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The Sri Lanka model

DHANVANTARI by BUDDHA BASNYAT, MD


Medical colleges have mushroomed like English "boarding" schools in Nepal. From just one medical college 15 years ago, we now will soon have almost 20. To be sure, just like English private schools, many of the new medical colleges are also commercial ventures which were opened by savvy business people.

And there is a stampede of students trying to get into medical schools with their parents urging them on. Unfortunately, the tuition fees and deposits are so steep that for most Nepalis, a medical education is a distant dream even with requisite aptitude.

An important question is: will these new medical colleges help solve Nepal's health problems? Most people who graduate from a medical college in Nepal will certainly want to go abroad to acquire more knowledge and wealth and probably settle down there. You can argue this will be global gain, but it won't help solve the health needs of the Nepali especially the ones living outside the capital. Furthermore, medical colleges are probably not the most cost- effective way of solving the health problems in a developing world.

We may have to learn from Sri Lanka. Despite the three decade civil war, Sri Lanka has the best health indicators in South Asia. Average life expectancy is 75 years and infant mortality is 9 per 1,000: incredible statistics for a developing South Asian country. Soon after independence from Britain in 1947, Sri Lanka invested heavily in public health and women's education, and this investment is paying them rich dividends today in health.

An important point in Sri Lanka has been focus on primary health care, especially maternal and child health through a multi-layerd health system with adequate provisions of basic services at the community level. They have not only talked about this as is common practice, they have put their money where their mouth is. For example, Sri Lanka till 2005 did not have a single magnetic resonance scanner in the public sector, symbolising their emphasis on primary and secondary care. In sharp contrast, many poor countries (Nepal included) boast expensive tertiary care institutions with low funding of primary and rural care.

New medical colleges may satisfy our academic thirst for knowledge. But insofar as solving Nepal's health problems are concerned, we may be better adopting the Sri Lanka model.



1. Anonymous
The mushrooming of medical schools is not going to be a panacea for public health problems in Nepal. Specially, when such schools are established on the basis of political 'source-force' and emerging elitist attitude to medical care and arrogance of the 'novoua riches' class with the intention of not moving out of the KTM valley or the big cities of the South. Had schools (does not matter even if a couple of them were private ones) been opened strictly as a national priority to the health care needs of the Regions (or upcoming Federal Units), some could justifiably argue for a total of up to five medical schools in Nepal. The sole purpose of doing 'business' in the name of training medical doctors, and over saturating the market with  'for-profit' proprietary schools with sub-standard and obsolete curricula, unqualified 'imported' teachers, and poor basic science and clinical infrastructures have been historically discarded long ago by Flexner (2010) in North America. Ironically, even those who returned from the New World seem to repeat the same old mistakes. Can we, the professionals of Nepal, ever learn to think out of the box?


2. B2B
I for one advocate for a preventive medicine. That means before the folks fall victims of any illness they should be given the basic knowledge about how one catches a malady and in what circumstances.

Some of the write-ups were very informative though. Even so, I would emphasize on repeating every time possible to let folks know that sugar and salt are extremely harmful for our body when one overuses them. So why if you can keep them away from your dining table many diseases shall be prevented. For the very reason, whatever we eat as cereals have enough carbs and glucose to meet our everyday need. Maybe in an underdeveloped country you need iodized salt because of malnutrition.

I would better give preference and recommend to eating vegetables and fruits, if possible five fruits and vegetables each day. It could be rather difficult in Nepal, for you still need to alert the populace to be conscious to eating more fruits could make them healthier and free from health complications.


3. Ramesh Bikal
I am not sure what the writer was trying to pin-point here. I agree medical colleges are not the solution, and also agree with his view point that primary and secondary health care has to be emphasised. But I am not sure why is he bringing these two together? New medical colleges are private investment, and of course they mean business like any other private funded investment. Primary and secondary health care are government's responsibilities, thus a separate part of the bargain. Is he suggested that private investors invest on -primary and secondary health care instead of medical colleges?

4. Laxmi Tamang

Primary Health Care is the best and appropriate model of health care delivery system for our country. All these mushrooming colleges graduates are definately not going to contribute to poor and rural people and the nation because they had paid so much money to study and become a doctor which is beyond the general Nepali people expectation. We can't expect them to do the work for poor and rural people because they have to repay or earn that money back. Their investment of 5 years study needs to be returned or earned.

Rightly pointed out by the author that we've to learn lesson from those countries which have proven successful in improving health of its people in a cost-effective and quality manner. In real sense, examples of Comprehensive Health care system could be found in Costarica, Srilanka, Kerala State of India, China and Cuba. These countries had followed the Alma Ata Declaration and they have managed the responsibility of the state to provide free health services and education to their entire population. Thus, your writing on Cuba is accurate. We should not follow the selective approach but Comprehensive PHC where everything covers and people will be able to have access.

Learning from the Cuban Healthcare System (Learn more at http://www3.uakron.edu/worldciv/pascher/cuba.html):

"Health care is not as expensive as one might imagine. Government intervention is essential to guarantee access to health care and to guarantee, therefore, greater effectiveness of the medical system."

Unfortunately, in Nepal including many developing countries. Government think just the otherway around. Corrupted mentality!!!!

Interesting research article to read at http://www.longwoods.com/content/19916

"Medicine was acknowledged as "powerful, but within limits"; the major determinants of health lie elsewhere."

"Where there are more doctors, and greater hospital or equivalent capacity, costs are much higher but outcomes are worse, not better."

 Report from the World Bank "Investing in Maternal Health Learning from Malaysia and Sri Lanka" at http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2007/08/28/000020439_20070828164038/Rendered/PDF/259010REPLACEM10082135362401PUBLIC1.pdf



5. B2B

It is the smaller nuances and the several unsaid that make the day-to-day of everybody's health care. It therefore requires to be very cautious not to impose on others only one way of seeing things. Because some of you are observing certain rituals for generations without causing harm to your health, and sometimes some homemade treatments may prove to be very trustworthy and effective as well.

A physician to my mind should be not only somebody who prescribes a drug or a medicament after finding out the cause of sickness but also applies the human psyche to deal with those patients who are sometimes suffering from a sort of hypochondriac or imaginative ill health.

At the beginning there is always that nature and nurture or innate and acquired. Some of us inherit from our parents some of the diseases but now many of them are getting eradicated by the experts in DNA analysis by extracting those defective genes which cause diseases in a person. This type of biological analysis has a great future as there are still many remaining things are to be discovered.

Whereas those which are relevant to the environment or what you eat to live, you can possibly compare your individual experiences with that of other folks avoiding flaunting anyway. That will be a bit of all right.

I suppose sometimes you are before a cornelian choice, that means to put your health fitness above all other options. Which is why many hit the gym daily, workout or do kickboxing to maintain a sound health.

First of all, it is quite essential to make attention to what you eat. A breakfast in the morning should be the most essential meal of the day, albeit in the morning you seldom are in the mood of eating anything solid. A bowl of oats in milk or yogurt can fill your stomach largely. Add a kiwi or a golden apple, if possible, half of a pomegranate will be marvelous. Then add a cup of cacao and a chicory blended with coffee in case you suffer from backache or osteoporosis.

Your lunch if you take in the canteen of the society where you work should be frugal not very much charged with fat. A salad with a roasted chicken or else could be most welcome but avoid alcohol or beer and dessert. Because alcohol, smoking and sugar in dessert are found to be very noxious for your health. If you get a very good grape wine of several years old you can take a few glasses from time to time.

The evening meals are often the only meals you take with your family altogether. It depends entirely upon you to make it a happy meal. For that why don't you procure an electric mixture so that you could put several dry fruits like raisin, almond, fig, apricot, cucumber, ginger, tomato, rape seed oil, olive oil and many other fruits to make a sort of a homemade gazpacho that could rejoice everybody. And always use wholewheat or brown rice to procure all necessary vitamins and minerals for maintaining a good health. Plus mung lentil will be perfect. The aforesaid gazpacho shall be really perfect in the morning while you take your breakfast. Amongst all, almond is highly recommended because of its oil, containing mono and poly unsaturated like Omega 3, and 9, copper, zinc, vitamin k and many other minerals.

Do not fall victim to junk food. Woebegone, they are meant for only commercial gains which only give you wobbly bits or roll of flesh.

It is found that some of the berries like blue berry, goji berry, pomegranate are containing much antioxidants which arrest the free radicals that cause the cancer of different organs, prostate included. If you manage to take them everyday there is less chances of being the victim of such lethal diseases.

What's more, your body doesn't create D3 vitamin, Omega3, 6 and 9. Hence every three to six months of interval if you can consult a doctor to make him prescribe D3 vitamin especially after crossing 40 years that would be most welcome.

And never forget that if you take aspirin (75mg) everyday that will prevent you from having heart attack, that's for sure, and will definitely reduce the chances of suffering from almost all cancers.





6. Health Promotion

While health care delivery system is one aspect of health it is important to look at all the social determinants of health that causes ill health. For example the WHO Commision on Social Determinants of Health model is example of how every sector influences health and this model can be used to build healthy public policies, a declaration of the Ottawa Charter for Health Promotion. Both private and public sectors are important aspects.  This fact was recognized a long long time ago by the Black Report, Lalonde Report and other WHO reports. What I am trying to say is every sector (agriculture, communication, politics, medicine, primary health care, government institutions etc etc) must have some consideration of health in their policies to tackle the burden of diseases in a holistic way and the emphasis on one sector while neglecting other sectors will not help. So everyone is correct in their own way but all the comments needs to put together as one.Good Examples from Laxmi.



7. Gaury s Adhikary

One way to complement  Sri Lanka model would be to integrate mission and objective of " Nick Simon Institute " http://www.nsi.edu.np/aboutus.php by the Ministry of Health of Nepal.

Nepal already is ahead of meeting the Millenia development goal on maternal and child health benchmark; continuing and investing aggresively in this front will make maternal and child health even more safer for Nepali polulation .

By promoting model developed by Nick Simon Intitute for rural health care in Nepal , government of Nepal could close the gap even in curative medicine wchich is glaringly deficient at the moment.

People do have actue sickness, fall from trees, meet road accident and they need urgent and long term care for their wellbeing; focusing only on preventive care does not address the immediate care for the patient  in hinterland.

I think a model which addresses both health care isses ( preventive and curative) is possible and Nepali should not be deprived of these essential services at the cost of one over other.



LATEST ISSUE
638
(11 JAN 2013 - 17 JAN 2013)


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