18 Outreach Centers to Serve Nepal’s Population
A Medical Network Based on the Hub-And-Spoke Approach Ensures Access to Healthcare in Nepal’s Rural Areas.
Michael Radunski | 18-11-2015
Nepal is ranked 145th out of 187 countries on the Human Development Index1 – and in many places, the healthcare system is still rudimentary. Professor Ram Shrestha at Dhulikhel Hospital has built a medical network that could serve as a model for the entire country.
Photos: Walther Appelt
Challenge: Large sections of the population in rural Nepal have no reliable access to medical care.
Solution: With the help of national and international donors, Nepalese surgeon Professor Ram Shrestha built a high-performing hospital near Kathmandu connected to 18 rural outreach centers in a hub-and-spoke model.
Result: The hospital’s network covers a population of two million people; more than 200,000 patients are treated every year. A donation-based fund covers the treatment costs for those in need.
Dhulilkhel Hospital is a not-for-profit hospital located about 30 kilometers east of the capital, Kathmandu toward Tibet. What began in 1996 with just under 30 beds has since developed into a hospital complex with around 20 departments – several disciplines are represented ranging from surgery, internal medicine, and gynecology to pathology, radiology, and even dentistry. The hospital is the teaching hospital for Kathmandu University.
18 Rural Outreach Centers
What makes Dhulikhel Hospital so special, however, is that it is the heart of a widespread medical network. It includes a total of 18 rural outreach centers – small medical facilities that offer basic and emergency care 24 hours a day in remote regions. Specialists from Dhulikhel regularly visit the outreach centers and conduct training courses. The main focus is on healthcare and the treatment of common diseases and illnesses. Diarrhea, for example, can be treated quickly and affordably, and minor operations can be performed locally. In difficult cases, patients are transferred to Dhulikhel Hospital.
The Healthcare System in Nepal
Nepal is one of the world’s 20 poorest countries2 – and in many areas the healthcare system is relatively basic. However, significant progress has been made in the last few decades.
For example, the maternal mortality rate continues to decline, and now 90% of all newborn babies are fully immunized against diphtheria, tetanus, and whooping cough. Still, the high poverty rate, lack of education, and low sanitation standards all have a negative effect on health, particularly in rural areas. In addition to infections, chronic illnesses such as diabetes, cardiovascular diseases, and cancer are an increasingly significant factor in healthcare for the young and growing population of more than 27 million people. There are currently only two doctors for every 10,000 people.3
Nepal’s interim constitution provides free basic healthcare for its citizens, but it does not yet have a national health insurance program. The state healthcare sector includes “primary healthcare centers” at the national, regional, and district levels, as well as smaller “health posts.”4 One focus is on primary care close to home, but there are many deficiencies. For example, there are not enough well-trained doctors, nurses, and midwives, and the replenishment of medications and medical materials is often difficult and challenging in remote mountainous regions. Even today, many patients still seek the help of local healers and shamans.5
In addition, the past few years have seen the emergence of a fast-growing sector of privately managed hospitals and medical practices, which usually provide better care – naturally, at a price. About 60% of all medical services in Nepal are financed by private funds.
200,000 Patients a Year
It may be the law in Nepal that everyone is entitled to free basic care in the public hospitals, but the reality is often quite different. Since there are not enough doctors and hospitals, people often have to travel long distances for care. With a hub-and-spoke model, Professor Ram Shrestha and his colleagues can offer medical care to more people than would be possible with a single well-equipped hospital. Approximately two million people live in the area that Dhulikhel Hospital covers with its rural outreach centers, and the network treats more than 200,000 patients a year.
“Saving lives was our only goal”
One day after the interview and film shooting with Professor Ram Shrestha took place, Nepal was hit by a devastating earthquake. Medical Solutions talked to Professor Ram Shrestha about the new challenges.
The network of medical care under the management of the Dhulikhel Hospital has undertaken the greatest efforts to help thousands of people. Thus, it has proven its functional capabilities under extraordinary circumstances.
What was the situation like after the earthquake?
The most important task right after the earthquake was to ensure that Dhulikhel Hospital was ready to receive the injured. Most of the staff were home and needed to be called back immediately. The medical supplies and the operating theater needed to be ready. This was the first thing in my mind. I immediately headed back to Dhulikhel Hospital. When I arrived, I was pleasantly surprised to see that the staff was already prepared. Our staff showed exemplary dedication and selflessness as they treated the injured. Even during the aftershocks, our surgeons did not stop their work.
What were the most common conditions you had to attend to?
Injuries sustained due to falling objects like beams, bricks, stones etc. Many of the patients had been rescued after being buried under the rubble of their houses, walls or other infrastructure. The majority were trauma and orthopedic cases; arm and leg fractures, spinal injuries, skull fractures, rib fractures, head injuries, as well as bleeding, cuts, wounds.
What role did Dhulikhel Hospital and its outreach centers play in providing healthcare to the people affected by the earthquake?
We provided free medical services to all, immediately after the earthquake. Most of our outreach centers were damaged but the medical service was still provided in tents, under tarpaulins, and even in open spaces. Our team of doctors also went on foot to provide medical treatment to many places in our catchment areas that had been cut off due to landslides and road blockages caused by the earthquake and aftershocks.
Did the network structure of Dhulikhel Hospital and its outreach centers prove to be effective under dire circumstances?
Three of our outreach centers collapsed and others have major to minor damage. The staff at the outreach centers showed a high level of dedication and commitment. They managed to keep the medical services running even in these challenging circumstances. Since many of the outreach centers are in the badly hit region, there was a high number of injured there. Numerous teams of doctors and staff with medical supplies were sent to different outreach centers. So yes, I think we played an important role in caring for the injured in our catchment areas. And also the collaboration with the local volunteers and the government went very well.
Are you back to ‘normal’ working conditions now?
Yes, we are back to ‘normal’ working conditions given the circumstances. We have started rebuilding and restoring our damaged infrastructure. We also have a few earthquake survivors still receiving care in Dhulikhel Hospital. Additionally, we are now also receiving a number of injured who need recuperative care, especially physiotherapy.
What are the most challenging problems?
The repercussions of this earthquake will undoubtedly continue to affect us in the years to come. The general population has shown amazing strength in spite of their losses and are doing what they can to make life bearable for themselves and others. Those left homeless are living in temporary shelters. Rebuilding homes, schools, and public infrastructure is a major challenge. Bringing agricultural production back to normal and preventing the spread of communicable diseases are other challenges. The monsoon, which is causing landslides and floods, is an additional hardship for the people.
In the face of such terrifying reality, hope is sometimes the only lifesaver. Reinforcing this is one thing that we as doctors can do. Having the skill to save someone’s life takes on a whole different meaning under such dire circumstances. I am inspired by the thousands of ‘heroes’ who forgot themselves in selfless service of others. I see a better, brighter future for Nepal chiefly because of our people, who showed such dignity, strength, and kindness in the face of such adversity. I am deeply grateful to the overwhelming support from all levels of the society – national and international – during this catastrophe. We, at Dhulikhel Hospital, Kathmandu University Hospital are now more committed than ever to continuing to provide quality, affordable healthcare for all Nepalese. This has been and will be possible due to the close collaborations with national and international governmental and non-governmental institutions and support from all our friends and partners who have helped us reach where are today.
A Model for Healthcare Delivery
Dhulikhel Hospital combines the idea of equal healthcare for all with the quality standards of private hospitals. If a patient cannot pay for their treatment, it is paid for by a fund financed solely by donations from Namaste Stiftung in Munich, Germany. Dhulikhel Hospital also trains medical students – and thus helps to address the lack of doctors, nurses, and other health professionals in Nepal. Professor Ram Shrestha believes that Dhulikhel Hospital could be a model for healthcare throughout Nepal and South Asia.
About the Author
Michael Radunski has been living in Delhi since 2012 and reports for print and online media from India and other countries in the region. His subjects include politics, economics, and contemporary society. He regularly writes for leading German-language newspapers.
1http://hdr.undp.org/en/data, accessed May 11, 2015
2http://data.worldbank.org/indicator/NY.GNP.PCAP.CD, accessed May 11, 2015
3World Health Organization, Key Country Indicators: http://apps.who.int/gho/data/node.cco.ki-NPL?lang=en; Global Health Observatory Data: http://www.who.int/gho/countries/npl/country_profiles/en; Cooperation Strategy Briefs: http://www.who.int/countryfocus/cooperation_strategy/briefs/en/, all accessed May 11, 2015
4Rai SK, Rai G, Hirai K et al. (2001) The Health System in Nepal – An Introduction. Environ Health Prev Med. 6:1-8
5Karkee R, Jha N (2010) Primary health care development: where is Nepal after 30 years of Alma Ata Declaration? J Nepal Med Assoc. 49:178-84
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