The pain and discomfort were unbearable for Rajendra Mahato (37) of Sarlahi and he came to Kathmandu at Bir Hospital for the diagnosis. After a physical examination, it was confirmed that he had kidney stones.
Looking at his medical report, Dr Rabin Bahadur Basnet, Head of the Urology Department Rabin Bahadur Basnet said, “There is a stone in the kidney. It should be surgically removed. Please visit the hospital on December 5 for surgery.”
When Mahato asked the doctor to do the surgery faster than that, the doctor showed the surgery record book and said, “Many patients are waiting for their turn like you. The number of patients is high. So you have to wait for your turn.”
He cannot perform surgery in a private hospital immediately. Surgery in a private hospital costs Rs 80,000 to 100,000. Now there is only one option, to wait for his turn.
“I cannot afford to go to a private hospital for treatment. So, I just have to live with the disease until my turn for surgery,” said Mahato.
Balkrishna Bhusal (23) from Chitwan was in the same crowd. Bhusal, who went to the hospital after severe abdominal pain and discharge of blood in the urine, was also confirmed to have kidney stones during the physical examination. Doctors have scheduled him to undergo surgery after nine months. He lives in Kirtipur for his studies and says, “There is no other option than to wait for the turn.”
Managing the healthcare system chaotically
More than 900 people have registered their names for surgery in the urology department of Bir till December 12. Now new patients will get their turn only after that.
Head of the Urology Department Dr Basnet said that due to the chaos in the administrative management of the hospital, patients have to wait for a long time for surgery. Bir currently does urology OPD and surgery three days a week and a kidney transplant one day a week.
According to him, the hospital has to deal with a few problems to make urology services proactive.
First, the number of patients in OPD. According to the Department of Urology, more than a thousand patients visit the OPD, which operates only three days a week. Out of which around 180 need surgery. However, the Urology Department can operate on around 60 people three days a week.
Patients with problems such as kidney stones, prostate, adrenal gland, kidney orifice closure (congenital), ureteral constriction, etc wait their turn for surgery.
Patients who come to the Urology surgery department are divided into three groups— emergency, semi-emergency and general— who are given a turn for surgery. “We prioritise emergency cases including cancer,” Dr Basnet said.
After waiting more than one and a half years for the operation, the hospital administration arranged to perform operations six days a week for urology. According to the statistics, up to 125 operations are done six days a week. This reduced the waiting time for patients up to five months.
But recently, due to the removal of eight nurses and one doctor from the urology operation theatre, only around 45 surgeries are performed three days a week, and the number of beds has decreased from 50 to 22.
According to the doctors, there is also a shortage of the minimum tools required for surgery. Eight years old tools are being used in surgery. When asked to provide new equipment, the hospital administration replied that there was a lack of funds.
Waiting for the turn of surgery leads to health consequences
Not only in Bir Hospital but in the central hospital of the valley, one has to wait a year for non-emergency surgeries.
Children who are referred from all over the country do not get easy services at Kanti Children’s Hospital, Maharajganj. “One has to be in the queue for hours at the OPD and has to wait for seven months for surgery,” said pediatric surgeon Dr Balmukunda Basnet, “Daily 800 patients visit the OPD and 150 patients arrive at an emergency.”
In Kanti Children’s Hospital, surgery is done in six days. However, since only two operating theatres, only 8 to 10 operations can be performed daily according to Dr Basnet.
It is the same in Bir’s Neurosurgery Department. According to the Head of the Department Dr Rajeev Jha, patients suffering from swelling and bursting of brain veins, brain haemorrhage, stroke, head tumours, injuries, and nerve-related problems need immediate surgery. Neurosurgery is performed only four days a week at the hospital.
Recently, when the hospital administration removed the nurses in the neuro department, the number of operations from 125 per month dropped below 80. The 60-bed neurology service has been reduced to 35 beds. Dr Jha said that the condition of most departments is the same. Jha said, “Sometimes there is a situation where you have to wait for three to four weeks even for an immediate operation.”
Having to live with the disease in the body, the patient suffers both physically and mentally. Doctors say that if one has to live with the disease for a long time, it can lead to organ failure or death.
“After years of waiting for their turn, some patients give up and return home saying that they will not be treated,” said Dr Basnet, “Some patients are mentally disturbed and they even believe that the disease is incurable.” Sometimes, even in a simple case, waiting for a long time can have dire consequences. For example, when a kidney stone moves and becomes trapped in the ureter, the kidney itself may already have sustained damage.
Patients were also satisfied when the treatment was provided quickly. However, the government or the hospital administration have no interest in reducing the time to wait for surgeries.
Reducing the pressure of surgery
It is not that this problem cannot be solved. But no work has been done in that direction. According to experts, the patient should go to the local level hospital. If there is no treatment, one should go to the provincial hospital. However, due to the lack of easy, accessible and quality services, citizens distrust district and provincial-level hospitals.
Due to the lack of trust in the lower-level hospitals among the citizens and the ineffectiveness of the referral system, the number of general patients is increasing in the central hospitals.
A study by the urology department of Bir Hospital states that 75 per cent of patients can be treated at the provincial and district levels. But for that, it is necessary to increase skilled manpower and resources in provincial-level hospitals.
According to Dr Basnet, of 60 patients who need surgery, there are only 10 surgeries which need to be done at Bir Hospital. Other remaining cases can be solved at the local level hospitals. “Not everyone who comes to the central hospital needs specialised services. By making the referral system effective, the pressure can be reduced at the central hospitals,” Basnet said, “Even patients with normal urinary burns travel from far away to be seen at the central hospital, and patients who need specialised services are being affected.”
Getting a patient with normal cases to undergo surgery at a specialised hospital takes a long time. “To reduce the pressure on central hospitals, the government should develop a system to provide accessible and quality services to citizens near their homes by expanding services including physical infrastructure, workforce, and equipment, said Former Vice-president of Nepal Medical Association, Dhundiraj Paudel. It has been three decades that health services are running on the same quantity of workforce and infrastructure.
More than 30 per cent of the total population are children. Kanti Children’s Hospital, the only central hospital that treats them, has five pediatric surgeons. According to Dr Basnet, the hospital serves from two operation theatres built by the Japanese government 27 years ago.
“There is no revision on the workforce and the fracture in the hospital and we have been operating on the same infrastructure and human resources for three decades ago,” Dr Basnet asks, “How can only five of us manage when patients from all over Nepal come here?”
The government issued guidelines in 2013 for the establishment, operation, and enhancement of the infrastructure of health institutions. The guidelines specify the number of operation theatres in hospitals and the beds. It is specified in the guidelines that there should be one major and one minor operation theatre with a capacity of 50 beds. Apart from this, it is mentioned that for every 25 surgical beds, one major OT and necessary minor OT should be arranged.
Health Institutions Operation Standard 2020 also says there should be one major operation theatre (OT) and one minor OT for every 25-bed capacity. There should be arrangements for two major OTs in 50-bed hospitals, four in 100-bed hospitals, eight in 200-bed hospitals, 12 in 300-bed hospitals and 20 in 500-bed or more hospitals. However, the guidelines and standards have not been implemented even in the big government hospitals of Kathmandu. “Due to lack of sufficient OT in the hospital, there is a situation where the turn has to be cut even for emergency surgery”, Kanti’s pediatric surgeon Dr Basnet said.
Neurosurgeon Dr Jha also said that to eliminate the queue system at the hospital and wait for months for surgery; government hospitals outside Kathmandu should first be upgraded and the central hospital should also adopt a policy of performing surgeries from 10 am to 4 pm.
The government has not been able to monitor the treatment fees of private hospitals and medical colleges. During any surgery, one pays six times more in medical colleges and 10 times more in private hospitals than in government hospitals.
For example, stone removal surgery can be done in a government hospital for Rs 3,000 to Rs 5,000. It costs Rs 50,000 to Rs 60,000 in a medical college and Rs 80,000 to Rs 100,000 in a private hospital. The difference in fees is similar in other services as well.
Doctors also assert that there is a tendency for surgeons to prioritise surgeries based on undue influence. According to a doctor at Bir Hospital, political leaders, government employees, and hospital staff attempt to expedite surgeries through coercion. He said, “The underprivileged will continue to suffer until the practice of favouring patients based on connections with influential individuals ceases.”
