Saturday, March 22, 2014

Nepal: Violence in Nepal’s health system

Photo: Kyle Knight/IRIN. Inside a hospital in Kathmandu

Source: IRIN

KATHMANDU, 21 March 2014 (IRIN) - Regular attacks and harassment of Nepalese health workers are undermining health care in the country, authorities and doctors say.

“Health workers are routinely being threatened or harmed in the workplace and it’s taking a toll on their ability to do their jobs,” Anjali Jha, president of the Nepal Medical Association, told IRIN.

Weak rule of law and insufficient practitioner communication skills underpin a culture of impunity and fuel vigilante responses when care is perceived as insufficient, experts say, leaving doctors who experience, witness, or hear of violence against peers, operating in a climate of fear.

“Last night in the Emergency Room a patient started complaining of random pains after we did a full examination,” Deepak Aryal*, a doctor at Patan Hospital in the Kathmandu Valley, said. “Within minutes there were a dozen men who were unrelated to the patient surrounding us two doctors. They came out of nowhere and started asking us questions - why are you not giving him an IV? Why no CT scan?”

While Aryal has never experienced physical violence at work, he says threats from patient families or groups assumed to be racketeering gangs are a routine part of his job, and other physicians regularly share stories of similar threats turning into violence against them or the hospital facilities.

While such attacks have been specifically outlawed in Nepal since 2010, pervasive impunity since the end of Nepal’s decade-long civil war in 2006 has resulted in weak enforcement of existing laws and little faith in formal mechanisms for resolving disputes.

A 2010 report by The Asia Foundation, entitled Impunity In Nepal: A Study of Excesses in the Transition, construed attacks on doctors as a symptom of post-war impunity, explaining: “When patients at hospitals died owing to the alleged negligence of doctors or hospitals, family members and onlookers stormed hospitals and attacked medics rather than let the law take its course.”

A 2013 survey of 747 healthcare workers in Nepal reported that 23 percent felt insecure at their workplace due to threats or attacks. A 2012 report by Merlin, an international humanitarian organization working on health care, said there had been seven deaths related to doctor-patient disputes and that support from local government officials in conflict resolution was weak.

The NMA, while using incomplete data, recorded 61 incidents of violence or harassment against medical professionals between 2007 and 2012 and claimed not a single perpetrator had been penalized.

According to donor reports, while Nepal’s health budget has increased in recent years, nearly one quarter of the population still lacks access to even basic health care.

A culture of fear

At the same time, patients and their families can also face degrading treatment in health centres, spurred by weak communication skills by staff, commentators say.

“Doctors yelling at patients or even hitting them happened pretty regularly, and not explaining the possible outcomes of a medical procedure was the norm,” a US medical student who just completed a one-year internship at a hospital in the Far West Region of Nepal said on condition of anonymity.

“Nepali doctors have historically been unwilling to listen to patients and explain conditions well,” Saroj Dhital, a surgeon in Kathmandu, confirmed. “This reflects elitism in the medical institution. Patients are expected to never question doctors,” he said.

“Such communication break-downs create a gulf between practitioners and patients, which erupts in its most extreme form in violence,” he noted, adding that some doctors feel compelled to improvise to avoid attack.

“Sometimes when patients arrive in critical condition, we see them handed down to the lowest ranking doctors,” said Sumit Pradhan*, a physician at a government hospital in Kathmandu.

“The young doctor ends up taking the patient, and sometimes just prescribes every test to make a performance - to make it look like with all the tubes and machines and needles that every effort is being made,” he said, adding that families of critical patients sometimes demand guarantees that treatment will cure them.

According to a 2011 op-ed in a Nepali newspaper, some medics went to the opposite extreme. “Doctors now feel their security lies in giving the worst possible diagnosis, i.e. death,” the author wrote, describing her experience with a sick friend at a hospital being told that dehydration was extremely dire.

Care through communication

Attacks and threats against healthcare practitioners, however, also have an adverse effect on community health, experts say.

“Incidents like this can have an insidious multiplier effect - attacks on healthcare providers really are attacks on the broader communities they serve,” said Vincent Iacopino, senior medical adviser at the US-based Physicians for Human Rights, who explained that regardless of whether such attacks happen during war or peace time, they violate the right to health.

A 2014 article in Health Science Journal cited violence against healthcare workers in Nepal as one of the main reasons Nepali doctors and nurses leave the country to seek employment abroad.

*Not a real name