Conversation overheard at a barber shop in Biratnagar one evening this week: "Should I make the booking? I can confirm it tonight if you can pay 10 lakhs by tomorrow morning. But if you can't, remember I have others waiting in line."
You would be forgiven for thinking that this man, waiting for a haircut, was a stock broker or a real estate dealer. But he is not. This man was talking to the father of an aspiring medical student who had obtained high marks in the medical entrance result of BP Koirala Institute of Health Sciences in Dharan (BPKIHS) in Dharan. But admission is not guaranteed, and the man boasted he could use his political influence to get the boy into any college as long as he was willing to pay up.
There are 18 private and government medical schools in the country, half of them are in Kathmandu. They produce up to 1,500 doctors a year, and there are thousands of others who graduate in nursing, assistant health workers, anesthesiologists and x-ray technicians. Yet, there are district hospitals in this country which don't have a single doctor, health posts have no trained personnel and the messenger boy often fills in for the absent auxiliary nurse midwife.
Medical service in the country is a glaring divide between urban and rural healthcare, the exorbitant fees for simplest medical procedures and for consultations by physicians in private clinics.
Families sell their land to afford surgical fees charged by private hospitals for relatively minor operations. A treatable medical condition can be a death sentence.
Kathmandu Valley alone has 65 hospitals, most of them private. What passes for zonal and district hospitals cannot cope with demand, they never have the required doctors and staff, most doctors run private clinics just outside the government hospitals and refer patients to themselves.
Auto mechanic Satrughan Kusiyat's wife gave birth to a son at Biratnagar's Kosi Zonal Hospital on Saturday evening. The child was born with complications, and the doctor advised him to admit the child in neo-natal intensive care. There were no beds available and the child was rushed in ambulance to the BPKIHS in Dharan, 50 km away. There were no beds there, either. Miraculously, the baby survived 18 hours without proper medical attention, and was finally admitted into intensive care on Sunday afternoon.
"I don't earn that much, if I had money I'd have taken my baby to Kathmandu," Satrughan told me, sobbing, "I had to watch helplessly as the baby struggled for life." Even in the government hospital, Satrughan had to go out to find a private pharmacy to buy medicines, injections, and bandages.
The absence of quality healthcare in the villages forces people to make long journeys to the cities, but once there they find government hospitals overcrowded, understaffed and ill-equipped. The private hospitals are slightly better, but are out of reach of most Nepalis.
"If you don't book an expensive cabin, even the nurses don't visit you regularly," complained Gafar Miyan, 68, as he lay in a general ward of a private hospital in Biratnagar. Many run out of money, and entire families camp out in the open outside hospitals here, waiting for treatment for their relatives.
Bishwa Nath Adhikari is a physician at the newly-opened Nobel Medical College here, which treats more than 1,100 patients every day from remote parts of eastern Nepal in its out-patient department.
"The government hospitals just can't cope with the demand," says Adhikari, "it is the government's responsibility to invest in quality rural health care, but there is a systemic failure."
Young medical graduates are reluctant to serve in remote areas citing lack of facilities and low pay. Half of those who graduate every year ultimately leave Nepal, and those who remain behind prefer to work in city hospitals.
Surya Lama is a young medical intern at Nobel in Biratnagar who has been studying under a government scholarship. He says the medical profession in itself is not profit driven, but the failure of the state to invest adequately in the health sector has corporatised it.
Lama took me aside in the corridor, and said matter-of-factly: "I may still go and serve in the rural areas, but my friends who have spent millions for their education will not."
A nation's health, EDITORIAL
Selecting medical school applicants with district backgrounds and who have worked their way up as paramedics improves chances of doctors serving in rural Nepal
Why some doctors stay and others go away, KUNDA DIXIT
New study finds factors that make Nepali doctors more likely to practice in rural Nepal instead of moving to Kathmandu or migrating abroad
Public participation in public health, BHRIKUTI RAI
Communities in western Nepal act to improve local governance and healthcare