BIKRAM RAI

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
No home delivery, DAMBAR KRISHNA SHRESTHA in BARDIYA
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