Tentacles of the treatment industryWhat Nepal needs most are more barefoot doctors taking their services to the people's doorsteps.
Janakpur displays the symptomatic extravagance of a settlement that has come into some new money. Most SUVs parked along the main thoroughfares belong either to provincial ministers or mayors of neighbouring municipalities. Motorcycles of political party cadres, many of them masquerading as journalists or NGO-entrepreneurs, fill narrow streets that house exotic eateries serving hot and spicy savouries at all hours of the day. Sweetmeat shops sell mithai mostly made of refined wheat flour. Street-corner stalls that once served betel-leaf preparations make more money these days by dishing out chewing tobacco sachets, sugary cola bottles, fruit-flavoured soft drinks in tetra packs and packets of instant noodles. Tipper trucks ferrying crushed stone, sand, bricks, cement and rebars pass by nonchalant pedestrians at breakneck speed. Vendors that sold assorted grains and vegetables from bamboo baskets have been driven away from the main roads into the backstreets.
Rampant exploitation has pushed groundwater levels downwards. Receding water level has intensified the land subsidence. For some unexplainable reasons, land prices in Janakpur are higher than in Birgunj or Biratnagar. That could be the reason why residential houses rarely leave enough space in the front yard to plant a mango tree or maintain a flower patch. However, the most alarming building practices can be seen in the erection of hospitals of the profit sector in densely-populated downtown Janakpur within Parikrama Sadak.
Once called the rice bowl, the breadbasket, the legume pot and the fruit platter rolled into one, the Bagmati, Rato and Kamala plains are still as fertile as before. But agriculture is no longer as remunerative as it once was due to costlier inputs, stagnant output prices, and lack of investment in upgrading farming technology and irrigation facilities. Since the late 1990s, remittance inflows have helped the region's economy move away from agricultural production to the consumption of consumer staples and essential services. By the early noughties, the so-called "boarding schools" had become a flourishing business even in small villages. However, the demand for consumer goods has now plateaued. Families of remittance receivers have begun to realise that return on investment in educating their children reaches the point of diminishing return after a decade or so of schooling. It makes much more sense to get a passport when a person becomes eligible for the citizenship certificate than spend time and money acquiring higher education.
Savvy investors have discovered an even more lucrative avenue for their money—the so-called healthcare industry. An increase in the number of households that receive remittances and a slight rise in families' income as more members go abroad for work means that a sizeable class has emerged with the wherewithal and the willingness to spend on the health of their women, children and elders. With life expectancy going up and awareness about timely treatment increasing, demand for healthcare is on the rise. The supply side of the industry has responded with alacrity.
Janakpur Cigarette Factory has closed down for good. Once flourishing, the rice mills of the town are all but gone. Even newer maida mills have closed shop. Government service in the formal and the construction industry in the informal sector continue to be the two biggest employers. For third place, there is close competition between the education and healthcare industries, with the latter having less regulatory oversight, higher expansion possibilities, more profitability, better social acceptability and more professional respectability.
Janakpur seems to be in the grip of a hospital building spree. New buildings around Rangbhumi grounds that look like hotels or shopping malls from outside turn out to be for-profit hospitals. Hoteliers are diversifying into hospital businesses. Shutters and shop fronts that once hosted physicians from Kathmandu on weekend trips to their local clinics have begun to upgrade into full-service treatment centres with pathology and radiology services. Until the 1960s, the Ayurvedic Dispensary of Baidya-Ji from Suga village near the Janak Temple was where everybody went for primary healthcare: Consultation was free, and medicines cost a pittance. Dr Jay Ballav Das had brought allopathic medicine to town with his clinic near the railway line in the mills area. He had no fixed fee, and patients were free to offer what they deemed fit; he made a living from his services to the employees of the cigarette factory.
When public service sectors such as banking, education and health were opened up for private investment in the mid-1980s, Janakpur saw its first for-profit hospital euphemistically called a "nursing home". The enormously profitable sickness industry hasn’t looked back ever since. The complex world of treating the sick works at several levels. The government funds and runs primary healthcare centres, district hospitals and provincial referral hospitals. The for-profit private sector has begun to dominate the treatment industry through its network of touts, ambulance drivers and pharmacists in the countryside. No charitable organisation runs a hospital anymore. There are cases of NGOs, civil society organisations and development agencies maintaining healthcare facilities for the poor in several developing countries. They don’t do it here, leaving the field wide open for the inefficiency of the government and the insincerity of the profit sector.
The modus operandi of treatment providers is profit at every level. Pathology, radiology, expert consultations and pharmaceutical products bring in the money. Surgical procedures bring in more moolah. Referrals to bigger hospitals in Kathmandu, India or abroad secure lucrative commissions. The cost of running a hospital is high, but the market is big, and the customer base can further be increased with the addition of training centres for nurses and paramedics. The pandemic showed that for-profit hospitals are of little use in augmenting public health services. Charitable trusts can perhaps fill in the gap, but the concept of corporate social responsibility often means respectable ways of reducing the tax burden.The Madhesh Academy of Health Sciences is still in the embryonic stage. While such an initiative will definitely help improve the quality of health services, what most of Nepal will continue to need in the foreseeable future are more barefoot doctors taking their services to the people's doorsteps. The moment a patient steps out of the house, chances of them falling into the dragnet of the treatment industry go up. The tentacles of the treatment industry badly need some trimming, which can only be done by improving the service delivery capacity of the public sector.