Somebody who is not exactly with Dr KC in Nepal

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Right now I am not exactly with Dr KC even though I agree with him that things need to be fixed and brought out into the open. Dr KC is a positive and inspiring role model. The members of the Mathema Commission also included some other top guys who also have fought against corruption in the medical sector.

The Mathema Report

The effort  to reform medical education financing in Nepal needs to focus on more than just the Kathmandu Valley.

What this blog is not about 

I’m not going to recapitulate the entire history of Dr. Govinda KC’s hunger strikes, or the buying and selling of licenses to operate medical colleges, or the allegations of corruption at the highest level, or bribery required to obtain a seat at one of the more prestigious Medical College post-graduate programs, or the Medical Mafia, or the likelihood of implementation of the Mathema Report.

If you are a bideshi reading  this, it seems – messy. That’s because it is.

The problem?

It’s best illustrated with the following diagrams, originally from The Nepali Times in April 2015.

There twenty one medical colleges in Nepal, one third are in the Kathmandu Valley.

There twenty one medical colleges in Nepal, one third are in the Kathmandu Valley.

The above diagram omits the Karnali Academy of Health Sciences, in Jumla (mid-western, not in Terai. It’s new.)

Here is another, more striking diagram:

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e.,

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e., “private” – and I should add, in this region of Nepal there is a higher per centage of Hindi speakers.

One of the key objections of the #IamWithDrKC movement has been the announcement that two (or three? or four?) more medical colleges would be granted permission to open in Kathmandu. High level politicians have invested in these and money has changed hands.

Another way to look at the number of colleges in Kathmandu by comparing with Delhi. I agree with those who say there are already too many

Another way to look at the number of colleges in Kathmandu by comparing with Delhi. I agree with those who say there are already too many

Dr KC had an eleven-point agreement with the government, just last week ( Sept 8th). The next day, the Association of Private Medical and Dental Colleges of Nepal held a press conference to register their objection. At present, the government has pledged to bring all parties back to decide the next step.  (this is exactly what the government would do if this was the USA).

Now, I don’t pretend I know all the details, but I do know I have traveled  outside  Kathmandu Valley and I have taught doctors and nurses in Terai and the hills. Of the 2,130 people I trained, more than half were from outside Kathmandu. Half of Nepal’s population lives in Terai.

-The teaching hospitals of these schools in Terai are critical to the health of people in Terai. Every one of these is doing rural outreach and medical camps to the surrounding region as well as the hills such as Makwanpur. Before these schools were established,  people of the terai needed to go to Kathmandu for sophisticated treatment. (they still do need to go to Kathmandu in some cases, but not as much).

– The supply of MBBS doctors who will do service in rural areas for debt forgiveness is greater, due to these colleges.

– colleges such as Chitwan Medical College are producing graduates just as  skilled as those coming from TU or KU.

This summer Nepal had widespread protests in Terai about unfair treatment, and for those who have been to Terai the contrast between Terai and Kathmandu is dramatic. Many more living in poverty in Terai. It’s only in the past dozen years that medical care has become more widely available there. If Nepal closes the private schools in Terai , the availability of care will be taken away.  Reports in the newspapers indicate that the government-run medical schools are just as corrupt, so converting  the privately run schools will not improve things. Look at Bir Hospital: they are run by the government, and the problems caused by lack of funding there are quite well known. Same with the zonal hospitals.

A complete government takeover will result in eleven more places that are dramatically underfunded, like the zonal hospitals. Is that what is wanted?  

For these and other reasons, I think that any plan should be careful not to  destabilize the medical education outside the Kathmandu Valley. (I’m not saying it’s perfect). The summer andolans over the constitution in Terai are not ended. Let’s not give the people of Terai one more reason to be unhappy.

I do think that clinical education needs to be strengthened. The present system in all of Nepal is for the  MBBS degree to focus on bookwork and library study.

One little thing I would add to the already long list of what I would like to see:

I was at one place outside Kathmandu where they told me: You are the only foreigner who has ever come here. When I’ve been to many of the places in Terai they tell me “You’re not just the only foreigner, you are also the only one who comes here from Kathmandu to teach us.”

On Planet Earth, in “the west,” there is a long tradition of visiting medical professors. Nepal does not quite participate. (the ones who come from India have been criticized, which I think is unfair. It’s easy to bash India, this should not be so freely seized as an opportunity to join in).  There is a longstanding practice of having videshi doctors visit Nepal, and yet they all seem to congregate at just a few of the schools in Kathmandu. Or in many cases, they spend time in a village in Solu Khumbu (for example), reliving some fantasy of what Nepal used to be like but has now outgrown. Now, the villages of Solu Khumbu need medical care, but – is this the best way to provide it?  Nepal is increasing urban.

It’s all too often that when foreigners come to share knowledge, they do so by only teaching a dozen or two dozen people in Kathmandu. Nepal could benefit from systematizing this somehow, and spreading it around.

I think more effort should be made to develop connections between each school and those foreigners who bring medical expertise.

There’s clearly been a massive expansion of MBBS education, and in a few years these same men and women will all apply for post-graduate courses as an MD. Right now, the medical establishment needs to plan for this, and create slots.

In summary, I want to support Dr KC but I think the schools from the Terai have valid points that need to be included.


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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