<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114121112/637222f59c7e80680e0c0327jpeg.jpg" alt="" width="760" height="486"/><figcaption>Govinda KC, Nepal’s crusading surgeon and health activist, plastering a patient’s ankle at the Mugu District Hospital on Sunday. He saw 177 patients for free in five days before travelling on to Jumla on foot. Photos: ACHYUTRAJ BHANDARI</figcaption></figure>Nepal’s  crusading surgeon and health activist Govinda KC has been on hunger strike 19 times since 2012, demanding medical education  reform and equitable healthcare. After retiring from his government job, KC has served patients in all 77 districts and other disaster-stricken countries. He is currently at Khandbari District Hospital in Sankhuwasabha where Nepali Times caught up with him.Excerpt from the conversation:Nepali Times: What is the state of healthcare in Nepal?Govinda KC: Most citizens from both urban and rural areas do not have access to healthcare. Many patients are too poor to afford quality treatment, and those who can not get quality care.The law specifies that 70 types of medicines should be available free of cost in district hospitals, 50 in primary health centres, and 35 in health posts. That is not the case in practice.Some government hospitals even charge money for medicines that are supposed to be free. And hospital fees are just too expensive, so they end up dying, being disabled for life, or sinking deeper into poverty.Health facilities in many rural districts are under-equipped, under-staffed and many patients have to return home without treatment. There are no big hospitals there to begin with, and even the urban poor cannot afford priate city hospitals.Doctors, nurses and office assistants have stuck around in government hospitals only because they are bound by contract. Some hospitals are led by junior non-physicians, making a chaotic and inefficient system.So, where is the problem? The problem in providing basic healthcare arises when the local representatives and  politicians do not work to provide it. When the 2015 constitution was announced, I was in satyagraha. My only demand was that our representatives be treated in health facilities in the same place as their voters. That demand was not fulfilled.The Constitution guarantees the citizen's right to health, but elected politicians do not care about health reforms. They are too busy getting rich overnight by commodifying education and health.I have been fighting to have hospitals and schools in every village, but people prefer to open hospitals in the city. Locals can have access to specialist services at a hospital in their village. This can also help to produce doctors, nurses and public health workers in the provinces. But no one is willing to do that. Politicians are on the payroll of the medical mafia.Do you regret going through all those hunger strikes? Many of my demands were not met. Some promises have been made, but not been implemented in practice. But some have been addressed, like the Medical Education Act was formed after multiple satyagraha. Then the Medical  Education Commission was formed.Before the Act, MBBS entrance exams were conducted by colleges and institutes in their own way, but now it is regulated by the Medical Education Commission.Only those who pass the entrance exams are now eligible for government scholarships and can pick their own college. Action is taken against private institutions if they do not follow the regulationsNow, medical colleges are selected based on their infrastructure, equipment and human resource.  Fees have also  dropped from Rs7-9 million to Rs4.2 million. Medical school is a lot cheaper now, especially for students who are unable to get scholarships.Government medical schools charged up to Rs10 million for  specialised education. Now, students do not have to pay, but get paid instead. After getting an MD they also need to serve for two years in a place assigned by the government. These contract doctors run the country’s healthcare todaySo, the hunger strikes have not been in vain. One of my demands was to have one government medical college in every province. At present, the Karnali Institute of Health Sciences is in operation in Jumla, and the physical infrastructure of Geta Medical College in Dhangadi has been completed. One medical college is soon opening in Dadeldhura after my hunger strike.Despite this, some goals have been lost to the challenges posed by the alliance of political  parties with the mafia. The construction of the Rapti Institute of Health Sciences in Dang was halted due to obstruction from local leaders, and a medical college in  Bardibas due to land acquisition issues.What policies should the government focus on now?First of all, access to basic services, human resources, equipment and medicine should be extended to people in rural areas and the urban poor. If primary health centres and district and provincial hospitals are improved, then 80-90% of patients do not have to  come to Kathmandu for treatment. The government needs to add more human resources to meet the current demand for healthcare.There should be a 15-bed operational hospital in each municipality. Hospitals should also be made free for people to have quality healthcare. The government should take actions against hospitals that operate without meeting proper standards.Additionally, the Medical Education Commission, Nepal Medical Council and other organisations should appoint qualified applicants, not political activists. In fact, the practice of hiring contract-based employees should be eliminated. Contract doctors have a higher chance of fleeing if they are not given temporary incentives to stay.Despite the huge demand for rural doctors, the Public Service Commission opens only 20 seats for doctors each year. This has to change.Any more hunger strikes?I am committed to campaigning for medical education reforms. Along with health and education, we are also fighting for good governance and social justice, without which reform is impossible.I also want to serve in remote areas, which is why I am here in Okhaldhunga. I will fight for people in all parts of the country to have quality, free, affordable and equal access to healthcare as guaranteed by the Constitution for as long as I can.Read more: <a href="https://www.nepalitimes.com/latest/govinda-kc-treats-patients-in-remote-nepal/">Govinda KC treats patients in remote Nepal</a>, Achyutraj Bhandari

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"Nepalis are dying because they are poor”

<img width="3724" height="2151" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c729c7e80680e0bd491jpeg.jpg" alt=""/><a href="https://archive.nepalitimes.com/news.php?id=12452#.YlFKe9NBxH0">Goitre</a> was once so <a href="https://www.nepalitimes.com/latest/from-pandemic-to-epidemic-to-endemic/">endemic</a> in Nepal that it was considered a sign of beauty. Entire villages across northern Nepal that relied on <a href="https://www.nepalitimes.com/banner/the-salt-of-the-earth/">Tibetan rock salt</a> suffered from iodine deficiency, and cretinism was widespread.Read also: <a href="https://www.nepalitimes.com/banner/the-salt-of-the-earth/">The salt of the earth</a>, Jag Bahadur BudhaUnlike sea salt which contains adequate iodine, the micronutrient mostly evaporates from rock salt, and people who used it were affected by <a href="http://archive.nepalitimes.com/news.php?id=9144#.YlFK49NBxH0">iodine deficiency</a>. Those suffering from it had throats disfigured with large growths.A successful public-private partnership between the government, Salt Trading Corporation and aid agencies <a href="http://archive.nepalitimes.com/news.php?id=9144#.YlFK49NBxH0">iodised salt</a> under the brand आयो नुन and this all but eradicated visible goitre — it went down from 55% in 1965 to only 0.4% in 2007. This is one of Nepal’s public health success stories.However, in solving one problem, we may have created another. The country is now facing thyroid disorders caused in part by excess iodine intake. Recent studies show an increasing prevalence of thyroid disorders, even among younger Nepalis.A 2019 community-level survey in five districts found the prevalence of thyroid disorders at 4.32%. Nearly three-fourths of those were subclinical hypothyroidism, 13.7% primary hypothyroidism and another 13.7% were hyperthyroidism.Hypothyroidism is when the thyroid gland does not produce enough hormones. In hyperthyroidism, on the other hand, the gland is overactive and produces too much hormones. Subclinical conditions do not need immediate treatment.The figures for hospital-based surveys are much higher. In a paper published in 2015 based on 5,230 cases from Teaching Hospital in Kathmandu, 29% were diagnosed with thyroid disorders. Higher prevalence was found in the 31-45 age group.However, experts are cautious about pinpointing excess iodine in the diet as the only cause for thyroid disorders.“The prevalence of thyroid disorders has indeed increased in the last 10-15 years, but this could also be a result of better diagnosis even in rural areas,” says endocrinologist Ansumali Joshi.The recommended daily intake of iodine is 150 micrograms, but is higher for <a href="https://www.nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time/">pregnant and lactating women</a>. <img width="477" height="544" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114111144/63721c759c7e80680e0bd492jpeg.jpg" alt="">A 2016 survey showed that 67.5% of households in Nepal have excessive iodine intake in food. School-age children were classified in the ‘excessive’ range, pregnant women in ‘adequate’ and women of childbearing age in ‘more than adequate’. Iodine intake was higher in the central and western parts of the country and the Tarai.“Iodised salt has reached every corner of Nepal and because there is excessive use of salt in food items, logically people are overdosing on iodine,” says cardiologist Prakash Regmi. “Excessive salt intake is already a leading cause of <a href="https://archive.nepalitimes.com/news.php?id=18115#.YlFMNtNBxH0">heart</a> and <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639">kidney diseases</a>. And excess iodine is now adding thyroid dysfunction which can affect the brain and the nerves.”After the 2016 assessment, the government reduced iodine content in salt from 50PPM (parts per million) to 30PPM. Experts say it might be time to reduce it further, or even add the micronutrient in some other food item.Misinterpretation of iodine ‘overdosing’ could also send out the wrong message, they warn, leading to the public avoiding iodised salt, and thus reverse Nepal’s successful eradication of iodine deficiency.Other factors affecting thyroid glands include viral infections and endocrine disrupters like <a href="https://www.nepalitimes.com/latest/biodegradable-plastic-launched-in-nepal/">plastics</a> and certain chemicals. Thyroid disorders can also be hereditary. Covid-19 has also been associated with thyroid inflammation, resulting in hyperthyroidism or thyroiditis.Untreated hyperthyroidism can lead to ‘thyroid storm’, a very rare but life-threatening condition in patients often referred to Kathmandu hospitals due to <a href="http://archive.nepalitimes.com/news.php?id=4980#.YlFMxNNBxH0">lack of treatment facilities</a> elsewhere.“We know either too much or too little about thyroid disorders. But there is a general lack of clear understanding, I have a lot of patients who visit me all panicking about their thyroid test results,” says endocrinologist Jyoti Bhattarai. “But there is a spectrum to thyroid diseases, and many do not need treatment. Subclinical hypothyroidism is one example.”Read also: <a href="http://archive.nepalitimes.com/news.php?id=18379#.YlFJb9NBxH0">Diabetic dilemma</a>, Buddha Basnyat There are groups more at risk: pregnant women and those planning to conceive who should take thyroid function tests to prevent possible premature birth, miscarriage and even stillbirth. Women unable to conceive should also be screened.And ideally, all newborns should also take a test because early diagnosis of a congenital hypothyroidism can almost entirely prevent mental disability. Another risk factor is obesity.“Growing up in the mountains I had several family members afflicted with goitre. We have made much progress since then, but it is time to change our focus and study the prevalence of thyroid disorders today,” says Pokhara-based physician Bikash Gauchan. “It affects multiple systems and patients experience a wide range of symptoms with implications on both <a href="https://www.nepalitimes.com/latest/the-other-pandemic-mental-health/">mental</a> and <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">physical health.</a>”Endocrinology and the study of hormones used to concern only the well-to-do. Public health in Nepal was all about preventing infectious diseases which afflicted the poor. Today, the lines are blurred, and Nepal needs treatment for chronic diseases of the vital organs like the lungs, heart, kidney and stomach for all sections of society.Says Jyoti Bhattarai: “The field of endocrinology in Nepal needs much more commitment and investment. While hormonal dysfunctions including thyroid disorders are often not immediately fatal, they can significantly affect one’s quality of life.” Read more: <a href="https://www.nepalitimes.com/latest/why-do-so-many-nepalis-have-high-blood-pressure/">Why do so many Nepalis have high blood pressure?</a> Sonia Awale

Sonia Awale

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Either too little, or too much iodine

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664f9c7e80680e059974jpeg.jpg" alt="" width="1200" height="793"/>Around the world, in rich countries and poor, financing healthcare is one of the biggest challenges. In poor countries, it becomes a life-or-death issue.Over 40% of global healthcare expenses are still covered by patients and their families, and more than half the world’s population lacks access to essential health services. Medical bills push 100 million people into extreme poverty every year.Nepal has taken remarkable strides in healthcare in past decades despite internal conflict and instability, but <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical care is still unaffordable</a> or inaccessible to most. More than half the healthcare expenditure of Nepalis is still covered out of pocket. Nearly a third of families spend over 10% of their annual income on medical care.Read also: <a style="background-color: #ffffff; font-size: 15px; 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://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">State of the art rural hospital</a>, Marty LoganThursday, 12 December, is Universal Health Coverage Day, an important date to remind ourselves of the next steps we need to take to achieve healthcare for all. The 2015 constitution of Nepal declares basic and emergency healthcare as fundamental rights of citizens, putting the responsibility of financing such care on the state. Following federalism, municipal governments have got the responsibility to manage basic and essential care. A national health insurance bill has been passed and is being implemented.The state guarantees quality healthcare without financial burden on citizens, for which the insurees pay Rs3,500 per year for a family of five, and receive care worth Rs100,000. This is expected to reduce the burden of out of pocket and catastrophic expenses, while the government covers the premium for citizens under the poverty line.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>, EditorialThere is also a provision for free essential drugs and free treatment for patients with cardiovascular disease, cancer, spinal injuries, renal ailments and sickle cell anaemia, through the Disadvantaged Citizens Medical Treatment Fund.None of these initiatives is being implemented fully yet, but with federalism Nepal has a chance to build an accountable and sustainable healthcare system. The country therefore needs to focus on the following areas to manage health financing to meet the targets of the Sustainable Development Goals:<ul><li>Increase public sector healthcare investment to at least 7% of annual national budget. This should also be targeted towards reducing external aid.</li> 	<li>Empower people for self-care and make treatment more strategic and efficient as the burden shifts from communicable to non-communicable diseases.</li> 	<li>Focus on primary health care and improve services at the first point of care with comprehensive, accessible and community based care.</li> 	<li>Coordinate multisectoral policy action involving education, agriculture and social behaviour.</li> 	<li>Launch a priority national campaign to spread insurance coverage. Enrollment can be top-down starting with all government officials and then the public at large.</li></ul>A mixed financing model using tax-based funds through the treasury, and premium-based funds through health insurance can work for public, private, community, and other hospitals that run under the state-non-state partnership. An example of state- non-partnership is Bayalpata Hospital in Achham district, managed through a public-private partnership between the ministry of health and population and the non-profit Nyaya Health Nepal, where insurance reimbursement covered over 60% of the hospital’s operating costs.The hospital provides healthcare with no user fees. The care is extended from hospital to communities using a network of community health workers. How can care delivery with no user fee sustain? Can Nepal afford to provide such care to its entire population?It is possible. The country should effectively implement the national health insurance program, and strategically invest tax based funding. In the mixed financing model, for a ‘district level hospital, insurance can cover 60% of healthcare operating costs, and tax-based funding can take care of the rest. But to ensure effectiveness, the tax-based investment will need to be unrestricted and tied to audited performance indicators. The cost of care should also incorporate the extension of hospital-based services into communities in the catchment area.Bayalpata Hospital serves both as a primary care facility and also as a referral hospital. In this case, the tax-based contribution can be split into the three government tiers, with the federal government providing support for infrastructure, and provincial and local governments covering the cost of basic healthcare, and referral care not covered by the insurance.Insurance reimbursement then covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage.<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490" target="_blank" rel="noopener">Bayalpata Hospital</a> provides basic and referral care, and its tax-based contribution can be split into the three government tiers, with the federal government providing support for basic infrastructure and provincial and local governments covering the cost of basic and referral care not covered by the insurance.Insurance reimbursement then covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage.The proposed model has a 60:25:15 ratio to pay for health care, with 60% from insurance and provincial and local governments paying 25% and 15% of the cost. When the benefit package increases to cover the cost of healthcare without capitation, the share of health insurance coverage percentage will increase significantly, thereby reducing the tax-based direct public sector investment.S P Kalaunee is Executive Director of Nyaya Health Nepal, which manages Bayalpata and other public hospitals in partnership with the ministry of health and population.

Is free health care possible in Nepal?

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"Nepalis are dying because they are poor”

Either too little, or too much iodine

Is free health care possible in Nepal?