KATHMANDU, Aug. 15: The Urban Health Promotion Center, also known as a first-contact hospital, is operating in Te Bahal of Kathmandu Metropolitan City-27. The facility provides medicines for conditions ranging from hypertension to diabetes, offering 98 types of medicines, as well as laboratory tests, physiotherapy and other services. Despite being located in a densely populated ward, however, the number of people seeking care at the center remains remarkably low. Since the health insurance program was introduced at the center, doctors have increasingly found themselves busy referring patients rather than examining them.
According to Manisha Shrestha, information officer at the Center, much of the staff's time lately has been spent directly referring patients seeking treatment at Bir Hospital. She said around 60 percent of the patients who visit the center each day come only to obtain referrals under the health insurance program.
“Service users ask for referrals directly without undergoing a health examination,” she said.
Previously, the center received 40 to 50 patients a day. Among those who regularly seek services, patients with hypertension and diabetes make up a significant share.
Under basic health services, hospitals are required to provide X-ray, ultrasound, laboratory and pharmacy services, as well as 24-hour emergency care. They can also operate inpatient services with five to 15 beds, depending on need. At the Te Bahal Center, however, X-ray services have yet to come into operation. The center said a shortage of human resources has prevented it from starting the service.
Dr Surendra Budhathoki, a medical officer at the Center, said the low number of service users appears to be linked to several factors: inadequate public awareness about the services, the Center's location in an inner area where it is not easily visible, the absence of expensive diagnostic services and the failure to build public confidence in basic healthcare services.
“The main issue is that citizens do not have much information about basic health services, and many do not trust them either,” he said.
Although the KMC has been providing information about the services, not all citizens have been reached, according to Information Officer Shrestha.
The situation is similar at the Urban Health Promotion Center in KMC-15. Despite being located in a densely populated ward, many residents do not visit the center for healthcare.
Dr Sadish Shahi, a medical officer at the Center, said an average of only 15 to 20 people visit the facility for outpatient services each day. He believes the number of service users remains low because the center does not offer all the services patients seek and many residents are unaware of the services available.
He also said a mismatch between the center's operating hours and the schedules of its target service users has compounded the problem.
“The citizens who are supposed to come here are busy at their offices throughout the day, while our services are also available during the same hours. They cannot come,” he said.
The center also does not provide X-ray services and expensive diagnostic tests that are supposed to be available as part of basic healthcare services. Dr Shahi said a lack of awareness among local residents is another reason for the low number of visitors.
“Only economically disadvantaged citizens come here,” he said. “Even laborers are busy throughout the day and therefore go to clinics in the evening.”
The two basic hospitals are not exceptions. Most of the urban health promotion centers operated by KMC face a similar situation.
The KMC has established urban health promotion centers in all 27 wards. Of these, 10 centers have also introduced the health insurance program. However, many centers lack ultrasound and other advanced diagnostic facilities.
An estimated three million people, including both temporary and permanent residents, live in KMC.
Municipalities without facilities
Dipak Kumar KC, in-charge of the Health Department of KMC, said 280,000 people received services from the urban health promotion centers last year. He acknowledges, however, that the number remains low compared to the city's population.
KC said the KMC has begun a door-to-door health service campaign this year to raise awareness because only a small proportion of local residents are still aware of the services available at the centers.
Although MBBS doctors provide services at all the centers, city residents continue to prefer large hospitals whenever possible, which means public confidence in basic health services remains low, he said.
Health experts say a similar situation exists at many basic hospitals across the country.
Specialized hospitals overwhelmed by patients
Bir Hospital receives an average of 3,500 patients a day for outpatient services. After Tribhuvan University Teaching Hospital (TUTH), Maharajgunj, and Manmohan Memorial Community Hospital stopped providing health insurance services, the number of patients visiting Bir Hospital rose to as many as 5,000 a day.
The hospital currently has 960 beds in operation for inpatient services, although its approved capacity is 775 beds. The facilities include intensive care units, emergency services, cabins and a high-dependency unit.
At the Outpatient Department (OPD) of Patan Academy of Health Sciences (PAHS), an average of 2,500 to 3,000 patients seek services every day. The Emergency Department is also under similar pressure.
Previously, around 1,800 patients visited the hospital's OPD each day. The patient load at PAHS increased after TUTH and Bir Hospital stopped providing health insurance services.
Prakash Chandra Khadka, chief administrator of the PAHS, said the number has also increased because Patan has continued providing services under the health insurance program even after the other two hospitals discontinued it.
Khadka said patients have long been attracted to PAHS because of the quality of its services, which dates back to when it began as a mission hospital.
Around 70 percent of patients visiting the hospital receive services through health insurance. Khadka said the hospital's continued provision of insurance services even during difficult circumstances, its policy of initially treating patients who cannot afford to pay, and its system of allowing families to pay later if they are financially capable while the hospital adjusts the cost when they cannot pay have also contributed to its popularity among patients.
TUTH is also among the hospitals facing a heavy patient load.
The hospital receives an average of 2,500 to 3,000 outpatients every day.
“Patients are supposed to come to a tertiary hospital only when the capacity of local-level facilities is insufficient. But ambulances are being reserved from across the country and patients are brought directly to Teaching Hospital,” said Dr Pawan Raj Acharya, deputy director of the Hospital.
Compared with other days, the patient load is around 1,000 higher on Mondays.
Around 700 patients who visit the outpatient department are admitted to the hospital each day. Of them, around 80 percent require surgery.
As a result, patients have to wait at least three to six months for their turn for non-emergency surgeries. To reduce the waiting time, the hospital has added separate operating theaters for orthopedics and gynecology.
The hospital is also preparing to add five more operating tables next year.
Despite these measures, the patient load remains high because people continue to visit TUTH even for routine surgeries and diagnostic tests, according to Acharya.
“Hernia and gallstone surgeries are available at all provincial hospitals, but the practice of coming directly to Teaching Hospital has increased the crowd,” he said.
Acharya said the Hospital is also looking for new alternatives because its existing infrastructure was designed for the population of Kathmandu four decades ago and is no longer adequate.
Neither efficient services nor public confidence at basic and provincial hospitals
With the objective of providing equitable healthcare, the government has made provisions under the Public Health Service Regulations 2020 for 530 hospitals across the country to provide basic health services, provincial hospitals to provide secondary-level care and specialized hospitals to provide highly specialized services.
According to health service standards, patients are required to first seek care at basic hospitals before accessing specialized hospitals. If the required service is unavailable there, they should be referred to a district or provincial hospital. Only when the required service is unavailable at both levels should patients be referred to a specialized hospital.
Public health experts say people are going directly to specialized hospitals because services at basic and provincial hospitals are not efficient and citizens do not have sufficient information about the services available there.
Adequate human resources, medicines and equipment are essential for hospitals to provide efficient services. Dr Acharya, deputy director of TUTH, says human resources are the most important requirement.
He said there is a shortage of necessary human resources from federal hospitals all the way down to basic health facilities.
He has also observed an increasing tendency to refer serious patients directly to TUTH or Bir Hospital because of attacks on doctors and health workers outside Kathmandu Valley in recent times.
Private hospitals, private medical colleges and even government hospitals outside the Valley have also been making such referrals, according to Acharya.
Health experts say the lack of professional security, combined with the failure of provincial hospitals to build public confidence in the services they provide, is another reason specialized hospitals are overcrowded.
Local governments are required to ensure that basic hospitals have the services, doctors, pharmacies, X-ray and laboratory facilities specified under basic hospital standards, as well as 98 types of free medicines and the necessary human resources.
Local governments can also expand services at basic hospitals according to need.
Mahendra Shrestha, former additional secretary at the Ministry of Health and Food Safety, said basic healthcare provisions also allow hospitals in remote areas to be equipped with inpatient facilities because patients there cannot immediately travel to another health facility when necessary.
He said the inability to build public confidence in basic healthcare services has also contributed to the growing patient load at specialized hospitals.
“Ninety percent of the people who go to specialized hospitals have common illnesses. Because of that, the 10 percent with serious conditions do not get timely access to care,” he said.
Information Officer Shrestha said that after the health insurance program was introduced at basic hospitals, around 70 percent of their work now involves issuing direct referrals.
“Introducing insurance into basic healthcare services has disrupted the system,” she said.
A challenge to quality healthcare
The growing number of ordinary patients at specialized hospitals is making it increasingly difficult to provide quality healthcare, Information Officer Shrestha said.
“While serious patients should receive services quickly, we are also seeing ordinary patients who have come using influence or pressure getting services faster. As a result, treatment of critically ill patients is delayed,” she said.
According to Dr Acharya, deputy director of TUTH, Nepal's existing health workforce is based on an outdated structure and population figures.
He said healthcare services have continued to rely on the same workforce for 30 to 35 years, leaving doctors increasingly vulnerable and prompting many health workers to migrate abroad.
“If the government had increased the sanctioned positions in time, it would have been possible to provide quality services. Only now is the ministry preparing to add more than 800 health workers,” he said.
Acharya believes that strengthening basic and provincial hospitals with adequate human resources, equipment and physical infrastructure would automatically reduce the pressure on specialized hospitals.
He also suggested that strengthening and regularly maintaining the health insurance system could help ensure quality healthcare.
The state should also clearly define the level of curative services it intends to provide, he said. With federal hospitals facing growing patient pressure, Acharya said there is now a need to expand curative services even at basic hospitals.
Doctors say quality healthcare can be ensured and the pressure on specialized hospitals reduced if the government can build public trust in the health services it provides, ensure the safety of health workers, and establish a tiered referral system under which patients are referred only when necessary and according to the level of care required.
