As of Wednesday evening, Senior Professor of Institute of Medicine Dr Govinda KC has been on fast-unto-death for 10 days demanding clear health and medical education policy besides much-needed reforms in health sector. Dr KC's Satyagraha started this year after the government reneged on its promise not to grant affiliations to medical colleges without drafting national policy. Who are posing hurdles to health sector reform? What has Dr KC's movement achieved so far?
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Assistant Dean of Institute of Medicine, Professor Dr Bimal Kumar Sinha, who also served as the coordinator of the committee formed last year to investigate the irregularities in granting affiliation to private medical colleges, shared his insights with Mahabir Paudyal and Arjun Poudel.
We must all be very grateful to Dr Govinda KC for his sincere effort, dedication and sacrifice for improving quality of medical education in Nepal. Initially, he started with efforts to save Institute of Medicine from various ills, most notably political interference and political pressures to grant affiliations to medical colleges. He has been partly successful in controlling political interference in IoM. But the government and Tribhuvan University authorities have not done much. Even today we have to bear with various pressures from TU administration. They set constraints on IoM which has hampered its smooth functioning.
TU officials and the government seem to treat IoM and medical colleges like general colleges like Trichandra. And they seem to believe that what works for a general college also works for medical colleges. Therefore, they do not feel the urgency to have separate rules, regulations and policies to guide medical colleges. When Dr KC started agitation in the past, he had demanded autonomy for IoM. He relaxed this demand after TU officials promised to grant some administrative, financial and academic freedoms for the proper functioning of IoM. They backed down later. Now we realize that they fooled us. So this tendency of making promise and not abiding by it is the big problem.
What kind of financial problems does IoM face?
When we start new service in the hospital or introduce new programs, we also require new human resources and equipments. But TU does not provide us funds. IoM has to pay the salaries to the newly acquired human resources itself. TU has not sanctioned fund for new recruits and new equipments for the last several years. The available darbandis (positions) in IoM are far less than required. We are working with the same human resources we had when Tribhuvan University Teaching Hospital started with 300-beds and with around 40 students. The number of human resources is the same as it was in the initial days though we have about 800 beds now, new services added and new equipment bought. But TU has not opened new posts to manage these new services. There are junior faculties working on contract basis for the past eight years. They have not been made permanent. TU does not provide us any fund. IoM has to generate income to sustain and to maintain health services. Besides, salary of our faculties is low. This is why some faculties tend to quit and work for private colleges because they provide them handsome salary. Most serious of all, as the junior faculties have not been promoted there is a big gap between the professors and the lecturers. In certain departments, there are no human resources at associate professor level. Imagine the situation when all professors retire. We will have only junior lecturers left. There will be no human resource to fulfill this vacancy. IoM is going to face serious human resource crisis if this problem is not sorted out on time.
What do you think should the government do to address these problems?
If the government cannot give full autonomy to IoM, it should give adequate financial, administrative and academic freedoms so it does not have to look up to TU or the government for everything. And it should immediately announce new openings and promote the junior faculties.
It seems we are digressing. What kind of reforms does Dr KC want in country's health sector?
Dr KC's reform agenda is also related with the issues I have just raised. But his agitation is not limited to affiliation issue. It is a national issue. He is demanding a national policy to decide where to open up medical colleges and hospitals and the infrastructures required for this purpose. This issue can be addressed only when the government establishes more government colleges. Only this will force private colleges to maintain standards. But the situation is quite opposite here. We have about ten times more private colleges than the government ones and they have started to dictate to government colleges. If this trend continues standard of government colleges is bound to decline further.
Dr KC has been raising this issue for the last few years. Why does not the government listen?
This is surprising. Last year, we had a lot of discussion about Dr KC's agenda at the secretary level. They all agreed to bring a national policy. They also agreed that government should be strict while granting affiliations to medical colleges. Secretaries like Leelamani Paudyal and Krishna Hari Banskota seemed really sincere. And we had an agreement. But things changed.
How come? They had an agreement with Dr KC on behalf of the government.
I believe their hands are tied. They do not have a final say when it comes to policymaking decision. Promoters of private colleges are so influential. They have money and power. Some of the promoters are politicians themselves. So they do not allow the proper rules to be framed and implemented. Their priorities are different. This is the reason why promises do not materialize. Frequent government change has also contributed to the mess. This creates space for the political parties to game the system.
Do you suggest that the situation has gone out of control?
Not really. If the government brings out national policy at the earliest and let it regulate medical colleges, it can change the situation. Our problem is virtually everyone is investing in medical colleges whereas government should be the only body to do so. Government should start medical colleges in different regions so that health services reach the rural poor and the poor and intelligent students can study medicine at affordable fees.
I also blame Nepali mindset. Here in Nepal, once someone starts a business and it becomes successful others blindly follow. The way people are dying to invest in medical colleges reminds me of carpet industry boom of the 1990s. Literally everyone had tried their hands in carpet industry. But it finally collapsed. Today they are funneling money into medical sector as if there is no limit to it. If this continues it will meet the fate of carpet industry. Private colleges have been thriving because there is no proper monitoring system in place. Once we have a strict policy to regulate them, we have right men in Nepal Medical Council and Tribhuvan University, they will either have to abide by new regulations or shut shop. Change is not far off. We only need a strict policy to make it happen.
It is about two decades since private sector was allowed in medical education. Where did we go wrong?
Perhaps the system worked well in the beginning. But later affiliation started to be granted without proper feasibility study. They only looked into the number of students. They cared little about the faculties required to train the students and the infrastructures. Medical Council was lenient in granting affiliations and increasing the number of seats. The whole system was politicized. We are bearing the brunt of it now.
Given this, many doubt new medical education policy will escape political influence.
There are such doubts. This is the reason Dr KC is pressing for strong policy. After all, the government has promised so on a number of occasions in the past. Committees were formed and reports submitted but never implemented. If politicians are thinking of bending the policies in their favor, it will be very unfortunate.
How many times should Dr KC risk his life to improve things?
Truly, this is very unfortunate. But it would be a mistake to understand that Dr KC's struggle has failed to achieve anything. His Satyagraha of the past helped to stop open political meddling in IoM and TUTH. Now officials are appointed on the basis of seniority and merit. TU officials cannot dictate things like they did before. But these are nothing compared to the sacrifice and risks Dr KC has been taking for health reforms. I hope the government won't betray his cause this time.
Finally, what should the government do to stop the malpractice in medical colleges and private hospitals?
First of all, we need to have a clear national policy on health and medical education at the earliest. I am hopeful that the expert committee will come up with a good policy. I hope they will not be influenced by the political parties. Having done this, the government should start homework to invest in establishing government medical colleges. Once we have required number of government colleges, private colleges will be irrelevant. Third, IoM should be given autonomy on administrative, academic and financial issues. But this alone won't change everything. We need to establish the credibility of government hospitals as well. These hospitals need to be well equipped and doctors should be bound by professional ethics and abide by code of conduct.
