Getting doctors to stay

[Mati]

Dear Friends,
Dr Mark Zimmerman, former Director of Patan Hospital, has following article in Nepalitimes:

Getting doctors to stay - Nepali Times


the fulltext is:

Crying Out for Change
Mark Zimmerman, MD

On our last morning in Bajhang, a man walked up and asked me to see his son. Kiran was a 7-year old, and the day before his father had carried him down 8 hours from their village in the hills to the district seat of Chainpur. aThe boy had 2 weeks of fever and a tender bulge on the left side of his neck.
The father showed me a paper from the Chainpur Hospital, written late the day before. The recommendation read, "Refer to higher centre for treatment." The man asked if we couldn't do any more for his son.

We walked with them over to the hospital. In fact, all the boy had was a skin abscess and all he needed was a minor surgical procedure. He was frightened and had to be held down, his crying filling the hallway. Unfortunately, because the hospital did no operations, no anesthesia or pain medicine was available. The incision into his neck, though successful, was very painful. As we were cleaning up, we watched the grateful father laying his son on the porch outside the hospital to warm him in the winter sun.

Unfortunately, in towns and villages across the land of Nepal, scenes like this one play out over and over again. There is a hospital building and some staff, but for some reason they cannot provide the care that is needed, even at a basic level. The boy Kiran is joined by thousands of others – women in childbirth, children with broken arms and legs, people with burns, fever, and pain – all of them crying out for change, a change in the existing health care system.

The dedicated men and women of Nepal's Health Ministry work against huge obstacles to provide comprehensive health care in remote places, with a limited budget, and in the face of political turmoil. While the building infrastructure of government hospitals and health posts is generally adequate, the big problem lies in area of human resources: assuring that staff are on duty, have competent skills, and are caring in heart.

In the last 10 years, Nepal has seen such a tremendous growth in medical colleges – 13 currently in existence and 20 new groups have applied – that the production of new Nepali doctors will soon cross 1000 each year. There are now over 40 nursing campuses. And each year, the 125 separate medical institutes under CTEVT produce over 4,000 new health assistants, nurse midwives, and community medical assistants. So where do all these young people go? What are they doing while the Kirans of Nepal come into government hospitals and find no care?

On average, only 15% of Nepali women who deliver babies will have a trained health worker in attendance. For the poorest parts of the country, a trained worker will be there less than 5% of the time. While the women of Bajhang District deliver approximately 8,000 children each year, less than 100 of these take place in the district hospital. Childbirth usually comes off without a problem, but when there is one, it can be serious: Every day in Nepal, 5 to 10 women will die while delivering a baby. Their cries are muffled by the high mountains around them, but also by indifference.

I want to propose that this situation calls for some radical changes in our thinking. The traditional approaches, the local remedies, the age-old sayings – these have had their day, and have proven ineffective for Nepal. Some of these old approaches of building another grand medical center or teaching institute – they may still win votes in a political contest, but they are not saving enough lives. It is time for us to create new local systems, using the experience of innovators around the world. It is time for us to advocate for real change.

Let me outline what I feel are three necessary shifts in thinking:

(1) Provide quality care to the greatest number.

Unfortunately, in Nepal as in other countries the prevailing vision is to provide "highest quality care." We add on more levels of the latest technology and produce sub-specialists, all at great cost. This results in some benefits: Better health care for the rich. More prestige for the Kathmandu medical establishment. But these benefits are at the expense of those most in need: the Bajhangis and their sister districts.

Today the Health Ministry of Nepal is in the process of making some significant and difficult trade-offs. They are creating posts for health care workers who can cover much wider areas of the country. For example, while a specialist anesthesia doctor is unlikely to ever venture into the district hospitals of Panchtar, Baglung, or Jumla, today there are Anesthesia Assistants in each of those places enabling operations for the local people. Similarly, there is a major program emerging (called "SBA" for skilled birth attendant) to train all level of health care workers – not just doctors, but also nurses and ANMs – to conduct safe deliveries. In this and in other trainings of health care workers lies a hard choice but one that we must face: 'highest quality care' for a few or 'quality care' for many.


(2) Support health care workers in the field.

Why with thousands of new doctors, nurses, and mid-level health workers graduating each year is there so little "trickle down" to the rural hospital? First, there is a strong pull on these workers to migrate to the developing world. Last year, one of Nepal's premiere medical colleges had over half of its graduating class of d0ctors leave to train in the United States. Though they depart from Nepal saying otherwise, more than 95% of these doctors will settle in America, only occasionally returning to Nepal to visit. In the last 5 years, nurses have joined the doctors in this mighty exodus. And who can blame them? A staff nurse will earn 10 times higher salary working in England than in Nepal.

But some of these young graduates will stay, and for those who do the emphasis must be on taking good care of them while they work in often difficult circumstances. This is not only the responsibility of the Nepal Government. Increasingly, local committees are starting to manage their rural hospitals, sometimes with excellent results. We have found that several factors can make a big difference in keeping a health care worker happy and productive. These positive "sticking" forces constitute what we call the 5 C's of health worker support:

Communication: Link the hospital with other centers, and with the world through internet.
Continuing Medical Education: Provide professional nourishment for staff growth.
Connection with a higher hospital: Create a link with staff in another, regional center.
Community governance: Hospital staff do better when they are managed locally.
Children's education: Unless their kids are looked after, the staff will soon move away.

These days in Nepal, there is no shortage of health care workers. The central problem is providing enough support for them to stay where they are most needed. This is the place where we should direct our limited resources.

(3) Build beyond the MBBS doctor.

I am a doctor, and I have trained young doctors in Nepal for the last 20 years. Doctors are needed throughout the health care system – but they are not a remedy to all its problems. Lack of a doctor in rural communities has made them into a sort of sacred cow. We now realize the limitations of placing a freshly graduated doctor by himself (or herself) in a rural hospital. In medicine, it's experience that counts – sometimes even more than fine training. I know of experienced health assistants who can diagnose better than most new doctors can, and ANMs who are far better at delivering babies. And often, about the time the new doctor has gained the necessary experience, he moves back to Kathmandu for further training.

So what is beyond the basic-qualified MBBS doctor? The captain of the rural health care team: Nepal's MD General Practice doctor. Across the country, we have seen this all-round specialist transform local health care systems. An MDGP can do operations, deliver babies, take care of kids and adults, and has some administrative training. Another specialist – such as a pediatrician or general surgeon – is more highly qualified in his/her field, but they just aren't as effective in a setting where one doctor must manage all. Nepal's future ideal district hospital will have this: 2-3 MDGPs working together. That will be a community with fine hospital health care.

Today in Nepal, I find ample reason to hope. The political situation has turned a spotlight towards those most in need: the rural communities. The Health Ministry today has shown a readiness to tackle chronic problems, like the MBBS scholarship system, and it now has a High Level Task Force that is searching for new, effective remedies. Multiple partners stand ready to help.
Perhaps, though, what we need is for those with the power and resources to leave Kathmandu and pay a visit to the countryside. If you are there long enough and you listen, you will hear someone crying.

Dr. Mark Zimmerman is Executive Director of Nick Simons Institute,
an organization working to enhance health care in rural Nepal.

Get going Mark,
Hope to read from you more in the future!


Best wishes,
mati

[Walrus]

Hope people like him have good intentions

[medicalmarvel]

rural people are always been neglected as the money is spent on newer technologies rather than on their health issues. i agree with Dr. Mark that sometihng has to be done out of the traditional way to provide medical facilities in the rural parts of the country.

[schwann]

thankx dr Mark,who write facts.
chhabindra mbbs students china

[bhimcmc]

interesting isn't it?
this guys who would have had the the best of medcal training in his country has served our place and find his training relevant. i have met him personally when he came down to India in my college and i should say it was really inspiring.. i believe that we should look at the realities we live in and try doing something to uplift our health standards.. its for all of us to make individual commitments on this regard...it was an ecouragind article.. thanks for putting up the link to it..

[de.malady]

i salute respected Dr Mark for his earnest concern in the 'health status' of unfortunate Nepal; of course government is the one who deserves all the credits of this health-trauma the poor citizens are having..
i think limited funds, poor facilites & security are the main drawbacks that keep the doctors going to the remote regions for service..
when we drive even only 17, 18 km away from kathmandu then we can find many examples of poor villagers deprived of the immediate medical treatment if unwell in anyway so the districts like Panchtar, Baglung, or Jumla as Dr Mark noted are too far away places from the valley, is not it..
However as Dr Mark says 'I find ample reason to hope', let us all hope that with new political changes going on in our country, crying of the sick village people will be heard for the promt proper medical treatment they need from able doctors throughout the hills&mountains of the nation..