Nepal is a wonderful, beautiful, wild, and poverty-stricken landlocked country.
It is located between China to the north and India to the south. Years of civil war and political upheaval have contributed to stagnation of growth and development in Nepal, in contrast to its dynamic neighbors. It is the 22nd poorest country in the world, according to the IMF, with GDP per capita of $1,300 in comparison to Canada’s $40,300 (2011 estimates). The literacy rate is 68%, and the average life expectancy is 58 years for men and 57 for women.
Many aspects of health care in Nepal are unfavorable:
- There are only 0.21 physicians/1,000, about a tenth the rate in Canada.
- There is no publicly-funded health care and little access to affordable health insurance.
- Organised trauma care is in its infancy.
- Rehabilitation has only recently become part of the health system, and rehabilitation services are not available to most people.
- The mortality rate from spinal cord injury is high.
Nevertheless, Nepal has made progress:
- The proportion of people earning less than US$1.25 per day declined from 53.1 to 24.8 percent between 2003/04 and 2010/11.
- Net primary school enrollment increased from 81 to 94.5 percent between 2002 and 2010
- The Maternal Mortality Rate declined from 538 to 280 per 100,000 live births between 1996 and 2011
- The Infant Mortality Rate dropped from 162 per 100 live births to 39 between 1990 and 2010, and at least one-third of deliveries are now in the presence of trained health workers.
- Full immunization coverage rose from 43 percent in 1996 to 87 percent in 2011.
What progress has been made for patients with new SCI who need specialised care?
- The availability and affordabilty of spine surgery has improved but remains limited. Spine and spinal cord surgery is not yet established as a specialty and training is not available in Nepal. Spine surgery is still done in general hospitals by general orthopaedic and neurosurgeons rather than specialty units which have been shown to offer better results.
- The opening of the Spinal Injury Rehabilitation Centre (SIRC) has made specialized rehabilitation available, but services do not reach into the community.
- A nascent spinal cord network exists, but requires much more work.
- SIRC has developed effective external links, however, there have been until now no trained spinal rehabilitation doctors.
What is a spinal injury system?
All spinal injury centres (SICs) function to a greater or lesser extent within a “System” which includes various necessary components supporting an overall care path: the acute hospital, the rehab hospital, discharge and follow up options, and patient advocacy organizations including sports. Specialized training is necessary to care properly for people with injuries of the spine and spinal column. Such training includes spinal surgical fellowship training, SCI-specific rehabilitation medicine and special skill-sets for nursing and physical therapy. Efficient team function and dynamic medical leadership is critical. Last but not least another necessary component is a data monitoring system and a prevention program.
Nepal has developed a number of areas of strength – for example, the emerging spine care in the acute hospitals in the Kathmandu region. Until now, the traditional neurosurgical/orthopedic separation has governed but it is expected that these can work together well given a supporting climate of opinion. (These include among others Bir Hospital, Tribhuvan University Teaching Hospital, Nepal Orthopedic Hospital, Patan Hospital, Kathmandu Model Hospital). The Association of Spinal Surgeons of Nepal was formed in 2012 and can be found here .
Spinal cord injury care is provided elsewhere in the country at the Green Pastures hospital in Pokhara, which collaborates well with SIRC and rehabilitates a substantial proportion of patients with SCI, and the hospital in Tansen. However, no overall funding system yet exists to pay for needed medical services, which are supported by the hospitals and their NGOs. Financial support for training, continuing medical education and peer support systems should be part of the funding structure.