A Health Care Crisis: My Experience in Nepal

By Alana Fruauff


Health care reform has become one of the most pressing issues for nations throughout the world today because it is such an important aspect in maintaining a fair standard of living. Perhaps the most urgent concern is the health care of developing countries because these nations have such poor populations and limited access to resources. The people of these nations suffer from immensely inadequate health care if they receive any health care at all. These countries also often have a strong history of traditional medicine and thus, the development of modern facilities is impeded by these cultural customs. My desire to better understand the reality of health care in developing countries led me to design a study focused on the health care issues in Nepal. The isolated nature of Nepal and its strong cultural heritage made it a perfect location to study the development of modern medical facilities in coexistence with traditional systems. After spending the summer in Nepal navigating health care facilities, interviewing health care personnel, and becoming familiar with the people of Nepal, I gained invaluable knowledge and experience that has allowed me to effectively reflect on health care policies in Nepal.
Because Nepal has a long history of inadequate allopathic facilities, traditional medical facilities have always been a major source of relief for Nepalese people. Ayurveda, Tibetan Medicine, and Chakra are three of the most prominent traditional systems present in Nepal. These alternative medicinal systems are still ubiquitous in Nepal today, even with the advancement of allopathic facilities. This speaks to the cultural and social importance of these medical systems to Nepalese people. These systems have been passed down for generations, and they incorporate many spiritual aspects important to religious life. Traditional systems are particularly important in villages, where allopathic medicine is very limited. In the absence of modern medicine, many villagers use their local resources for healing, and thus herbal systems such as Ayurveda persist. Although alternative medical systems are present in urban centers, they aren’t as dominant and authentic as those in more rural places. Traditional systems in the city are normally used as an alternative option. Several doctors and administrators informed me that alternative medicine in the city tends to be used by people with specific diseases, especially chronic ones, such as gastritis, arthritis, jaundice, and mental illnesses. Additionally, urban residents use alternative medicine when they feel that modern medicine has failed them. Whether traditional systems are used as an alternative option or as the primary care system, it is apparent that traditional medicine is integral to society. Most Nepalese people believe in these traditional systems and a substantial amount of people even prefer traditional medicine because they are skeptical of modern medicine and its side effects.
Although traditional medicine is a major component of Nepalese health system, the development of allopathic medical facilities has allowed increased emphasis on allopathic services. The allopathic health care sector in Nepal is divided between public facilities run by the government and private amenities that are independently funded. A large portion of my experience in Nepalese health care took place at Paropakar Women’s hospital, which is a government hospital in the capital, Kathmandu. Government hospitals tend to be much more affordable than private ones and as a result, a majority of patients in these facilities come from the lower and lower-middle classes. Because there is a shortage of medical facilities, the hospitals are extremely overcrowded with patients. There is also a great shortage of faculty resulting in a very hectic, congested environment not conducive to productivity and optimal patient care. In 2004, the World Health Organization (WHO) reported that there were only two physicians and two professional nurses for every 10,000 Nepalese people (1). The shortage of physicians in the country is worsened by the fact that many physicians want to leave the country to find work elsewhere. An article from the Himalayan Times sited a “lack of security, poor remuneration, and limited opportunities for professional development” as reasons for doctors leaving the country (2). As a result of the shortage, government hospitals are known for having long queues and slow service. This has caused a distinctive form of health care to emerge in Nepal. Physicians are forced to strategize—choosing only certain tests and medicines—in order to efficiently diagnose and treat patients while also keeping costs low. Physicians must also be extremely efficient so that they may tend to the large number of patients awaiting care. In many cases, however, this means that treatment is compromised because physicians are less thorough and attentive. In the gynecology outpatient department of the Paropakar Hospital, for example, physicians spent roughly four minutes on each patient—barely enough time for a few questions and a quick physical exam.
The high ratio of patients to physicians is only one of many urgent problems facing this poor country. To make matters worse, the hospital has greatly inferior facilities that debilitate the staff’s ability to perform. In general, the technology is about fifteen to twenty years behind the Western world, and the technology that does exist is immensely inadequate. For example, there is only one ventilator at Paropakar Hospital, and at one point two newborns needed the ventilator, which resulted in one baby eventually dying. Additionally, the city lacks technologists and as a result many machines have no operators or repairmen. The mammography machine at Paropakar hospital was out of service for months simply because they had no technologist to work it. Another prime example of the lack of adequate facilities can be seen by the government’s attempts to initiate transplant services. In 2004, the government tried to start kidney transplant services at a city hospital, but failed because of “a lack of expertise and adequate equipment (3).” Even now that hospitals have started transplants, they are so under-resourced that only one transplant occurs a week and appointments are booked for eight months in advance (3). This is the case for a lot of care: patients are forced to wait weeks or months for procedures due to a lack of staff and equipment. In addition to inadequate facilities, basic accommodations are deficient and sanitation efforts are dismal.
Although care in the capital is inadequate in many ways, there is still a reasonable amount of accessible facilities. This cannot be said about many areas in Nepal where health care facilities and personnel are even more scarce. The WHO reported that in 2002, there were only 4.26 hospital beds per 10,000 people in Nepal (1). There are considerably more beds in urban areas, whereas rural areas suffer tremendously from deficient beds. The hilly terrain and scattered populations of rural Nepal make it very hard to access remote villages, let alone provide care to them. The facilities that do exist in more remote places are difficult to staff because few physicians or nurses want to work there. The structure of the health care system itself illustrates the lack of widespread facilities. There are seventy-five districts in Nepal and each only has one district hospital. Below this, there are primary health care centers, which only have one physician each. Lastly, there are health posts that completely lack physicians. Additionally, district hospitals only have general physicians, so in order to see specialized doctors, patients have to go to zonal, regional, or central hospitals that are much more scarce. Most of the time, cases are sent to central hospitals in Kathmandu; however, this journey isn’t practical for many patients because the transportation system is abysmal and the cost of travel is too high. Several physicians told me terrible stories about families that carry their sick relatives miles to reach a hospital.
Not only is health care sparse, but also it is unattainable for a considerable portion of the people in the country because it is such poor country. In 2005, thirty percent of the population was below the poverty line (1). Several administrators told me that one of the greatest struggles for Nepal is making health care easily accessible and affordable for the masses. Although the care in government hospitals is significantly discounted and there are several programs to aid low-income patients, these measures are not sufficient. Every hospital only uses five percent of its government funds and five percent of their own profits for the care of the poor (1). Although primary care is fairly accessible for most patients, higher care, such as surgeries is largely inaccessible because the costs are too high even after receiving aid. Many patients also struggle to pay for medicine, which is not normally discounted through the hospital. To make matters worse, most people are not aware of the importance of looking after their health. Hygienic measures aren’t practiced among many people leading to propagation of diseases. In 2005, only thirty-nine percent of the population had adequate sanitary disposal facilities available (1). Systemic preventative care is also largely non-existent. Patients usually come in late stages of their illness, making it hard for doctors to treat them and increasing the costs of their treatment.
The issues I faced while working in the allopathic facilities were alarming. Everywhere I turned there seemed to be inadequacies resulting in inferior delivery of health care services. Most of the health care problems stemmed from poor government administration and insufficient funding. In 2003, only 5.1 percent of the national budget was devoted to healthcare measures (1). The country depends largely on aid from other countries but this aid is not enough. Furthermore, poor administration prevents efficient use of this funding. For the past ten years, Nepal has seriously struggled with political instability and incompetency. The nation has been desperately trying to institute democracy and a constitution but these measures have been largely unsuccessful. The constant power struggle that ensues prevents productive administration and policies cannot be effectively implemented. This severely debilitates health care reform. In order for health care reform to be effective, the Nepalese government must be reformed. If the Nepalese people can successfully institute democracy and instate a more effective government in the next few years, it would be instrumental for the nation’s health care. Thus, it is very important for international aid to help initiate effective health care policies and it may even be important for foreign authorities to help ease the country’s transition into democracy.
Although political reform is crucial, health care reform must coincide with government reorganization in order for progressive measures to be made in the health care sector. The wide range of daunting issues plaguing Nepalese health care must be addressed in order to preserve the country and its health. International intervention is essential in this quest because without positive influences, Nepal will remain as it is. First, foreign aid must continue with even greater amplitude because without funds, no changes can be made. Additionally, it is essential that the medical community donate equipment to Nepal so that the country can build up its supplies. Shipping money and equipment to Nepal, however, will not be sufficient because the same mistakes will persist. International intervention must increase drastically to fix the multitude of problems. Foreigners need to take action in Nepal and promote a more positive role for the government in health care. International aid should train technicians and initiate programs that can continue to train them. Also, aid must help create new health facilities so that existing ones aren’t so scarce and overcrowded. In order to staff the facilities, Nepal must begin to promote careers in the health sciences. Measures must also be made to reach out to the Nepalese people to inform them about the importance of maintaining healthy lives. Although these are just minor steps, they will help lay the foundation for a greater future for Nepal.

1. “Country Health System Profile-Nepal.” World Health Organization. World Health Organization, 21 2011. Web. 19 Oct 2012.
2. Maharjan, L. (2012, July 21). Doctors’ flight from country paints a gloomy picture. The Himalayan times.
3. Ghimire, B. (2012, July 31). Bir, TU hospitals basking in kidney transplant glory. The Kathmandu post, p. 2.

Subject: Healthcare Policy
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