Author: Dr. Santosh Paudel, Assistant Prof., National Academy of Medical Sciences
I was in Hiroshima City Asa Hospital, Japan, for about three months to learn the principles and practice of spine surgery. I was fortunate to visit one of the best spine centers in Japan. I was exposed to many modern technologies in this surgical field. The main principles were intended to be applicable to the maximum number of people while employing minimal invasive techniques. The focus was on surgical principles rather than using expansive implants inside the body. This would be very useful for Nepal, where the affordability of surgical costs (including implants) is always a decisive factor in surgery.
Another learning point was management and patient care. The chain of command at work and the team dynamics among the coworkers were excellent. The junior doctors did not have to worry about managing the complicated cases independently, nor were the senior doctors reluctant to leave surgeries entirely to the juniors. In the hierarchy, cooperation was in harmony.
The ever-learning attitude among the professionals was another insight. Nearly everyone was keen on learning new ideas or skills. Doctors and nurses routinely discussed patient care, which was a central theme embraced by every staff member. Consultants would discuss cases on phones or sometimes meet personally to formulate management plans. Interdepartmental coordination was excellent. Thus, patients’ interests were always placed before personal interests!
After completing my fellowship training, I began to consider how I would apply my learning in Japan to everyday practice. I realized that in Japan, individual patient care is based on the foundation of a good health care system. In the Nepalese context, vulnerable populations, such as children, the elderly, and marginalized people, are deprived of basic health needs and still have difficulty accessing health care for their needs. Malnutrition and infectious diseases are still public health problems. Many trauma victims are dying at the sites of accidents, or if an individual survives an accident, he or she may become disabled for life because of the poor care he or she receives after the accident. However, this example is not meant to place blame on someone in the system or the pubic but to highlight the fact that the current health system inadequately and inefficiently addresses the current trends in health care problems. For Nepal and similar countries, we need to focus more on improving the health care systems rather than merely the care of individual patients.
I would like to discuss the health care system of Nepal and its various components described by the World Health Organization: leadership and governance, health system financing, health information systems, human resources for health, and essential medical products and technologies.
After the federal system of governance was introduced in Nepal, health care responsibilities were divided among the federal, province, and local governments. Local government mainly handles health promotion and sanitation. Province government has the chief responsibility of health care delivery and public health programs. The federal government provides direction via policy guidelines, superspecialty services, clinical protocols, disease control, and health regulations.
Health system financing functions through revenue collection, risk pooling, and strategic purchasing. Contributory health insurance is the most sustainable type for Nepal. In this system, the government bears the major bulk of the health care costs via the revenue collected from public taxes (around 70%); the remaining amount (around 30%) is paid by the patient directly.
Nepal’s health information system is still not computerized, and hospital staff use hand-written data-collection sheets in most of the government hospitals and public health offices. Moreover, the data are the main source of knowledge about the whole health care system, and it affects the planning, policy making, and protocol designing.
Human resources for health are produced mostly by private institutions; only a few are provided by public institutions. However, most of the human resources are generalists who have not been trained for their specific technical jobs. I recommend the health manpower, such as doctors, should work full time in a single institution. Moreover, they should have three chief responsibilities: clinical (looking after patients), academic (teaching and learning), and research. They need to be paid according to the time and contribution they make in the abovementioned domains, so that they will be scientists and teachers who are financially strong and take full responsibility toward their institutions.
The consumption of essential medical products and the use of updated technologies for patient care is beyond the reach of most public institutions. This is the consequence of the inadequate health financing system.
Maintaining a strong social structure with family support has been at heart of the culture of Nepalese society. It is the family that takes care of one another, rather than public institutions. Thus, building a strong foundation for the health care system is the prime concern rather than individualized care.