepal. Annual Report 2068/69 (2011/2012) of Department of Health Services, Ministry of Health and Population, Nepal. http://phpnepal.org/index.php? listId=453#.U6R7iJSSy2E.
Cite this as: BMJ 2014;349:g4913 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
