Privately run medical services in Kathmandu have been commercialised to such an extent that falling sick is now an expensive affair. In the absence of medical insurance and a social security net, medical treatment is fast turning into a luxury.

Public hospitals on the other hand, often criticised for inefficiency and mismanagement, have become oases of hope, the only resort for poor and middle-class Nepalis when ill. They provide all sorts of basic and sophisticated treatment at a low cost, or even free in some cases. "It isn't sophisticated instruments or five-star luxury that cures people in hospitals. It is the devotion, skill and care of medical professionals that performs miracles," claims Bir Bahadur Khawas, Chief Executive Officer of Patan Hospital.

A hospital management veteran with 40 years of experience, Khawas has seen Nepal's medical sector grow with the introduction of advanced medical services and technology. Patan Hospital itself has seen people's expectations and medical needs change over the last few decades. Established by the United Mission to Nepal (UMN) in 1954 as a referral hospital that provided only general care, it was turned into a full-fledged hospital in the early 1980s after being handed over to an independent board in November 1982 under an agreement between the government and the UMN. Patan Hospital provides heavily subsidised services-the actual cost of the delivery service for low-risk deliveries is Rs 3,000 at its Birthing Centre, and around 4,500 such babies are born here annually. Their mothers pay only Rs 1,000 or, if the hospital's Social Service Department recommends it, absolutely nothing. (The Department gathers detailed information from all patients admitted to the hospital regarding their financial situation. It then makes recommendations for a full or a partial fee waiver if the patient cannot afford to pay for the service, whether or not the patient has put in a request to be considered as a "charity case".) For those who can afford it, and for those who need it, Patan Hospital also has more expensive wards that provide specialised care.

The entry of significantly more expensive private medical institutions means more choices for those who can afford them, and have thus reduced some of the burden on public hospitals. But even subsidised hospitals want to cash in on the rising medical expenditure of the upwardly mobile segment of the urban population-Patan Hospital is establishing the Patan Private Clinic and a specialised paediatric ward by the end of this year. Here, you can book a service or fix an appointment over the phone, for charges as high as those at private nursing homes. "The introduction of these expensive facilities are important to sustain the hospital's charity programmes in case donors pull out," says Khawas. In the last fiscal year, Patan Hospital provided subsidised services worth over Rs 7.2 million, in addition to the subsidised medicines received from individual and institutional donors, the UMN and through government grants.

The inexpensive services and lack of adequate medical facilities in rural areas have created a rush at subsidised hospitals like Patan Hospital. This means better health care for people who otherwise would not get it, but it is also a cause of discontent among patients and their families. Anil Shrestha from Paanchkhal has a nine-month-old son with pneumonia undergoing treatment at the Kanti Children's Hospital (KCH), and he believes he has cause for complaint. He cites a scarcity of trained medical professionals, and mismanagement. "There are not enough nurses-two nurses handle four cabins," he says. He also expresses concerns about the hospital's cleanliness, saying bed linen is sometimes not changed for a week at a stretch.

But overworked medical professionals have their own complaints. The average bed occupancy for the children's hospital is 98.9 percent, and with the rapid growth in population fuelled by Kathmandu-bound migration, and complicated referral cases, the pressure on the hospital's resources is immense. Last year the hospital saw 83,933 outpatient, 20,221 inpatient and 29,371 emergency cases. KCH was established under Soviet patronage in 1963 with 50 beds, and its management was handed over to His Majesty's Government in 1968. The management transfer, followed by the transfer of Bir Hospital's paediatric department, saw Nepal's first children's hospital completely in place. Presently, the hospital has an overarching medical ward that includes oncology, cardiology, a neonatal intensive care unit (ICU) and paediatric ICU (PICU) services, a surgery ward including the burn and plastic surgery wards, an anaesthesia department and a nursing department where trainee and intern nurses are also put to work.

The hospital provides both free and paid services. Public health workers evaluate the economic situation of patients, and the poor are treated free and provided any advanced services they might need. There is a separate 'non-paying ward', which treats poor children but conditions there are pretty bad. "There are serious financial constraints. It is the dedication of the staff that keeps the hospital running," says Dr. Govinda Prasad Ojha, Director of the Kanti Children's Hospital. (Hospital sources even say that sometimes rich urbanites come significantly dressed down, and ask for a waiver.) The hospital's free supplies are supported by a trust, with funds coming in from the interest on deposits put in place by various trusts like the Nepal Paediatric Society, the KCH Appeal Fund, the Hashimoto Trust Fund set up by former Japanese prime minister Ryutaro Hashimoto, and the Oncology Fund set up by Carmal Dersch.

The KCH has a world-class paediatric ICU, considered one of the best in developing countries, and the ward is staffed around the clock with doctors and nurses. But things might not stay that way for long-the equipment is deteriorating and the government grant is insufficient to meet the hospital's actual funding needs. The service costs charged are very low, appropriate for "10 years back," say management staff at the hospital. The KCH charges Rs 500 for 24 hours at the PICU, but their running costs are over twice that. "If the government fails to extend the kind of support we need, things might slacken," says Dr. Ojha.

His neighbour, Dr. Manohar Gupta, ex-director at the Tribhuvan University Teaching Hospital (TUTH), thinks that despite all their weaknesses, Kathmandu Valley's public hospitals offer the best of doctors, equipment and treatment, as compared with private nursing homes. "The diagnostic facilities have improved and public hospitals are motivated to improve their efficiency after the arrival of private nursing homes. But in any case treatment at private institutions is out of the reach of many because of the expensive [and privately-funded] medical equipment they have, and also because they are run more like businesses," he says.

A doctor at the emergency ward of the TUTH who did not wish to be named has another criticism to make of private hospitals-patients in critical condition at these places, he says, are finally sent off to government hospitals as the private clinics don't want any "black marks" on their record which might harm their investment. This may not be true for all privately run nursing homes, but there are several cases that seem suspiciously like the result of such a mindset. Man Bahadur Gurung of Pokhara has had such an experience-his wife was referred to the Bir Hospital from a Kathmandu nursing home after she was treated there for a gynaecological complication for six months, to little improvement.

The Bir Hospital, established in July 1889 with 15 beds, is the true pioneer in the establishment of modern medical services in Nepal. Even now, the hospital prides itself on being the first-and to date the only-medical institution in Nepal where coronary artery bypass surgery, closed-heart surgery, haemodialysis, neurosurgery, microneurosurgery and laproscopic cholecysectomy (surgical removal of the gall bladder by laparoscopy) facilities are available. The hospital offers the services of 10 speciality departments and 15 super-special units. Presently, the hospital has 90 percent bed occupancy, of which 320 (82 percent) are free and 70 (18 percent) are paying beds. With an annual average of 9000 admissions, the present bed count is far less than the 800 to 1000 beds the Bir Hospital needs to meet the actual demand. The hospital has been promised funds for expansion by the Indian government, but the grant has not been forthcoming for the last 12 years. The land needed for expansion has been acquired (behind the Sajha dispensary and to the north of the nursing campus) and the foundation stone was laid during the state visit of India's former Prime Minister Inder Kumar Gujral. But the promised 200-bed trauma- and emergency care-centre has not materialised. Though the Indian Embassy in Kathmandu has repeatedly assured the Bir Hospital's management that the promised funds will be released imminently, it hasn't happened. Apart from the approximately 1,200 out-patient visits daily, the Bir Hospital serves an average of two "mass casualty emergency cases" (victims of road accidents, landslides, fires, etc) a month due to its central location and popularity.

"Political interference in the management of the hospital is crippling its performance," says Dr. Ram Prasad Shrestha, Director of the Bir Hospital. He is the first director of the Bir Hospital to complete one full year in the hot seat after the restoration of the multiparty system 1990. The hospital has had 10 directors over the last nine years.

Apart from interference in appointments to the post of hospital director, political and bureaucratic bigwigs also like to use their influence in the appointment and posting of doctors, and in the placement of interns. Most of them get appointments or admissions through phone calls, while civilians have to stand in never-ending queues and are referred to packed medical care units.

Despite the tremendous contributions of public hospitals in the Kathmandu Valley to public health, the government seems reluctant to provide them better facilities and vitally needed funds. The hospitals face an acute shortage of water. Bir Hospital, for example, consumes about 250,000 litres of water daily but is supplied with only 30 to 50,000 litres a day by the government. The situation is the same at other hospitals, too, forcing them to rely on untreated water supplied by private tankers. Patan Hospital and Prasuti Griha (the maternity hospital) rely entirely on their own shallow and deep tube-wells. Prasuti Griha has round the clock supply from an 80,000-litre water tank. "We are in a position where we can supply 20,000 litres of water at any time to fire engines as well," says Saraswati Padhyaya, Director of the Prasuti Griha.

Although these hospitals provide services at subsidised rates, they are charged at normal commercial rates for utilities like drinking water, telephones and electricity, which means a large chunk of their annual budget goes towards paying for essentials. Bir Hospital pays Rs 900,000, and Patan Hospital pays Rs 700,000 towards their monthly electricity tariffs alone, and then they have to rely on stand-by generators for an uninterrupted supply of electricity. All these hospitals are well-prepared for emergencies and have had disaster management plans in force for years, but no governmental body has taken their lead and assisted them by formulating a national plan to link all hospitals in times of large-scale disasters.

Kathmandu Valley's public health services could be a model for other developing countries. But if things go along the way they seem to be now, they will simply be one more lost opportunity.