Towards meeting health care challenges of rural Nepal:

The PAHS approach

Arjun KarkiPatan Academy of Health Sciences (PAHS)

6th July 2010Nyaya Health

BOSTON

It is not a new story

Everything has been said before, but since nobody listens we have to keep going back and begin all over again.

- Andre Gide

Nobel Laurate (1891)

National Health Policy (1991)National Health Policy (1991)

To extend primary health care system to the To extend primary health care system to the rural populationrural population so that they benefit from so that they benefit from modern medical facilities and trained health modern medical facilities and trained health care providerscare providers

SLTHP (1997-2017) ObjectivesSLTHP (1997-2017) Objectives

• To To improveimprove the health status the health status of most of most vulnerable vulnerable populationpopulation (women, children, rural, poor, (women, children, rural, poor, underprivileged / marginalized)underprivileged / marginalized)

• ToToprovideprovide the appropriate numbers, distributions the appropriate numbers, distributions and types of and types of technically competent and socially technically competent and socially responsiblehealth personnelresponsiblehealth personnel for quality health care for quality health care throughout the country, particularly in the throughout the country, particularly in the underserved areas underserved areas

Building a New Nepal – a national agenda

Millennium Development Goals

• Eradicate extreme poverty & hunger

• Achieve universal primary education

• Promote gender equality & empower women

• Reduce child mortality

• Improve maternal health

• Combat HIV, malaria & other diseases

• Ensure environmental sustainability

• Develop global partnership for development

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Accessibility of services by poverty quintiles

0 10 20 30 40 50 60 70 80 90

Poorest Second Third Fourth Richest Poverty quintiles

Perc

enta

ge </= 30 mins

30 mins- 1 hr 1-2 hrs 2-3 hrs 3 hrs or more

Nepal context service accessibility by the poverty quintiles

Source: NLSS- II, CBS

Current realities ….Current realities ….Regional differences (NHDS, 2001)Regional differences (NHDS, 2001)

Place of Place of ResidenceResidence

Infant MortalityInfant Mortality Under 5 MortalityUnder 5 Mortality

UrbanUrban 6060 9494Rural Rural 100100 147147

MountainsMountains 132132 201201HillsHills 8585 131131

TeraiTerai 104104 147147

Human resources for health“Manpower is the cornerstone of any health system and unless manpower development patterns are appropriate to people’s health needs and social circumstances, countries will never be able to achieve a level of health that will allow their people to lead socially and economically productive lives”

– H. Mahler

Former DG, WHO

Health Manpower Production: Current national capacity

1978 – 1993

Medical School (1) : 42 doctors annually

2007

Medical Schools (14) : 1175 Physicians (MBBS)(240 Scholarship)

Dental Schools (4) : 150 Dentists (BDS)(40 Scholarship)

Study at Manipal College of Medical Sciences, Pokhara, Nepal (taken from the ad @ www.nepalnews.com)

• Affiliated to Kathmandu University, MCOMS is recognised globally and offers world-class Medical Education through its renowned faculty, exceptional curriculum and teaching methods. MCOMS also provides a rich multi-culture experience with students from South Asia, Middle East, Australia, Africa and North America.

• More than 45% of MCOMS graduates are successfully practicing in USA, Canada, UK, Australia, South Africa, Singapore, Sri Lanka, Bangladesh, Maldives and the Middle East. Listed in the 7th edition of the WHO’s directory of accredited medical schools.

• Accredited by the New York Medical Board & California Medical Board. Also recognised by Medical Councils of Nepal, Sri Lanka, Bangladesh and Mauritius. A 38-acre, self-contained campus with hostels and an 865-bed teaching hospital.

• Faculty with proven expertise, experience and credentials.Prepares you to clear Medical licensing exams of any country in the world, including the USMLE, PLAB, ERPM and MCI screening test.

• There is no entrance Examination. Medium of instruction is English

Quality health care inaccessible for rural Quality health care inaccessible for rural population population

- Only 19 % of deliveries attended by - Only 19 % of deliveries attended by

trained health care workerstrained health care workers

- Doctor : Population Ratio- Doctor : Population Ratio

1 : 8501 : 850 Kathmandu (Korea 1 : 636)Kathmandu (Korea 1 : 636)

1 : 30, 000 1 : 30, 000 Hills Hills

1 : > 100, 000 1 : > 100, 000 MountainsMountains

What should we do ?

Do not accept injustice in any form

Make injustice visible

Be prepared to die for it

– Mahatma Gandhi

We believe . . .

1. Institutions like PAHS have the capacity for and responsibility to improve the health of the Nepali people, especially rural poor

2. They must show the willingness and commitment to achieve that goal through Education, Patient Care & Research

Social Accountability of Medical Schools

• The obligation of medical schools to direct their education, research and service activities towards addressing the priority health concerns of the community, regions and / or the nation that they have the mandate to serve.

• The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.

- WHO, 1995

MSSC Members …

PAHS Mission StatementDedicated to sustained improvement of the health of the people in Nepal, especially those who are poor and living in rural areas, through

innovationequityexcellence and love in

educationservice and research.

Good Doctor(generic)

Knowledge

Problem-solver,Conceptual thinker,

Ability to apply knowledgeappropriately

Technical competence,Psychomotor skills

Team worker

Organisation andadministrative skills,conscientious, reliable

Capacity toempathise

Communication skills(approachable, listens,uses appropriate language)

Ethical,high integrity

Calm under pressure,Copes well with stress

Life-long learner,maintained interest

Good decision making skills

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Process Personality Interests KnowledgePPIK theory:

We can not solve problems by using the same kind of thinking we used when we created them

- Einstein (1879 – 1955)

Addressing rural-urban divide :i) Innovative medical education

• Careful student selection (Rural, Paramedics)

• Provision of scholarship / mandatory rural service

• Innovative / appropriate curriculum

• Effective pedagogic methodology

• Early / adequate exposure to real world

• Necessary infrastructure / resources

• Committed faculty

• Enlightened / Visionary leadership

• Inter / national collaboration

International Partners & Collaboration• Harvard University (USA)• State University of New York (USA)• Texas Tech. University HSC (USA)• University of British Columbia (Canada)• University of Calgary (Canada)• University of Alberta (Canada)• McMaster University (Canada)• University of Oslo (Norway)• University of East Anglia (UK)• University of Catania (Italy)• University of Sydney (Australia)• University of Newcastle (Australia)• Ben Gurion University (Israel)• University of Geneva (Switzerland)• Maastricht University (The Netherlands)

Summary of PAHS Development

• Medical School SC formed on 2060-07-27 (13-11-2003)• PHB endorsed PUHS proposal 2060-11-26 (09-03-2004)• Feasibility studies completed 2062-03-22 (06-07-2005)• PUHS Project Committee on 2063-10-26 (09-02-2007) • Formal request to MOHP 2063-11-15 (27-02-2007)• Follow up request 2064-02-15 (29-05-2007)• Cabinet OK PAHS Proposal 2064-05-04 (21-08-2007)• Parliament passed PAHS Act 2064-10-23 (06-02-2008) • Appointed Vice Chancellor 2065-04-06 (21-07-2008)• Rector / Registrar appointed 2066-06-06 (22-09-2009)• Dean / Director appointed 2066-06-08 (24-09-2009)• First PAHS senate meeting 2066-08-25 (10-12-2009)• Student admission process 2066-11-13 (March 2010)

The Evolution of Modern Medicine

Medicine arose out of the primal sympathy of man with man, out of desire to help those on sorrow, need, and sickness.

- Sir William Osler

The Evolution of Modern Medicine

If medicine is to fulfill her greatest task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society ?

- Rudolf Virchow

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Namaste and Thanks very much