Why Dr KC's demands are genuine
Because I teach in a medical school, I have been following developments in Nepal’s health care and medical education since I first came to Nepal in 1977, a year before Nepal launched its MBBS program at the newly created Institute of Medicine, a once prestigious institution now under threat of decline due to political interference. Having lived in Jajarkot district for six years, 1977-1983, and having visited 68 of Nepal's 75 districts, I have some understanding of the health care needs of Nepal's rural population and I have followed with interest Nepal's political developments for the past 40 years, along with close attention to developments in its delivery of health care in both urban and rural settings of the country.
These interests compel me to support fully the demands of Dr. Govinda KC as he now is forced to stage his eighth fast-unto-death. As someone concerned for the future of Nepal, I urge the government to act immediately to honor its repeated promises and to fulfill Dr. KC's demands, all necessary steps toward guaranteeing high quality health care for all Nepalis. The right to health is guaranteed in Nepal's constitution, both in the Interim Constitution of 2007 and the new constitution of 2015. The significance of enshrining this right in the constitution cannot be praised too highly, but many steps now need to be taken to ensure that the right to health becomes a reality. Dr. KC's demands are clearly are one such necessary step toward a healthier Nepal.
Dr. KC is truly a living treasure in Nepal, a selfless individual with a unique moral aura, who repeatedly has put his life at risk to improve health care and medical education in Nepal. It is no exaggeration that the very rule of law is threatened unless Nepal's government honors its previous commitments to Dr. KC, including the immediate enactment of the Health Profession Education Policy recommendations made by the committee co-chaired by Dr. Bhagawan Koirala, as outlined by the Mathema Commission's report last year. Medical education in Nepal urgently requires a set of official rules and regulations, essential to guarantee quality medical education and competent health care for the future of Nepal. As the former Vice-Chancellor of Tribhuvan University, Kedar Bhakta Mathema (another extraordinary Nepali whose voice needs to be heard) said to me: "This is a very dangerous trend - people not listening to the government and government not listening to the people's voice. This is dangerous; this is a sure sign of a failed state."
Dr. Govinda KC is the most extraordinary Nepali that I have had the privilege to meet during the past forty years. He demonstrates in practice the highest ethical standards and genuine commitment to health care in Nepal. During a conversation with him earlier this year, Dr KC explained to me his position:
"Our demand is that Health Profession Education Act must come and there must be equitable distribution of educational institutions. Educational institutions not only give education, they also provide health services. In Nepal, they are all focused on how to draw students and earn money from medical college. They are not concerned at all about how to run the hospital well. Our aim is..It is also written in constitution. All Nepalese have right to quality health service and basic health services. It is written so, but they have ignored it. But we have been saying that a policy must be made for the achievement of what is written. And competent students who are willing to study medicine must get the opportunity. Everyone cannot study medicine, but the competent ones must get the opportunity. It is the responsibility of the state to ensure that. If competent students study, then quality human resources for health (HRH) can be produced. If quality HRH are produced, then the quality of health service can improve. So, in order to ensure that competent students can study, there must be governmental medical colleges... We have been fighting since long back, from the beginning. What will be the population after 30-40 years, how many doctors will be needed, how many nurses will be needed, how many lab technicians will be needed, how many radiographers will be needed. By analyzing all these statistics, there is a need to ascertain how many medical colleges are needed, whether they are needed in village or town, is it scholarship or they have study on donation. By keeping in consideration the state of the country and by studying the geography of nation, a policy must be made and then we have to work as per the policy."
Even if the Health Profession Education Act submitted by Health Profession Education Commission becomes law, many challenges remain to improve the quality of medical education and of health care in Nepal. In my opinion, the most important remaining challenges include:
1) A clear vision of principles to guide health education policies and practices, to make the entire health profession more scientific, credible, equitable, and socially accountable needs to agreed upon; efforts to enunciate a set of principles for the future of health education, as formulated in the preamble of the bill to establish the HPEC, is essential to guarantee the country a responsible health care workforce ensuring the best possible health care of the population. The key function of HPEC would be to formulate the national policy on health profession education.
2) Tentative projections of healthcare resource needs currently settle on a doctor : population ratio of 1:1000 needed to guarantee equitable health care for all of Nepal's citizens, and these are reasonable. Projections for other categories of health care personnel are also necessary, once the proposed but not clearly defined models of federal structures and the specific rights, responsibilities, resources availability and the management capabilities of the proposed state structures are clarified for the country.
3) A national debate must address and resolve whether the trend toward profit-driven health care and profit-driven medical education is genuinely in Nepal's best interests.
4) A regional balance must be articulated in the national policy by the HPEC between urban and rural areas of the country for the delivery of both education and health care.
5) Medical school admissions policies must be regulated to guarantee the selection of qualified students based on merit and equity not on political connections or wealth. Scholarships should be awarded to the most qualified students who otherwise could not afford to study, while financial aid could be repaid through rural service following graduation. The government has in fact already proposed a scheme of loans while keeping their certificates as collateral.
6) A stronger, autonomous regulatory system without political interference must be established to guarantee uniform academic standards, so that faculty are qualified, the curricula meet minimum standards, and students properly supervised.
7) Corruption and political interference in all aspects of health care delivery, medical education, and licensing must be controlled.
8) A rational, consistent fee structure must be enforced by the HPEC for all medical schools, along with limits on the number of students admitted in each class.
9) Opportunities for postgraduate residency education must be systematically expanded, with residents salaried to work in the hospitals in which they train. This, too, should be initiated by the HPEC.
10) A program of regular Continuing Medical Education (CME) opportunities needs to be established, along with well-defined career advancement paths for academic physicians, for whom scholarship should be the key basis for faculty promotion.
(Dr Maskarinec teaches at John A. Burns School of Medicine, University of Hawaii. He first came to Nepal in 1977 as a US Peace Corps Volunteer, teaching math and science in Jajarkot. He remained in Nepal for six years with a Mahendra Scholarship from Tribhuvan University until 1983 to study shaman oral texts, a topic on which he has published several books. During that time he visited 68 of Nepal’s 75 districts. Recognition for his work in Nepal includes the Birendra Pragyalankar, awarded by then King Birendra in July 1997, Vidhyadhari (Honorary degree of Sanskritic Scholarship) awarded by Yogi Naraharinath, Viswa Brhat Bauddhik Santa Sammelan (Nepal), January 1997, and "National Honor - 2016 Award" from the Nepal literary organization "Nepal Sahitya dot com," honoring his lifetime commitment to Nepali language and literature. He returns to Nepal regularly, most recently for six months in 2015-2016 as a senior Fulbright scholar for the second time.)
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