adventures in health care

a sabbatical rest, day 96

We have had coughs for a couple of weeks, not only because we are recovering slowly from colds, but also because of the stifling pollution that has settled over the valley for about 10 days. The Air Quality Index varies day by day from very unhealthy to dangerous. Just under 300 at the US Embassy today.

But Thursday we had a new challenge, as Katie felt she had kidney stones moving. So, we decided to be proactive and find a doctor in case her situation got worse; she has a history of stones too large to pass. Some friends helped us get an appointment at a private hospital, and we were glad the doctor could see us right away. Our friends offered to come and help us through the process. We said we would be alright, but in retrospect, that would have been a good idea.

Our adventure started with that private hospital (hospital 1- $), where Katie had some tests, and we met with a couple of doctors. Details to follow. But Friday we went to a western clinical at a small private hospital (hospital 2-$$$) near the tourist district in Thamel. It was much closer to where we live; in fact, we walked over there, which seemed like a good option for us. And for when we visit here with students again in two years.

The doctor there sent us on to a urologist at another private hospital (hospital 3-$$), that would have the surgical capacity for laser lithotripsy if it becomes necessary. He seemed competent and cautious, things we like in a doctor. If you are keeping track, that’s three hospitals in two days. One very western, two very not.

First the good news. Health care here is relatively cheap by western standards, even though the sign at the first hospital clearly said, “foreigners pay double.” That’s fair. Health care is heavily subsidized by the government, and I’m not paying taxes, other than the VAT built into most transactions. By cheap, I mean Katie got a chest X-ray for her lingering cold, which turned out to be clear. It cost $7 USD. A great investment for some peace of mind.

The bad news? It felt chaotic, but then again I’m not Nepali.

Pay as you go

Let’s start with billing. You pay for every service before you get it. You go to the reception/cashier when you arrive and pay to see the doctor. Then, after you see him/her, you go back to the cashier and pay for any tests he ordered. Then you go for prepaid labs and services with your receipt. Then you wait for the results and then take them back to the doctor. At the first hospital, the urologist also referred us to a pulmonary doctor, and each of them ordered radiological services of some sort, plus lab work. That’s four trips to wait in line at the cashier. And four labs or services to wait in line for. We figure this all out on our own.

We got an ultrasound result right away ($8.50 USD), but we were supposed to come back the next day for the X-ray report and blood work and the following day for the urinalysis. Furthermore, we had no idea how to schedule a follow-up with the doctors or what days they worked. It was a 20-minute taxi ride, and we thought the sampling processes in the lab a little subpar, so Friday we went to plan B, the western clinic recommended by the cross-cultural office at SAU and the US embassy here in Nepal. There we sat in a waiting room while the doctor came to us, and then we paid when we were done. It felt normal, but also more expensive. The urinalysis cost $46 USD, vs $4.60 at Hospital 1. Yes, you read that right; a 100x difference. But some things are worth paying for.

Hospital 3 used the same prepay process, but we only had one appointment and one test, a CT scan. It costs more: the doctor visit was $40 USD vs. $4.30 USD at hospital 1. The CT scan itself was $85 USD. A young English-speaking woman at the reception actually walked us through everything—literally. She even stood in line for us at the cashier while we rested on a bench.

Crowded spaces

Both Nepali hospitals were crowded, with inadequate seating for the crush of people waiting in the offices and labs. They are also organized by Blocks; think Block A, B, C etc. These are essentially different buildings or wings, with clusters of related services or activities. You just have to find them.

Let me describe hospital 1. Imagine a parking lot filled with motorcycles owned by patients and staff. Imagine a road through it and another one along one edge. And imagine then separate buildings spread around it, with crowded waiting rooms where people are standing around because they don’t want to lose their place in line, and every other seat is blocked off for COVID, and then imagine dozens of people crossing back and forth across the parking lot going to different blocks and throw in a few random ambulances and taxis. You have imaged all this, and you have not yet imagined how stressful it was for me to be there in a very different situation while worrying about my wife.

Carry your chart

Did I mention you are responsible for your records? Essentially, you carry your chart, a booklet where the doctor writes his notes and orders and you collect reports and receipts to show you have paid for the services. He also writes any prescriptions in it, which you take to the pharmacy on your way out. As far as I can tell, the doctor never sees any records unless you take them to him/her, although our specialist (hospital 3) came down to radiology after the CT Scan and talked with us while we were waiting for our results. (Remember we are paying double.) He also made an appointment in 2 weeks.

It was good news. No large stones at play. But here are a few observations:

1. We are grateful for the western clinic. The western trained Nepali doctor actually called us with our lab results yesterday. It will clearly be our go-to place with students for minor concerns. It will be our first stop for any challenges we face in the next couple of months.
2. Comfort has its price. We paid more at Hospital 2 and 3, but they were cleaner and less hectic. We are fortunate to have the resources we do, but we would have been well cared for at hospital 1. I think Katie was too sick to feel the stress I felt, trying to figure out how the system worked and navigate our way through it. But on the second day, I was more than willing to pay for order and familiarity.
3. I cannot imagine this experience in a government-run hospital here. The private ones we visited were different (not wrong) from our experience, but they seem to work. They process many people, and the patients seem patient. It’s a system that could be improved, of course. But so could ours. I’m sure people are willing to pay, even though the prices that seem low to us are often a stretch for the average Nepali. We saw families together, and I expect private care is often family financed.
4. There may be a level of care for government employees or wealthy Nepalis that I don’t know anything about. I’m only sharing what we saw and experienced.
5. We found the doctors to be thoughtful and knowledgeable. Despite the crush of people (except at hospital 2), they were attentive and kind and spoke good English. There may have been class and status issues involved, of course. But I’m comfortable being here and am sure we can be well taken care of if the need arises.
   

Thankfully, we are both well this week. It was Easter weekend, which meant we missed a Good Friday service we had hoped to attend. But Sunday things felt more normal, except for the air. We went to church. And Monday we took the day off, one adventure wiser.