ON GUARD: Riot police in Dharan guard Bijaypur Hospital earlier this year in March after an angry mob attacked it after a 29-year-old patient died.
Nepal’s constitution guarantees free basic primary and emergency healthcare services to all, but recent reports of violence against health care workers have surfaced tough questions about the right to safe, quality care. Additionally, workers want to know who’s looking out for them.
A recent incident in Dolakha provides an important case in point. A young child suffering from diarrhoea and dehydration died at a hospital managed through a public-private partnership between Possible and the Ministry of Health. By nightfall the hospital was surrounded by angry protestors, some arriving on motorcycles holding jugs of petrol and lighters, others physically assaulting clinicians.
A forcibly extracted apology and admission of guilt from the hospital team was video-taped in front of police. The clip received more than 1 million views, causing health workers throughout the country to protest over the humiliation and abuse.
Doctors on strike
Nepal’s private sector accounts for most of the healthcare provided in the country: it owns two-thirds of all hospital beds and employs more than half of all doctors. Yet, regulations have not kept pace with growth of the private sector. Government inspection of infrastructure and monitoring for quality in private facilities have been poorly implemented, and reporting requirements are not universally upheld.
Overall, the growth of the private, fee-for-service healthcare industry — alongside an epidemic of private medical colleges — has led to the increased commodification of healthcare in the country. Surgeon and activist Govinda K C is threatening a 12th fast-unto-death hunger strike to demand reforms in the for-profit medical education sector. Certain agreements have been reached and implemented, yet weak governance plagues further institutionalisation.
There is a prevailing culture of impunity in Nepal, and general distrust in government legal systems to offer legitimate recourse. The media fuels the fire by sensationalising or under-reporting events, often without follow-through on stories or awaiting the results of official investigations committees which themselves are often impromptu, formed under duress, and lack independent medical expertise, as with the case of Dolakha. This leads the public towards confusion, or to the impression that health workers are inevitably to blame.
As patient parties have no formal mechanism for grievances in cases of suspected negligence or medical error, they often take matters into their own hands. There persists a belief that one’s demands will be met only if pressure can be exerted through a sizeable group. Violence has been legitimised in Nepal through the boundless excesses by both state and non-state forces in the name of ‘the people’. Banda, julus, aandolan are go-to methods for being heard, and the putative way to get results.
Hospitals in rural areas remain woefully understaffed. Often doctors are young, recent graduates struggling to provide care with inadequate equipment and medicines. The high flow of patients to under-resourced hospitals as a last resort can create challenging situations. It also takes considerable time, training, and a brand of humility uncommon in the leading echelon of society to understand and communicate to patients on the determinants of disease, treatment options, and the range of possible outcomes.
This lack of communication compounds the already strained doctor-patient relationship, which plays out across steep gradients of class, caste, gender, and religious-based inequalities, particularly in rural areas.
Workplace violence directed towards healthcare workers is not just a Nepal phenomenon. It is pervasive and under-reported in the US, where nearly 75% of all workplace assaults between 2011-2013 happened in healthcare settings. In India, despite laws in some states, hospitals have taken to hiring security guards, and some doctors have requested permission to carry firearms.
It is hard to come up with a term that encompasses the full range of acts and threats against health workers in Nepal: from verbal abuse, physical assault, intimidation, property damage, stalking and sexual harassment, to threats of public embarrassment and shame, such as putting a necklace of shoes and smearing black soot over the face and parading people through the streets.
There are no laws protecting people against medical malpractice, and health workers against violence in Nepal. Following the Dolakha incident and the subsequent strike the government agreed to introduce laws including ‘jail without bail’ for violence against health care workers.
However, political instability and constantly shifting priorities have delayed progress on this front. A National Health Act tabled in the Parliament includes laws to protect health care workers from violence and to create a unit at the Ministry of Health to handle patient complaints. The Ministry has also released an amended code of conduct for doctors to promote patient-centered practice and principles of beneficence.
As this goes to print, the Nepal Medical Association is on an indefinite strike over the recent decision directing the MoH to manage cases of patient death resulting from negligence through independent investigation, professional liability insurance, and compensation to families. Doctors’ concerns about being blamed for every death in a hospital are valid, yet there remains a need for improved accountability measures.
Meanwhile, reports of violence against health care providers continue unabated. People will surely need to see the in-fighting cease and regulations in practice before faith in these systems of care can be restored.
Agya Mahat and David Citrin are affiliuated with Possible.
Cashing in on tragedy, Sonia Awale
Sinking fast, Om Astha Rai
Fear of the future, CK Lal
The malaise in medical care, Shikha Darnal