National 6 (Spotlight Weekly)

Doctors' Dilemma

Scarcity of professionals and poor coordination ail the sector

By AKSHAY SHARMA

"I returned to Nepal hoping that I would be able to serve the people. But after two years here, I have a very different attitude," says Dr. Bisal Kant Mainali. That's a sentiment you get to hear a lot amid the apathy that has gripped the country these days. When it comes from the custodians of our collective well being, it forces the rest of the country to sit up and listen.

What makes doctors, who have invested so much time, energy and money in acquiring the knowledge and developing the skills necessary to keep the rest of us hale and hearty, succumb to such listlessness? "At first, I was supposed to do an internship for a year at Bir Hospital, even though I had already done one in the Philippines," Dr. Mainali says. "Then I didn't want to go to the rural areas. My family spent so much money on educating me and I feel I have to recover that. Besides, there are no facilities for doctors in rural areas. After all, we need to keep abreast of latest technologies and developments."

For decades, trained medical professionals have been recognized as a key underpinning of the country's social and economic health. The state, which has laid great emphasis on the production of skilled doctors and other medical professionals, has sent students for medical training abroad. Moreover, countless Nepali parents have invested personal resources in the medical education of their children.

But where have all the doctors gone? In a country where 90 percent of the population is still deprived of health care, this problem becomes all the more distressing. Like many other sectors, public health in Nepal is in a chaotic situation. Doctors are accused of refusing to accept postings in rural and remote parts of the country where they are needed the most. Doctors, for their part, reject such criticism and blame the government for failing to provide the basic clinical facilities they need to do their job well.

Government hospitals are the cheapest medical facilities open to the public. For the middle class, the upper middle class and the upper class, countless private nursing homes have sprung up. These days, a lot of such establishments have been registered as research centers. But, again, these are concentrated in a handful of urban pockets.

"Among general practitioners, 53 percent are in government service, while 20 percent are in research and medical centers. Some 15.5 percent are with non-government organizations and 11 percent in general practice," says Dr. Ramesh P. Acharya of Tribhuvan University Teaching Hospital. "Eighty-seven percent are stationed outside Kathmandu valley."

Experts say public health has been a failure because of the poor distribution of scarce manpower. "Nepal should take bold steps toward utilizing the health manpower it has for the community," says B.H. Poudel. "Now that the country has a number of medical colleges, the focus should be on producing community doctors."

"Community-oriented medical education is a new approach. The Institute of Medicine (IOM) has been pursuing the approach of training in the settings of the community as the primary focus," says Dr. Ramesh K. Adhikary, dean of the IOM. "The community-based program for MBBS training at the IOM is based on such experiences as field-based diagnosis, concurrent field trips with families, training through posting in district hospitals," he adds. "There are certain areas, particularly in the origination of students and logistics that support the needed supervision."

There are other problems. "We've seen cases where doctors do not know enough about their patients, apart from issues relating to the labeling of drugs and basic reference material available to prescribe them," says Dr. Keshab Sharma. His prescription: Non-government organizations, government clinics, research centers and private medical units should develop a mechanism of working together to raise the health status of the country.