Kathmandu Teaching Hospital, Nepal (19/3/08 – 15/4/08)
To travel the world has always been a dream of mine since I can remember and there are many countries that I would like to see but the opportunity to see first hand some of the largest and most beautiful mountain ranges in the world coupled with the experience of such a rich and diverse culture, while being in one of the poorest countries in the world is truly unique. These are but a few of the reasons why I set out to complete my medical elective studies in Obstetrics and Gynaecologly in Kathmandu. My main objectives where to determine the similarities and differences between my previous experiences within the NHS system in the UK and the current system implemented in Nepal.
During my time in Nepal I gained insight into the health care system. I was able to learn how common conditions vary in Nepal as opposed to conditions in the UK. I was also able to witness how the management of such conditions differed in a setting with fewer resources. In addition I learnt about the day-to-day activities of students and doctors working in Tribhuvan, which is Nepal’s only government run teaching hospital.
Nepal has a range of common diseases. Many of the diseases reflect that Nepal remains one of the poorest and least developed countries of the world 1/3rd of the Nepali population live below the poverty line
Health care, much like that in the UK, is split into both public and private sectors services.
The main difference that I encountered during my time at the government Teaching hospital in Kathmandu was that medical treatment was not free of charge and the recipient requires payment at the time of accessing them. This includes all test needed, such as blood analysis and X-rays to operations and outpatient consultations. This differs from the current NHS system in the UK, as health care services are funded through taxation and no payment is required at the time of use. Although, in Nepal, this can cause problems as not all people are privileged enough to be able to afford the cost hat is required when they become ill meaning that health care can not be universal. The government subsidize the hospital system in order to keep prices affordable as possible and there are also a few beds that are charity funded ensuring that medical care can still be provided to those who severely ill, but too poor to be able to cover their own costs.
My experience within the outpatient department was vastly different to those back in the UK. Consultations would take place within a room occupied by more than one physician. Patients would come and go as they please and often a doctor would be consulting more than one patient at the same time. There seemed to be no emphasis on privacy or patient confidentiality, the patients are just happy to be seen. A far cry away from the private consultation rooms that are provided within the NHS. In Nepal local traditions and culture play a large part in health care and a difference that was brought to my attention was how if a woman was not married, a full history of previous sexual history would not be explored. Assumptions are made, based on cultural values and questioning along this line can cause embarrassment for both the patient as well as the Doctor. It is also deemed inappropriate to perform an internal examination on woman who are unmarried unless heavily indcated. So a standard examination performed within the UK is rarely carried out in Nepal, and then only by senior members of staff.
While working at the teaching hospital I spent the majority of my time within the labor room, observing obstetric emergencies, caesarian sections and normal deliveries. In the Nepaly year 2062, the total number of deliveries was 3657: 77.2% being vaginal and 21.7% as a result of Caesarian section, a procedure that is becoming increasing popular in Kathmandu. These are usually carried out due to emergencies and in 2062, out of the 647 procedures preformed 214 where due to pre-term deliveries; 191 due to low birth weight; 57 due to Intrauterine growth reduction (IUGR); and 25 due to fetal distress. Elective caesarians are also performed when indicted by protocol and an increased Bishop’s score but this only accounted for 147 of the total births seen in that year. This differing from the UK as elective Caesarian sections have become increasingly popular in recent times due to its ease and convenience. Although the two system protocols are in fact very similar for normal deliveries, where observations and normal deliveries will be handled by the midwives and nursing students and Doctors will only become involved if there is any complications suspected or confirmed.
Infant mortality has in fact dropped from 82% to 48% per 1000 live births in the past 15years. This 41% can be attributed to increased medical facilities around the big cities within Nepal and increased attention to antenatal care. Although there is still problems with the accessability of healthcare and antenatal education within the rural communities. Woman may have to walk for hours in order to receive healthcare so at the first juncture most Nepali people from villages would visit a ‘witch doctor’ before consulting a physician in a polyclinic or other hospital. This could be an explanation why many conditions are not picked up till a late stage. In order to tackle this problem the government has begun to offer people 1000 RPS (approximately 8 pounds) to woman delivering within the government hospitals. This has led to a further 15% decresese in infant mortality with the capital but has tackled the problem for those woman who live within the rural communities. This approach differs to that in the UK as now more emphasis is being placed on the de-medicalisation of child birth, with home births and water deliveries becoming more popular with the appropriate precautions. Although this can be accounted for by the increased funds an fascilities for healthcare that are available within the NHS, something not yet available in Nepal.
My experiences while on my medical elective have enabled me to learn a great deal about the health care system in Nepal, and about the prevalent conditions occurring within obstetrics and gynecology, affecting the local population. I was able to experience the impact of poverty on the ability of the local population to access the available health care resources. It has been an invaluable experience that I am sure will enable me to become a better Doctor in the future.
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