Nepali Times
Do hospitals have to be so expensive?



It was well past 4 pm but there is still a long line of patients getting their medicine at the pharmacy. The wards are still packed with people.

Several things stood out during a recent visit to Dhulikhel Hospital (right). First is that despite being a community hospital, how clean and well-managed it is. There are orderly lines, no shouting and chaos. Secondly, unlike most other private hospitals in Kathmandu, relatives of patients aren't carrying wads of cash to pay for treatment.

First-time patients at Dhulikhel Hospital pay a registration fee of Rs 15, for which they get a check-up by a cardiologist, nephrologist, a dermatologist or psychiatrist. No further payment is required. On the second visit the patient pays only Rs 10 and medicines are discounted. In-patients pay a daily charge of Rs 150, which includes three meals a day.

For people used to Nepal's government hospitals, the first thought that comes to mind is that since it is so cheap the quality of service must be  bad. But Dhulikhel Hospital probably has the best level of diagnosis and care in Nepal. How do they do it?

"This is a non-profit, community based hospital and our mission is to  provide affordable health care to all," explains Rajendra Koju, administrative director of Dhulikhel Hospital, "when setting the price for any service we just add the cost price, maintenance cost and a slight overhead. We don't have a profit margin."

Dhulikhel Hospital gets no support from the government, and although it gets donor help for new investment in equipment and infrastructure, the hospital meets its operational costs from fees.

"Everything comes down to management," says Koju, during a tour of the wards, "when we know exactly how much we spend and exactly how much we earn, we can set a number that is affordable to the people and yet not a loss for the hospital."

The question is why can't other hospitals in Nepal run like that? The answer seems to lie in the extreme commercialisation of Nepal's private health sector on the one hand, and the mismanagement of government hospitals on the other.

And in complete contrast to other hospitals where relatives of patients have to run around to buy bandages and medicines even for emergency cases before they are treated, Dhulikhel has a 'service first, pay later' policy. Many can't pay and the hospital ends up providing Rs 15 million in free treatment which is paid out of a charity kitty.
Dhulikhel Hospital operates with Kathmandu University School of Medical Science and staff work in both institutions, which also helps in keeping costs down.

"Health care is supposed to be about helping others, reducing their suffering, but it has turned into a business," says Dipak Dahal of Dhulikhel Hospital. "We are here to change that."

Remarkably, doctors and nurses here are paid modestly and yet none of them moonlight anywhere else. The trick has been to instill a sense of commitment and compassion. 

See also:
A people's hospital
It took the determination of one man to build Nepal's best-run community hospital.

Founder honour

Dhulikhel Hospital was founded by Ram Makaju Shrestha who got his medical degree in Vienna and returned to Nepal to set up Dhulikhel Hospital in 1996. He was inspired to become a doctor by the loss of his mother because of lack of access of proper treatment when he was a boy. In April this year, he was honoured with the Gopal Kamala Raj Bhandari Rotary Award for Vocational Excellence in recognition of his contribution to affordable health care for all. Says Shrestha about his guiding philosophy: "We treat patients whether they are rich or poor, no one is rejected. It is the faith and trust of the people that has made me who I am."

Paying less for more

Another example of a hospital with affordable health care is Chhetrapati Free Clinic. Patients pay a "donation" of Rs 100 and can visit any consultant they want. But those who can't even afford to pay that get treatment for free.

At first Chhetrapati clinic used to provide free services to all, but they changed that in response to popular perception that free care is not good. Explains the hospital's Bijay Bahadur Mali: "We had to charge people that nominal amount so they would take us seriously."

Mali says health care is expensive because medical education has become expensive, the prices of equipment and drugs are also very high. "Prevention is cheaper than cure," he says, "half the health problems in this country could be solved if sanitation and clean drinking water was available to the people."

Educating patients is also important. Most patients think a doctor who doesn't prescribe expensive drugs is not good, or that if a clinic doesn't prescribe expensive ultrasounds, there is something wrong.

"What is working against affordable health care is the Nepali people's love for technology," says Mark Zimmerman of the Nick Simons Institute in Kathmandu. "Nepali consumers judge medical service by how hi tech it is."

The cost of hospital fees can be brought down if unnecessary tests are not conducted. Zimmerman, who has worked in Nepal for 20 years, says the country's health system needs better care providers who treat patients with compassion and a holistic approach.

Read also:
Healthy progress
Nepal's maternal mortalityrate has dropped from 850 per 100,000 live births twenty years ago to 280 today.
A healthy majority, EDITORIAL
Birkha Dai's clinic, ABHAYA SHRESTHA in MUGU

See also:
Nepal's unsung health heroes
Nursing Nepal back to health
A unique training institute in Phaplu is transforming health care in rural Nepal

1. RK
I wish Dhulikhel Hospital will continue its tradition, commitment, enthusiasm. 

2. KiranL
Greed, selfishness, mismanagement, lack of compassion. Reasons why other hospitals are either way too expensive or so badly managed that even the poor won't go there.

3. niraj
True indeed ...Dhulikhel hospital is at its best . And other hospitals of Nepal if they did decreased their profit to 50 % , we could see a new Nepal with better health care . Its frustatating to see a hospital in chitwan , where they provide free treatment to maoist and rich people and rip off poor people . This is insult to humanity , I am sorry to see that ...

4. Dr. ranjeet baral
great job mate.
nepal needs people like you to implement what one preaches.
I am impressed with ur motivation, dedication and results.

5. prashun lama
i don't even believe that hospital over here are also of this type.
or you, people are making things looks like this 

6. chandra gurung
I like Mark Zimmerman. If he is a Nepali national, he can be a serious contender to be health  minister. He is very passionate about our health system and knows alot.

7. Howie
You should also have mentioned the Patan Institute for Health Sciences (PAHS) which is also training doctors to be field-based.

8. Shristi
Unless governments can arrange more funds or subsidize MBBS or gives some benefits to doctors who work non-profit, require new graduates to serve and develop a rating mechanism or can find private donors, yes hospitals will be expensive because of running cost. (In theory, all the above sugggestion are already in place.)  True every medical examination does not require expensive tests but one needs to be extremely careful about late diagnosis. Well all efforts cannot be included in one report and I laude the effort by Dhulikhel hospital and the coverage. But if this is not just another coverage due to business alliance, we need more coverage on such positive effort in medical sector and yes maybe another one on PAHS.

9. Yangi Sherpa
I am so happy that now we have something like this hospital which is based on public service and that too with private hospital facilities and cleanliness. Others too should improve their standards to this level and mobilize their staffs to maintain da top- standard.

(11 JAN 2013 - 17 JAN 2013)