An experiment with truth
- Dr KC’s satyagraha boiled down to providing quality health services, and at an affordable cost
Apr 8, 2015-
With the government finally capitulating to Dr Govinda KC’s demands on properly regulating the health education sector, Mahatma Gandhi’s most potent weapon, the hunger strike, has proved that it still retains the power to move mountains. Of course, it does not always work. Proof of that can be found not far from where Dr KC lay in protest, in the dead body of Nanda Prasad Adhikari, who passed away months ago, following a long hunger strike to seek justice for his son murdered by the Maoists. Gandhi’s antagonist, the British Empire, has itself not viewed hunger strikes all too kindly, most notably in the Margaret Thatcher government’s allowing 10 Irish Republican Army prisoners to starve themselves to death in the summer of 1981. In that sense, we are lucky to have the good doctor still with us and ready to fight another day, for knowing how things work around here, that is not an unlikely proposition.
As the stand-off between Dr KC and the government is only too recent, the particulars do not bear repeating here. It ultimately boiled down to providing much-needed quality services to the people of Nepal, and at an affordable cost. The commercialisation of medical education is only a symptom of the government’s failure in this regard, for I do not suppose anyone would have any objections to some rich parents forking out millions to businesses to train their children to become doctors, as long as our public health infrastructure was properly provisioned and functioning.
Positions to fill In the years since the demise of the Rana regime in 1951, we have made steady progress in health. According to Dr Hemang Dixit’s Quest for Life, life expectancy then was just 28 years and a quarter of all infants died. There were only 625 hospital beds in 33 hospitals spread across the country, which, of course, had less to do with providing services to the people and more with keeping the rulers posted in various parts of the country in good health. We had 24 dispensaries, and the entire health staff consisted of around 50 doctors supported by a now-extinct category of health workers called compounders.
The public health infrastructure is certainly much better now, not to mention complemented strongly by the private sector. Basic health services have become free since 2007 and that has increased access in the rural areas. It is in staffing that our government has failed miserably, especially in the remote parts of the country. First off, political parties pose grave problems in the smooth implementation of existing guidelines on transfers and posting. Transfers depend on which party controls the ministry at any given time and are often determined by the clout of trade unions, all of which are affiliated with one party or the other. A study by the London-based Overseas Development Institute counted up to 16 trade unions in the health sector but there could be more.
To the mofussil
One way to ensure the presence of doctors in various parts of the country is the requirement that anyone who studies on a government scholarship has to spend two years in rural areas. But, as we all know, this policy is breached all the time. As reported in this paper, one doctor protesting against this practice in 2011 said, “They send us to work in rural areas without considering the infrastructure available there. So we have asked the government to focus on developing infrastructures so that we can hone our skills.”
The medic does have a point, and it seems unfair to single out only doctors from poor backgrounds with the two-year mandate. Following the lines of the highly successful National Development Service (NDS) in the 1970s, it would make better sense for all doctors graduating out of Nepal’s medical schools to spend at least a year or two in rural areas before being certified. As anyone who underwent the NDS can attest, it is a life-changing experience that can only serve to make them better doctors. There is also the possibility that spending time in the country can induce more doctors to return for more years of medical practice.
A study led by Dr Mark Zimmerman that looked at 710 doctors who graduated between 1983 and 2004 from the Institute of Medicine, which incidentally is where Dr KC teaches, found some correlation between chances of working outside Kathmandu and previous exposure to such areas. Of those born outside Kathmandu, 41 percent were found serving there, compared to only 11 percent born in Kathmandu. Likewise, of those who entered medical school from the paramedic stream, and who would thus have had prior experience working outside Kathmandu, 40 percent were practising outside Kathmandu compared to only 12 percent of those from a science background.
Short on professionals
The biggest obstacle to adequate staffing of health facilities right now is recruitment. The number of positions sanctioned has not matched the population increase. According to a government document, Nepal’s population increased by 35 percent in 1991-2008 but the number of health workers went up by only 3.4 percent.
The government also has ambitious expansion plans. Three quarters of all health facilities in Nepal are sub-health posts and these are being upgraded to health posts (headed by a health assistant) while all of the latter are to become primary health care centres (headed by a medical doctor). This means the country is going to face a massive shortage of trained human resources although according to the latest annual report of the Department of Health Services, an impressive 96 percent of positions have been filled. But that is misleading since it includes all departmental personnel. The situation of trained health personnel is quite dismal, with only 55 percent of doctor positions filled nationally; nurses and paramedics do better at 81 and 76 percent respectively while administration shines at 97 percent. For comparison, the situation in Kathmandu Valley is much better with doctors at 90 percent, nurses, 102 (!) percent, paramedics, 80 percent, and admin, 125 (again!) percent.
Currently, recruitment in the health services stands suspended following a Supreme Court order that the Health Services Act incorporate the 45 percent reservations provision for marginalised groups in the Civil Service Act. That was in 2008 and in the seven years since, the health act has remained unamended. Instead, this past December, 146 of the CPN-UML’s Constituent Assembly members spent their time pressuring the prime minister to lift the ban on medical college affiliations. And, why, became very clear in the quote by UML leader Madhav Kumar Nepal, as reported in an online news portal, “What will happen to our medical college and the investments?”
Not yet weaned
Many have called Dr KC’s hunger strike a satyagraha, an innovative political strategy of Mahatma Gandhi’s. Gandhi went beyond the literal sense of the term to explain what it meant for him. Satyagraha, he wrote, sprang from his realisation that the “pursuit of truth did not admit of violence being inflicted on one’s opponent but he must be weaned from error by patience and sympathy. For what appears to be truth to the one may appear to be error to the other. And patience means self suffering. So the doctrine came to mean vindication of Truth not by infliction of suffering on the opponent but on one’s self.”
The self-suffering Dr KC underwent was certainly in the best of Gandhian traditions. But, are we ready to say that his adversaries have been ‘weaned from error’? I, for one, would not bet on it. Albert Einstein once said of Gandhi, “Generations to come will scarce believe that such a one as this ever in flesh and blood walked upon this earth.” The greater likelihood is that our future generations will scarce believe that of our current crop of leaders—and in the most negative sense.
Published: 09-04-2015 09:14