Ujjwal Thapa, the founding chair of Bibeksheel Sajha Party, died on 1 June last year due to complications from Covid-19.
Thapa’s treatment, which cost Rs2.5 million, was crowdsourced after he was unable to put together enough money to pay mounting hospital bills. His family raised Rs6.8 million for the treatment of a young politician known for his integrity and vision for the country.
Thapa needed financial support despite belonging to an upper middle class family with a house and business in Kathmandu.
Covid-19 exposed the pre-existing failure of Nepal’s public health system and high cost of treatment at private facilities have forced many families into a vicious cycle of poverty, as well as countless preventable and premature deaths.
Nepal’s healthcare mechanism is at odds with the constitutionally guaranteed fundamental rights of Nepalis, and needs a complete overhaul. Government hospitals cost less, but treatment is sub-standard and private care is too expensive.
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Nepalis have had to sell property and livestock to pay hospital bills, and fall prey to loan sharks. Others have had to abandon treatment midway or entirely knowing that doing so would mean certain death.
The government subsidises treatment for diseases including cancer, Alzheimer’s and kidney failure, as well as for families of those who were killed or injured during the conflict. However, the amount does not even cover transportation for treatment in most cases. Bureaucratic red tape means not all patients receive the benefits.
Arun Shahi, an oncologist at Patan Hospital says that cancer treatments might take up to five years, and cost as much as Rs20 million: “How much is the Rs100,000 government subsidy going to cover?”
Particularly tragic are the stories of children whose parents have had to discontinue treatment for lack of money. Doctors at Kanti Children’s Hospital say they have seen at least five such cases from Achham, Sindhuli and Sarlahi districts in the last six months.
“It is heart-breaking to be forced to send young children home, and we are very much aware that the lack of treatment will mean they will not live,” says Bishnurath Giri, a paediatric oncologist at Kanti.
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In Nepal, medicine for chronic diseases like diabetes and high blood pressure cost about Rs1,000 per month. Kidney dialysis, required to be done thrice weekly, costs Rs2,500 per session. Cancer treatment cost a minimum of Rs300,000, while bone marrow transplants at private facilities cost up to Rs3 million. A brain surgery, which is not available at government hospitals, costs around Rs2 million at the Neuro Hospital in Bansbari.
Meanwhile, the overall costs of a liver transplant could be as high as Rs3 million. Sagar Poudel, who sees up to 30 patients with liver disease at the Chitwan Medical College every day, says that at least five of those patients require liver transplants, but cannot afford it.
For families in remote areas, even a fall from a tree or injury in a highway accident can sink them deeper into poverty. Many of Nepal’s migrant workers admit they seek overseas employment to pay debts incurred for medical treatment of family members.
The average cost of treatment for an accident and surgery in private hospitals is Rs200,000. Just an ICU bed in a private institution in Kathmandu costs Rs20,000 per day, while the daily cost for patients needing ventilators is Rs100,000. Critical care at government hospitals is only about Rs15,000 cheaper.
Additionally, the absence of a medical audit for treatment in Nepal, unlike in foreign countries, has led Nepali service providers to charge money arbitrarily by directing patients into unnecessary tests and treatments.
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And since patients do not have technical knowledge of medical treatment, it is difficult for them to decide on the choice of service. “It is up to the patient to decide, but healthcare providers have taken the decision out of their hands,” says Poudel, the liver transplant surgeon.
And when families cannot afford treatment fees, hospitals are known to hold new mothers and babies, mentally ill patients, as well as bodies of deceased family members hostage.
The over-saturation of private health institutions in Kathmandu has also led to unhealthy competition between private hospitals which have been known to pay ambulance drivers commissions for bringing patients to them. Tests performed in one hospital are not recognised by another, and a patient needs to take them all over again.
Patients were already bearing the brunt of expensive medicines and over-prescription of unnecessary medications. Big pharma pays commissions to hospitals and doctors for prescribing drugs. Indeed, up to 75% of the total expenditure or medical treatment is spent on pharmaceuticals.
“While there is a big managerial weakness in the government health institutions, the private sector is engaged in unethical profiteering, and ordinary Nepalis are squeezed between those two problems,” explains physician Kiran Raj Pandey, author of Up is the Curve: A Genealogy of Healthcare in the Developing World.
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According to the National Health Accounts Report 2018, Nepalis spend 80% of their out-of-pocket expenses on private medical treatment. Nepal’s healthcare mechanism is not only causing people to spend a significant portion of their income on treatment, but also increasing indebtedness.
Experts have time and again called for the elimination of out-of-pocket healthcare payments due to continued investment into an unregulated private medical sector.
“The state has let hospitals and clinics charging arbitrary fees off the hook, this needs urgent fixing,” says public health expert Kedar Baral.
The answer is a citizen-centric national health insurance program to reduce the burden of medical costs. Public health expert Sharad Onta says: “Healthcare cannot be a commodity, and patients are not customers.”
Meanwhile, Baburam Marasini, former director at the Epidemiology and Disease Control Division says that the treatment cost of 90% of patients will be reduced if health services are decentralised to primary health centres as well as local and provincial hospitals.
Introducing a national health insurance scheme would then also mean sustainability for district hospitals and local primary health care centres.
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