Interview with Dr Bhagawan Koirala

'We don't turn away patients because they don't have money'

This week's guest for our Monday Interview is Dr Bhagwan Koirala, 45, executive director and senior consultant cardiac surgeon at Shahid Ganga Lal National Heart Center. He is an acclaimed heart surgeon well known in all South Asia. An MD from Kharkov Medical Institute, Ukraine, Dr Koirala played a key role in bringing the Heart Center to its present enviable position. The hospital has 150 beds and is equipped with all modern technologies to perform major heart operations. It has also been providing free and affordable heart care services, which are otherwise very expensive, to an ever increasing number of poor and deserving patients. In the last year alone, his team at the hospital saw more than 70,000 outpatients, did 1,200 cardiovascular operations and 2,500 cath procedures. There were more than 5,000 in-patient admissions.

 

Dr Koirala spoke to Kamal Raj Sigdel of The Kathmandu Post on different issues ranging from the hospital's welfare schemes to the future of Nepal's public health care system. Excerpts:

 

Q: Where do you see Nepal's public health care system in the next 10 years?

Dr Koirala: There are a number of possible scenarios. It will largely depend on how politics evolves. It seems that social welfare is going to be strengthened. Many state-sponsored health care delivery systems will be established, and similar other social welfare programs launched. In the health sector, I believe that we will have more free access to health care for poor people. There will be some sort of health insurance policy implemented in the next 10 years.

 

Q: What progress will we see in the treatment of heart disease, particularly at this hospital?

Dr Koirala: Progress in this particular field is an evolutionary progress. We now have all the basic infrastructure providing cardiac care in this country. Obviously, it is not enough. We have to improve the quality of service, and we have to expand into different geographical areas of the country, and we also have to go for research and do more training and teaching programs. And I think that is what is going to happen in the next five to 10 years in this institute.

 

Q: What sort of welfare schemes does this hospital offer to poor patients?

Dr Koirala: The government demonstrated appropriate responsibility by supporting this institute to provide free cardiac care to poor children below 15 years of age. This has been in place for the last two years. It has been a highly successful and satisfying program. We've given service to hundreds, if not thousands, of poor children under this scheme. We have also started giving free cardiac treatment to senior citizens over 75 years of age. And we have a rule to provide over 100 free valves to poor patients annually.

 

Q: How do you identify poor and deserving patients? I mean, how transparent is the process of selecting patients for these free services?

Dr Koirala: There is a transparent mechanism for selecting them. There are criteria for selection. There is a committee to look into it. They recommend the names to me. Obviously, the doctors make the initial recommendation, but then there is an administrative mechanism to screen the potential beneficiaries. The selection cannot be done personally, it's all formal applications, formal selection process, formal approval, and it's notified publicly. In general, I have been very satisfied with the selection process.

 

Q: What are you doing to expand these free services?

Dr Koirala: Besides the aforesaid three major welfare schemes, we also provide free patient care for those who cannot pay. For example, 20 percent of the hospital beds have been declared free for poor people. All the costs, including hospital fees and lab services except medicines, are free for patients occupying these beds. Apart from this, the hospital has been making other efforts. And there are groups who raise money for donating to this institute for patients like these because they trust us. A group of 180 managers have each been collecting Rs 1,000 every month for the hospital.

 

Q: Who are they?

Dr Koirala: They are managers and executives of different levels. They volunteered after they saw what we were doing. They call themselves "Sahayog Group".

Q: Are they part of the hospital's mechanism to raise funds?

Dr Koirala: No. They are a group of people who have volunteered to help our patients. We call them whenever some patient is stuck without enough money. There are also other groups who sometimes come to help.

 

Q: What is the trend of patients coming to this hospital for treatment? Do you accept all of them?

Dr Koirala: We do. When we started these welfare schemes, the number of patients, particularly children, coming to us rose suddenly. This is good news. The people know that there is a state system to help them. The number of patients coming from the far west, remote areas and Madhes and Dalit groups rose manifold. And this category constitutes about two-thirds of the beneficiaries who receive this subsidy. That is a great help.

 

Q: Are you handling all these patients?

Dr Koirala: We are struggling to provide services to all those who come to us. We don't want to turn away anybody because of patient volume or money.

 

Q: Have there been cases of patients being turned away for technical reasons or due to lack of certain machines, for instance?

Dr Koirala: No, we don't turn away any patient for such reasons. Also, we don't refuse treatment to patients just because they don't have money. We try to find resources for them.

 

Q: So you have all kinds of facilities to deal with all sorts of heart diseases?

Dr Koirala: We have facilities to deal with most heart diseases. I cannot say "all of them" because that does not happen anywhere in the world. Some American centers do close to all, but not all of them. Most of them do little less than that. Japanese hospitals provide most kinds of services, but not some operations which are done in America. So that is a very relative term.

 

Q: Do you think the quality of this hospital matches international standards?

Dr Koirala: We have to define what we mean by international standards. By and large, we provide most of the services at par with most regional centers. We cannot match the best centers of the world. But we have to look at the regional standard, the South Asian standard rather than American standards. 

 

Q: Of late, private operators have been entering the hospital sector. How do you analyze this?

Dr Koirala: Private institutions are important for health care delivery. But there are many issues which need to be dealt with first. They are about the practice of allowing [medical] institutions [to operate] without an accreditation system, quality control, declaration of their social responsibility and constant monitoring. And obviously, there is a huge problem with the substandard quality of training provided at private institutions. These are serious issues the government has to look into.

 

Q: Do you think there is a need for policy reform in the health sector?

Dr Koirala: That is what we are talking about. There are lots of things which I would rather say to policymakers face-to-face than letting them hear it through the media. But I would like to speak at least one sentence here publicly. I have strong opinions about rationalizing the establishment of new academic institutions. They are big institutions, and that needs to be justified by local needs and the needs of the inhabitants rather than business people's needs or professionals' needs.

 

Q: There are some new ideas that the health sector could be developed as an export-oriented sector where Nepal could have comparative advantages.

Dr Koirala: It is happening by default. It was not planned like it was in Bangladesh, for example, where the government planned to produce more doctors with the intention of exporting them. Medical professionals were not created in Nepal with that goal. There is a huge exodus of medical professionals to foreign countries. Not just doctors, large numbers of nurses are going abroad too.

 

Q: I don't mean exporting health professionals but developing health tourism and the like.

Dr Koirala: That is the key. That would be a good business for us. There is a lot of talk about it now. Americans are spending billions of dollars on medical care abroad. Why can't we get a share of that market? We could if we had good medical services. But it's not just about one thing. The security situation has to improve, and the political situation has to settle down. Then there is the problem of adequate air connections. If we can build good institutions, which is possible, I see a lot of our people coming back over the next five or 10 years. Right now they say that they have no place to work here. Our challenge is to create an environment where they can work. Another thing is that if we can provide services of standard quality and have good networking internationally, we can attract many medical care seekers as they are doing in Thailand, India, Singapore and Malaysia.

 

Q: Health insurance is not very well organized here. Who do you think should do it? Should this be left to the private sector alone?

Dr Koirala: There should be involvement of both the government and the private sector. The state could run health insurance programs for marginalized and poor people. They could have non-governmental organizations organize insurance schemes in which the government pays the premium for the poor.

The private sector is not doing it because they fear that they will suffer massive losses. I agree with them for two reasons. Health care has not reached a level where insurance companies can promise their clients a full range of services. People will pay only if they can get assurances that they will get all the services. Second, there are many cases of malpractice in which patients and medical professionals have been involved. They falsified documents, wrote wrong prescriptions and forged bills. These malpractices have to be stopped.

And we are yet to develop a culture of health insurance. You have to start paying now if you want to secure your health in your old age. At this point in time, there has to be a combination of government and private sector initiatives. (TKP, July 6, 2008)