<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e29c7e80680e0c031ejpeg.jpg" alt="" width="1086" height="724"/><figcaption>Charikot Hospital. Photo: NYAYA HEALTH NEPAL</figcaption></figure>Nepal’s medical industrial complex has modernised healthcare in the country, but it has also pushed treatment out of reach of most citizens.Collusion between politicians and medical magnates has made it so expensive to become a doctor that it has set off a chain reaction to make hospital treatment unaffordable.Meanwhile, government hospitals are <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/">under-funded, under-staffed and under-motivated</a>. Most medical personnel in district hospitals and health posts moonlight in private clinics, and patient treatment is substandard.Desperate families have to sell property, jewelry and other assets <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">to afford private treatment</a>, pushing even some middle-class families below the poverty line.Read more: <a href="https://www.nepalitimes.com/banner/in-a-healthy-state/">In a healthy state</a>, Nepali TimesBut there are notable examples of government hospitals that are running well because of various models of partnership with non-profits, foundations and charities. They prove that affordable high quality healthcare is possible, and those hospitals need not be so expensive to run.There is <a href="https://archive.nepalitimes.com/news.php?id=18362#.YrQjS-xByrc">Dhulikhel Hospital</a> which has a tiny registration fee, treatment is low cost, an insurance scheme pays for most treatment, and patients are charged according to their capacity to pay. Despite being a government hospital, Dhulikhel has upheld a consistently high standard of care and treatment.United Mission to Nepal has run a hospital in Tansen for over 60 years, a community hospital in Okhaldhunga, and was till recently managing Patan Hospital, providing high quality care at low cost to patients.Other public-private partnership institutions that could be models to be replicated across Nepal include:<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e59c7e80680e0c031fjpeg.jpg" alt="" width="1500" height="1000"><figcaption> </figcaption></figure><h3>Bayalpata Hospital</h3>After <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Bayalpata Hospital</a> was established in Achham 20 years ago, for many years it did not have a single doctor. Treatment was so poor that even emergency cases had to be taken on a grueling 12 hour drive down to Dhangadi.In those days HIV tagged along with the migrant workers returning from India, and there was a full-blown AIDS and TB epidemic in Achham and other district in Far Western Nepal. The mortality rate, already very high among women and children, soared.In 2009, Nepali and American medical students inspired by the community health model of <a href="https://www.nepalitimes.com/latest/paul-farmer-on-my-mind/">Paul Farmer</a> set up Nyaya Health Nepal (formerly Possible) taking over  Bayalpata under a public-private partnership with the government.Since then, Bayalpata Hospital has upgraded its facilities (left) and <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">treated nearly 1.5 million patients for free</a>, some of them for complicated caesarian and orthopedic surgeries.Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P KalauneeUp to 100,000 patients from Achham and surrounding districts come to Bayalpata because they get free treatment there, and many families have saved themselves from sinking into poverty.Bayalpata also runs a network of community health centres with an Electronic Health Record (EHR) system that digitally keeps track of all patients in the catchment area. The presence of just this one hospital has improved the health parameters of surrounding districts, bringing down the maternal and child mortality rates. Achham once had the highest maternal mortality rate in Nepal, today institutional deliveries make up 90% of total deliveries, and very few women die at childbirth.“We have a simple objective: to show that providing free and high quality treatment to the most underserved area of the country is possible at a very low cost,” explains Srijana Devkota of Nyaya Health Nepal.Once <a href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">fully funded by international foundations</a> to run hospitals in Bayalpata and Charikot, NHN now provides free medical treatment in Achham for just Rs200 million a year, of which half now comes from the Sudurpaschim Province and local municipality.+977 - 4100517<a href="https://www.nyayahealthnepal.org/">https://www.nyayahealthnepal.org/</a><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222e89c7e80680e0c0320jpeg.jpg" alt="" width="750" height="401"><figcaption> </figcaption></figure><h3>Spinal Injury Rehabilitation Centre</h3>The <a href="https://www.facebook.com/SpinalNepal/">Spinal Injury Rehabilitation Centre</a> (SIRC) in Banepa is a public-private partnership  providing treatment and rehabilitation to people with spinal injuries. It was started by journalist and civil rights activist Kanak Mani Dixit after his miraculous survival and recovery in a trekking accident in 2000 along the Annapurna Circuit that damaged his spinal cord.SIRC now <a href="https://www.nepalitimes.com/here-now/injured-use-internet-to-reach-physiotherapists/">helps rehabilitate up to 100 spinally injured patients</a> a year, and the numbers are going up every year due to injuries sustained in highway accidents and falls from trees and cliffs. The facility was located in Banepa because of its proximity to highways and nearby trauma centres. The hospital has also been providing community treatment and tele-rehabilitation services for follow-ups.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">POOR HEALTH MAKES NEPALIS POORER</a>, EditorialThe hospital has medical officers, urologists, physiotherapists, occupational therapists, nursing care, prosthetics, orthotics, psychologists and consultants. Those who cannot afford to pay are still treated for free, others are charged the same rate as Bir Hospital.“Because patients often have to stay for more than five months, it may be difficult for them to afford the cost, so we charge them according to their capacity to pay,” says SIRC’s Raju Dhakal.SIRC’s annual running cost is Rs50 million, of which most comes from grants by non-profits and other fund-raising activities. The government also chips in with a budget for the physical construction and equipment as well as occasional allocations to cover budget shortfalls.infosirc@wlink.com.np, spinalnepal@gmail.com<a href="https://www.sirc.org.np/">https://www.sirc.org.np/</a><h3>Charikot Primary Health Centre</h3>The 2015 earthquake damaged <a href="https://www.nepalitimes.com/latest/unique-hospital-handover-in-dolakha/">Charikot Primary Health Centre</a> along with 98% of the medical facilities in Dolakha district. But the disaster was a blessing in disguise for the Charikot centre. It was rebuilt and upgraded to a full-scale 50-bed hospital and managed first by Médecins Sans Frontières and then by the non-profit Nyaya Health Nepal (NHN). Residents of Dolakha did not have to make expensive journeys to Kathmandu because medical treatment was available for free at Charikot.Read also: <a href="https://www.nepalitimes.com/opinion/dangers-of-privatising-health-insurance-in-nepal/">Dangers of privatising health insurance in Nepal</a>, Gaj B Gurung and Sushil KoiralaIn 2020, NHN handed over management of the hospital to Bagmati Province and Bhimeshwor Municipality which now run the facility with low cost treatment for up to 300 patients a day. The Charikot experiment has been hailed as a model for successful transfer by a private non-profit to the local government, and it has been running well despite the presence of two private hospitals in Charikot.“It has been a seamless handover from Nyaya Health to the government, and the level of care and treatment is the same,” says chief physician Binod Dangal. “We perform caesarean sections, orthopedics, telemedicine, free check-ups for the elderly, children and pregnant women, mental health counselling, and chronic illness monitoring.”+977 49 421125<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222ea9c7e80680e0c0321jpeg.jpg" alt="" width="1080" height="608"><figcaption> </figcaption></figure><h3>Sagarmatha Chaudhary Eye Hospital</h3>For the past 30 years, the <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">Sagarmatha Chaudhary Eye Hospital</a> in Lahan of Siraha district has been providing the cheapest cataract surgery in the world for just Rs1,200 per operation.Thirty years ago when the hospital started, it had only 12 beds. It now treats 470,000 people every year with patients coming in from as far away as southern India and Bangladesh, and they pay the same amount as Nepalis. Just in the last three years, the eye hospital has treated 321,000 foreign nationals.“It is possible to provide the services at an affordable cost because we are a non-profit, and have an economy of scale,” explains Abhishek Roshan of Sagarmatha Chaudhary Eye Hospital.Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe hospital has <a href="http://archive.nepalitimes.com/news.php?id=10071#.YrQlROxByrc">also set up 15 eye care centres throughout the district, and takes treatment directly to the people</a> so they do not have to make the journey to Lahan. It has a separate department for paediatric services, care for newborn babies with vision problems. In 2021 alone, it performed 1,170 eye surgeries on children.Apart from providing treatment of retina, cornea, glaucoma, oculoplasty, the hospital also serves as an international research centre, collaborating with institutions like The London School of Hygiene and Tropical Medicine.The hospital subsidises its eye treatment for patients with revenue from its agribusiness ventures. A part of the hospital’s land is dedicated to fish farming, and an orchard for litchi and mangoes, as well as a bamboo grove.“Income from those ventures help us keep the cost of treatment down,” says Roshan. The hospital is also supported by Christian Blind Mission (CBM), the European Commission and Arvis.+977-33- 560080https://www.erec-p.org/sagarmathaRead more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

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Taking wealth out of health

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219c9c7e80680e0c02c6jpeg.jpg" alt="" width="1000" height="662"/>This year’s health budget kept the contribution to health insurance of the previous year's allocation of Rs7.5 billion. However, the plan to hand over the institutional management of health insurance programs to the private sector through the Ministry of Finance defeats the fundamental goal of the health security.This is not entirely surprising, of course, because the Health Ministry had passed a <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">narrow and poorly thought model of health security</a> for Nepal, and there were already concerns that it would eventually be handed over to the private sector and traded as a commodity.A private company can contribute to a health insurance program. But can they really contribute to national public health security, understand equity, expand <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">access to the poorest and the most marginalised</a> population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">National health insurance not as easy</a>, Sonia AwaleThe private sector has a role in contributing to achieving Universal Health Coverage by mainly serving the affluent. The poor neither can afford private health insurance nor access expensive private hospitals. Even if they are admitted to hospitals, they have to bear <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">catastrophic expenses</a> pushing them into the vicious cycle of poverty.The private insurance companies only pool the resource, they do not share the risk for those who cannot afford to pay the premium. It will be naïve to assume that such companies could be easily maneuvered to deliver services as a fair-price approach. There are around 20 registered private health insurance companies and 366 private hospitals in Nepal, and some are <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling health insurance at exorbitant premiums</a> many times higher than the current premium cap.There are six national health security indexes: prevent, detect, response, health, norms, and risk. During the pandemic, insurance companies got richer by <a href="https://www.nepalitimes.com/latest/nepal-tries-to-ensure-covid-19-insurance/">selling fake insurance schemes</a> while the hospital profits bulged through expensive Covid treatment. Very few hospitals treated Covid patients with a humanitarian approach. None of their technical advancements helped effectively prevent, detect, and respond to the pandemic.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111412118/6372219f9c7e80680e0c02c7jpeg.jpg" alt="" width="1641" height="1000"><figcaption> </figcaption></figure>The current health insurance program has identified the elderly, completely disabled, leprosy, Multi-Drug Resistant TB patients, people living with HIV, and ultra-poor as target populations to waive their premium. Though not adequate, this is an equity approach.But none of these target populations are <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">eligible for private health insurance</a>, or they will have to pay a much higher premium. It will be unwise to assume that these companies will change overnight and be equitable. They are powerful enough to influence government policy and have the power to bend them to suit their commercial interests.Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, EditorialInstead, the government should <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">strengthen the Health Insurance Board</a> and explore ways to integrate health security with the broader social security scheme. In the short term, there are urgent but straightforward reforms like recruiting adequate and skilled human resources, strengthening the organisational systems, revising the design of service purchase strategy and equity, and gradually, having effective providers/purchasers split for better implementation.Ultimately, the program will benefit by forming a broader and more robust social security structure, co-incidentally introduced at the same time by the government. It would be able to absorb costs by pooling tax-based health care contributions and merging subsidies given to the treatment of cancer, renal failure, and other chorionic diseases under one integrated umbrella.But the current government does not appear serious about <a href="https://www.nepalitimes.com/opinion/health-insurance-must-be-an-election-agenda/">reforming health insurance</a>, and simply does not understand the fundamental principles of health security. Health insurance is not just limited to providing health care, but is a part of broader health security.Read also:  <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, EditorialThe idea that health security can be strengthened by passing the buck to the private sector amounts to abandoning the constitutional commitment to provide health care, not as a service but as a citizen's fundamental right. The Nepal government is a signatory to achieving the health targets of the Sustainable Development Goals.As argued by Nepali Congress leader Gagan Thapa, who is one of the pioneers who <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">pushed health insurance</a> in Nepal, they contribute to strengthening the health system, strive for healthy populations, cushion the poor and provide them access to health services. It is a vehicle for mobilising adequate health resources, enhancing health security, and ultimately achieving Universal Health Coverage.These goals cannot be met by trading the people's health as mere commodities.Gaj Gurung has a PhD in public health from Chulalongkorn University and Sushil Koirala is a public health expert. Both are based in Bangkok.Read more: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee

Dangers of privatising health insurance in Nepal

https://www.youtube.com/watch?v=Czp7hVr4LTkHenry Marsh is a pioneering English neurosurgeon and the author of two widely acclaimed memoirs, Do No Harm: Stories of Life, Death and Brain Surgery and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/book-review-Admissions-Henry-Marsh-Neurosurgeon,4055" target="_blank" rel="noopener">Admissions: A life in brain surgery</a>. He was a colleague and friend of the <a href="https://www.nepalitimes.com/here-now/upendra-devkotas-lives/" target="_blank" rel="noopener">late Upendra Devkota</a>. Nepali Times caught up with Marsh at the <a href="http://www.neuro.org.np/" target="_blank" rel="noopener">Upendra Devkota Memorial National Institute Of Neurological And Allied Sciences</a> in Kathmandu, where he teaches post-retirement.Excerpts:Nepali Times: How did your involvement in Nepal start?Henry Marsh: Professor Devkota and I were neurosurgical trainees together in London more than 35 years ago. We became quite good friends then, and when I retired from working fulltime for the <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nhs.uk/" target="_blank" rel="noopener">National Health Service in Britain </a>four year ago, I really wasn’t ready to stop working. I wrote to the professor, who’s known to all his English friends as Dev, and I said, “Would you like me to come out to Kathmandu and help train some of your team?” and he said,“Please come”. This is now my fifth visit over the last four years. <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/from-the-nepali-press/i-want-to-live-my-last-among-friends/" target="_blank" rel="noopener">Tragically he died last year</a>, and everything therefore changed profoundly.Why were you drawn to Nepal?I was drawn because I like seeing the world. A lot of the potential privileges you have as a doctor is that you have a specialised set of skills which transfer over the world and English is really the international language of medicine.The great privilege of working in a cooperative professional way is that you get a much better insight into the country than if you are merely a tourist. For me, it is true travel but it is work – it is not easy always, and if you come to a country like Nepal to help your colleagues, you have to come again. You can’t just sort of dive in and then dive out again. It calls for a fairly major commitment, both in terms of time and financially and sort of emotionally as well.What do you remember most about Dr Upendra Devkota?The man was just this little ball of fire – he was extraordinarily energetic. There was never a dull moment with him. He was an extraordinarily dynamic person and to create an entire specialist neurosurgical hospital more or less from scratch was a quite extraordinary achievement.The problem with great dynamic individuals is the succession problem and of course none of us expected him to die at the relatively young age he did and really quite suddenly. I remember before his illness, sitting down with him in his beautiful garden and saying “What happens if you drop dead tomorrow? What will happen to the hospital?” Fortunately, he had some very good trainees and in recent years he had been giving them more and more, not exactly independence, but they were doing more and more of the work so they were fortunately able to take over the workload when he fell ill and they’ve coped remarkably well.I was involved a bit in helping them get better and training them. I take some personal pride in that as well. I was watching one of the senior ones here doing a very difficult operation a few days ago and it really was a joy to watch. He was using a microscope and he was doing a very difficult case – I was watching on a computer monitor and he really did it very beautifully. As a trainer, any senior doctors will tell you in a funny sort of way you get more pleasure from all the people you’ve trained and seeing their success rather than all the, in my case tens and thousands, patients I’ve treated over the years of my career. <figure><img width="2622" height="1612" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664a9c7e80680e059972jpeg.jpg" alt=""/><figcaption>Henry Marsh. Photo: SAKINA ABIDI</figcaption></figure>What are the challenges of specialisation in Nepal?It’s not unique to Nepal by any way, but the problem is this: if you have a relatively impoverished government and if people are reluctant to pay taxes, it’s very hard for the government to be able to afford good quality healthcare.Therefore, doctors working in expensive specialist areas like neurosurgery end up setting up their own private hospitals. This has happened in India, in Sudan which I know well, it’s happening in Ukraine and it’s happening here. You then end up with all these separate private hospitals which are basically locked in economic competition against each other. They all profess to be all working happily together for the greater good but it’s very difficult – they have to make a profit to survive and this sets doctors against each other.Now all surgeons, we all know that the more we do of a particular sort of surgery the better we get. If that workload is divided up and split between many different departments and different surgeons, no one person is really going to become very good at dealing with it.If you look at what’s happening in Europe and America, super specialisation is the game. I trained along with Professor Devkota in what’s called general neurosurgeon – I could do everything. But in recent years, we all stopped doing that, we became more and more specialised. I ended up specialising mainly in brain tumour surgery and even then, in particular sorts of brain tumours, which means I became very, very expert in that particular sort of case. That is not happening in Nepal.Do you have any solutions?I’m not here to tell people what to do because I don’t know. What I do know is that all healthcare systems reflect the underlying culture of the country. If there is a solution – it has to come from the people living in that country.Could you touch on the over-commercialisation of healthcare in Nepal?With all medicine, there’s a problem – is medicine a vocation or is it a business?Our judgement is easily distorted, unconsciously, and if you know you’re going to make a lot of money by treating the patient, or if you know your hospital needs to make money to survive, that’s probably on an unconscious level going to distort your judgement of whether to operate or not. Ultimately, with commercial healthcare, the patient becomes the means to the end of making money. With the other extreme, if doctors are only paid fixed salaries in a state system, in theory at least, the end of everything you’re doing is for the wellbeing of the patients and making money is not relevant.Read Also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor Health,</a> Editorial <figure><img width="500" height="574" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664d9c7e80680e059973jpeg.jpg" alt=""><figcaption>Henry Marsh training Nepali surgeons at the Neuro Hospital in Bansbari, Kathmandu in 2017. Photo: ESCAPMEDIA</figcaption></figure>What has your experience been like working with the hospital here?I think it’s a wonderful hospital. I love coming here. It’s not always easy for me, for various reasons, but I have absolutely no hesitation in wanting to help as much as I can. Clearly the transitional period following Professor Devkota’s death was very difficult. He was very famous, and it was like a magnetic attraction: patients came from all over Nepal to see him, often without neurosurgical problems. Inevitably now, with the change of staff, it’s been a difficult transitional period. What strikes me is the way the hospital’s survived. One might have thought it would completely collapse once he had gone but that’s not the case at all. How do we implement affordable and accessible healthcare in rural areas in Nepal?I’m not a public health expert. A major problem in Nepal, apart from the poverty, is poor infrastructure. In Europe, you can get patients fairly quickly from rural areas to central hospitals. That is often impossible in Nepal. You have to compromise, and you have to have more peripheral small hospitals out in the rural communities than you would in wealthier countries with more favourable terrain.Nepal has many problems. If you wanted to design a country to have difficult problems, Nepal is that. We all know being landlocked is a major problem for economic development. Having all these mountains and <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener">adverse geographical features makes life difficult </a>as well.Read Also: <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Policies-for-the-people,3640" target="_blank" rel="noopener">Policies for the people</a>, Marty Logan<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?,</a> S P KalauneeWhat are some of the values you want to pass on to the younger generation of surgeons?Firstly, to ask for help and not try to think you know everything because we don’t know everything. As young doctors, we’re often very anxious and frightened and we have to pretend to patients that we’re better than we are. We often end up pretending to ourselves as a way of boosting our self-confidence. It can be easier. I speak from personal experience; I can think of many patients who came to harm because I made this mistake. I didn’t ask for help from someone more experienced than myself.My message to young doctors is it is OK to feel frightened. That’s the nature of the work. You can’t be a good doctor, particularly when you’re young and fairly inexperienced, without being anxious and frightened. Don’t feel ashamed to say "I don’t know", not to the poor old patient, but don’t feel ashamed to say to a senior colleague “I need your help”.The other advice I give to young doctors, apart from ask for help, is listen to patients. So many doctors, including myself when I was younger, just sort of talk at patients rather than talk with them. Purely in terms of making a diagnosis and making the right decisions, listening to the patient’s story is very important. I’ve worked all over the world and medical systems vary all over the world. Doctors vary all over the world. As far as I can tell though, we’re all the same as patients: we’re frightened, we’re anxious, we want to be treated with respect. We want to be treated with respect and doctors are often bad at doing that – particularly in rather hierarchal societies like Nepal.

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Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota

For many decades it was an accepted truth that Nepal’s main public health threat was from infectious diseases, and the most cost-effective way to address that was through prevention. In other words, the first line of defence against communicable diseases was communication.Whether it was gastric infections caused by contaminated water, respiratory ailments due to cold and pollution, or diseases spread by insect vectors like malaria – the goal was to spread public awareness about prevention. Radio jingles about oral rehydration salts or acute respiratory infections in children indirectly helped save millions of lives over the years.Many of these challenges remain. Despite dramatic progress, many Nepalis still lack safe drinking water – not just in the roadless hinterland but right here in the heart of the capital. There are frequent <a href="http://archive.nepalitimes.com/article/nation/%20jajarkot-open-defecation-free,2023">cholera</a> epidemics. Children’s lungs are still affected by indoor smoke from wood fires. Malaria is on the comeback due to resistance and there is an annual epidemic of dengue and encephalitis.Yet, compounding these endemic infections, there is now an <a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">increasing burden of non-communicable diseases and injuries</a> (NCDI). New lifestyle-related cardio-vascular afflictions, chronic obstructive pulmonary disease (COPD) caused by <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/every-breath-we-take-air%20pollution,3536">pollution</a>, or <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486">mental health disorders</a> have added to the burden of disease and disability. <a href="http://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">South Asians are already genetically susceptible to diabetes</a>, and now there are new risk factors due to migration to urban centres. While the world average for prevalence of both types of diabetes is 8%, more than 14% of people in urban centres like Dharan have diabetes – even though the prevalence for rural Taplejung, for instance, is only 1%.A study by The Nepal NCDI Poverty Commission released this week shows that the burden of NCDIs has doubled in the last 25 years. More than half of all death and disability today are caused by NCDIs, with nearly 15% caused by injuries in conflict, natural disasters or highway accidents. <img width="900" height="802" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517699c7e80680e02c275jpeg.jpg" alt=""/>Being afflicted with an NCDI (or chronic disease) is more fatal in Nepal than in developed countries because of affordability and restricted accessibility to adequate medical treatment. The poor are disproportionately vulnerable. The NCDI burden in Nepal is also different than in other parts of the world – there is a higher incidence of ischemic cardiac conditions, asthma, neurological disorders, cancers caused by untreated infections and injuries, for instance.For us, the report’s main finding, and most damning inference, is about how <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">treatment of NCDIs is driving Nepalis into indebetedness and penury</a>. The survey shows that half of all medical expenditure of families is out-of-pocket, and 60% of that is for treatment of NCDIs. This is because the government spends only 11% of its budget on health care, and only 6.4% of that is for treatment of non-communicable diseases.Despite the proven link between chronic ailments and poverty, donors still allocate only 1% of their development assistance for NCDIs.Treatment of injuries, gastro-intestinal infections, heart diseases, cancers, kidney and liver diseases are the most impoverishing NCDs for households. The report’s main conclusions are corroborated by our <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">field report</a> from Achham and Kavre this week  about how the lack of even basic surgical facilities in district hospitals and health posts is forcing Nepalis to undertake expensive and extended trips to private hospitals in the cities.Another recent study of 39 government hospitals commissioned by the Nick Simons Institute (NSI) showed a huge unmet need in remote areas for basic surgery like caesarians, orthopaedics, and abdominal operations. Nepal’s surgery rate is well below the Lancet Commission’s target of 5,000 operations per 100,000 population. Only one-third of patients currently can reach an orthopedic surgeon within two hours of travel. <img width="640" height="456" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365176b9c7e80680e02c276jpeg.jpg" alt="">The public-private partnership models that NSI and Possible are carrying out in remote government hospitals are ways to plug this gap: ensuring minimum staffing of a MDGP physician, anaesthesia assistant, staff nurse and biomedical technician in each hospital can offer basic treatment and surgery in remote areas, reduce the need for referrals, and save household income. At present Nepal’s density of hospitals with such staffing and equipment is at 0.4 per 100,000 population, as against the Lancet Commission’s recommendation of 20/100,000.The Nepal NCDI Poverty Commission report suggests additional measures: national health care delivery should respond to the increasing burden of NCDIs by decentralising.Impoverishment of households due to the high cost of treatment should be addressed through disease-specific policies for high-cost conditions and expansion of insurance coverage.It is often said that health is wealth, but in Nepal wealth is health. That can only be changed by making treatment of chronic conditions and injuries accessible, affordable, inclusive and equitable.Read also:<a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">State of the art rural hospital</a>, Marty logan <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>,  Sonia Awale<a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">Communicating about non-communicable diseases</a>,  Elina Pradhan and Bigyan R Bista

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Taking wealth out of health

Dangers of privatising health insurance in Nepal

Henry Marsh returns to the institute created by his neurosurgeon colleague Upendra Devkota

Poor health