Print Edition - 2015-03-30  |  Editorial

Degrees of doctoring

  • High costs of medical education prompt doctors to charge high fees for medical services
- Jagannath Adhikari
Degrees of doctoring

Mar 29, 2015-Nepal has made significant progress in health in the last two decades. But this progress has not been shared equally, as there remains a high degree of inequity in availability and access to health services. In this context, the ongoing fast-unto-death protest of Dr Govinda KC is very relevant, because his agendas also include social justice in access to health services.

Highs and lows

Nepal’s average life expectancy has reached 68 years and there has been a significant decline in child mortality and maternal mortality. On the other hand, there are still wide discrepancies in health improvement across the region. For example, according to the government, average life expectancy in Kathmandu is now about 82 years. This health indicator is on par with that of developed countries. On the other hand, life expectancy in Karnali region is about 42 years—less than half of that of Kathmandu. Health problems and food security in the mid-western hills and mountains are considered similar to that of famine-stricken countries in Africa.

So, within Nepal, we have a few small pockets whose health indicators are more or less equal to developed countries and some significantly larger areas whose condition is similar to desperately poor countries. The case of Karnali could be an outlier but rural areas in general, particularly in the Mid West and Far West regions, have severe problems when it comes to access to health services and commodities.

Access to health services have become problematic since an overwhelming proportion of health services like hospitals, medical professionals, and institutions that train medical personnel are all concentrated in the few pockets that already have high health standards. This is akin to the ‘90:10’ scenario, a buzzphrase in the public health field, which means that 90 percent of resources for health research in the world are invested for the health problems of the 10 percent wealthy people. In Nepal’s case, we can also safely say that 90 percent of resources invested in health services are invested for the health services of 10 percent of the population living in wealthy areas like Kathmandu and Pokhara.  The concentration of health services, including medical colleges, in these cities has another consequence: it is a crucial pull factor in rural-urban migration, leading to rapid growth in the urban population and haphazard urban sprawl.

Rising costs and rising charges

The other interrelated problem that has restricted access to medical services is its high cost. Because of a lack of social welfare mechanisms like universal health insurance or public support, individuals need to bear all the costs of health services. The present medical education system, which gives priority to the private sector, is also responsible for increasing the cost of medical services. As it is very costly to get medical education in private colleges, the medical professionals trained in such a system tend to extract unnecessary fees from patients seeking their services to offset the initial high investment they made. As a result, it is not uncommon nowadays to find patients prescribed unnecessary medicine and medical tests by medical practitioners.

I have personally experienced this. A doctor asked me to undergo an expensive test at a certain private laboratory. When I inquired with the official manning the laboratory about the high cost of the test and the poor condition of the laboratory, he informed me that he really does not make much profit, as he has to pay 50 percent of the test charge to the doctor prescribing the test.

The very high fees that private medical colleges charge are partly a result of corruption in the medical education sector, which contributes to poor educational quality. They pay bribes worth millions of rupees to government personnel and other stakeholders responsible for providing affiliations to colleges and monitoring the quality of training, which is at the heart of Dr Govinda KC’s ongoing protest. Medical professionals produced by such a corrupt system eventually pass on their cost of education to the people to whom they provide their services. Its consequences can be seen in the high cost of medical treatment and the poor quality of service. Things have transgressed to such an extent that people have developed a feeling that they should have at least one medical doctor within their close family circle, who can provide them with second (and genuine) opinions on the drugs and recommendations prescribed by any medical practitioner. This high cost of medical treatment, in the absence of a welfare programme, certainly excludes poor people.

A public stake

The above reality, which a common Nepali no doubt experiences, calls for drastic changes in the policy that governs medical education, which cannot be left completely in the hands of the private sector. Moreover, emphasis should be given to public-private education to be run on a non-profit basis. In such cases, the government needs to build infrastructures for the college and teaching hospitals in regions hitherto excluded from such services. The running costs of such institutions can be raised through tuition fees and medical service charges. This can help drastically reduce the total cost of medical education, which will eventually help retain medical practitioners in rural and underprivileged regions, and will also reduce the cost of medical services. The Nepal government can easily open 10 such colleges-cum-hospitals, as each such institution would not cost more than Rs 1.5 billion. This is not a great amount for the country, but it can have far-reaching consequences in improving health services and closing the gap in health indicators across region and class. Dr KC is committed to addressing this problem and we all should support his cause.

Medical education in Nepal should also look into the attitude of students and their commitment to improving people’s health. Students (after Plus Two) are not mature enough when they enter the medical field. Some of them are attracted towards this profession as a social trend and others under parents’ influence. Graduate-entry has been adopted in some developed countries to deal with this problem. This is a worthwhile issue to be looked at by a commission responsible for drafting medical education strategies.  

Adhikari is a social scientist researching various aspects of development

Published: 30-03-2015 09:22

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