Fasting-unto-death in #Nepal
Dr. Govinda KC is fasting-into-death for the fifth time, bringing attention to government interference with the medical establishment of Nepal, and today is the beginning of a nationwide protest by the Nepal Medical Association (NMA).
This is an evolving situation, and today a government body proposed that certain standards be followed. The issue seems to come up over and over again, and this is the fifth hunger strike - in the past, the government has given assurances but hasn't not followed through......continued pressure is needed.
You can follow this on Twitter with the hashtag #IAmWithDrKC
How many medical schools are needed in Nepal and who controls them?
The issue is whether the government can authorize new medical schools in the country, based on political considerations that are independent of any assessment as to the need or quality. The present government says "yes", and the NMA and DrGKC say "no."
Due to the way that medical education is funded, starting a medical school is viewed as a way to make a lot of money for the proprietors. When the school s owned by politicians, they can use the funds for their own gain; the Nepali press has coined the term "medical mafia" for this phenomenon.
It's time for international pressure to be applied, so that the Nepal government will do the right thing......
Nepal is a beautiful country with many challenges, including the present lack of a constitution, the inability of the Constituent Assembly to write one after six years; the lack of natural resources; overpopulation; and a mass exodus of young Nepali men to work abroad. 73% of the people are under the age of 35 and 50% are under the age of 18. International tourism is a main industry, but recent disasters at Everest and the Annapurna Circuit have tarnished the image. Many Americans have a firm idea of sexual violence in India (a bordering country) that has hurt their willingness to travel to Nepal, even though that specific situation is nowhere near as dire here. ( my opinion after having travelled in both places).
The medical and public health challenges of Nepal are also daunting. There is a near-famine in the west (Nepal is a net importer of food despite all the terraced rice paddies); a complete failure of family planning; problems with human trafficking; a poor education system; and cultural factors regarding the role and status of women in society which make progress difficult. There is a long litany of infectious tropical diseases. (My two books about Nepalgive more background on the day-to-day challenges of running a hospital here).
Life is a daily struggle for most.
Maybe the most amazing thing of all is that so many Nepali people maintain a good attitude every day and work hard at making a better life for themselves. If you want to join me on a mental trek to Nepal, a part of Nepal the tourists don't see, just step over the orange DNA......
Note: there's a lot of background info, I admit. It's okay if you skip to the bottom!
How many medical schools does Nepal need?
It's a country of 28 million people, and up until fifteen years ago, there were only a couple of medical schools. India, Russia and China all had active scholarships to train promising young Nepali youth, to become doctors. (By comparison, there are still eleven countries in Africa that do not have any medical school in their borders; and a number of states of the USA, such as Maine, that do not).
Since the time of the Nepal peace accord, new medical schools have been authorized, so that now there are about 18 in the country, including a number of schools in the major cities of the Terai, the humid rice-growing plain that borders India where 50% of the country's population lives.
Funding of new schools?
Each new school requires an investment in infrastructure. They typically start out small, then use tuition money from the students for two purposes. First, they build a medical center, or expand the one they have, and call it a teaching hospital. All of the schools seem to be under a state of permanent construction or expansion.
Second, the tuition money is used for patient care. There is a system of low cost government hospitals that does not have modern infrastructure, and the new hospitals are trying to offer services up to western standards for the most part. In other words, the money for patient care has to come from somewhere. The system to deliver health care is funded by the loans taken out by the students for their own education. Many hospitals are dependent on foreign charities, often religious in nature, or funded by grants form foreign governments, but that is a matter for a different diary. The system to fund health care and hospital care in Nepal is not the same as in the West. Because of the extremely poor perinatal mortality rate, the government began to pay for in-hospital childbirth a few years back, but for most other services, money needs to be paid upfront.
From the student's perspective?
It is not unusual for medical school tuition to add up to the equivalent of $300,000 in US Dollars before it's over, and most students take out huge loans for this. Many of the ones I meet are planning to recoup this money by going to India, UK, or USA in the future.
The system of medical education is based on the U.K. model, in which the student gets an undergraduate degree known as an "MBBS," then does an internship and several years of supervision before going back to get a Master's. Only when they have a Master's are they able to be called a "Medical Doctor."
Affiliation Agreements with parent Institutions
When the new medical schools were granted permission to operate, each was assigned to an "affiliation agreement" with one of the existing schools - Tribhuwan University or Kathmandu University, (or some from India - Purbanchal University or Manipal University). The arrangement was designed to guarantee quality, and conformity with international standards of medical education.
Nepal government and expatriate Nepalis- the Nepali diaspora
Within Nepal, there has been considerable discussion about development strategy, and one path is to promote Nepali labor abroad so that remittance will be sent back to Nepal. This is also a subject requiring a lot of background, but quite a bit of the economy is propelled by remittance money, and there is a Western Union on every street in Kathmandu. One development proposal that keeps percolating is for Nepal to be like the Phillipines, and become a supplier of doctors and nurses to other parts of the world. (in fact the Phillipines has become notorious for setting up schools in these professions that exist solely to provide credentials for work overseas).
Here is the "Bottom" - the Bottom Line!
The danger here in Nepal is that Nepal would be producing medical school graduates who are not qualified, and who simply hold a piece of paper from a "medical school" that would not meet any internationally-accepted accreditation standard.
More doctors does not automatically mean more access to health care in Nepal. It's only when those additional doctors are well-trained, that access and quality will be improved.
More medical schools does not mean better medical education. The standards are being lowered. The parent institutions will not be able to ensure adequate quality.
There will be more incompetent or poorly-trained doctors serving the people here. More victims of medical malpractice. More suffering by the people.
This problem will ultimately lead to a poor reputation for Nepal, and produce an effect of making it more difficult for any Nepali doctor to go abroad. Countries such as the USA already have a system of credential evaluation to screen Foreign Medical Graduates before entry here. Fewer Nepalis will make it through the screen. Lack of quality will further isolate the Nepal medical profession from participation in international education.
Because of this international tie-in, I think it is time for governments and professional organizations outside Nepal, to join in encouraging the Nepal government to do the right thing and support the demands of DrGKC and the Nepal Medical Association.