barriers concerning standards and interoperability

mHealth in Nepal (part II of IV)

This is part two (of four) of mobile health series, which I am sharing after completing an online education on mHealth. For those who would like to read the Part One – its here.
The following are some of the concept we discussed in online class, and google group. I think this is very reasonable to developing countries like Nepal. Most of the barriers are specifically from mHealth Africa, but I have here tried to include my nepali perspective as well. Here are few of the barriers that I think I see in Nepal concerning standards and interoperability on mHealth.
  1. Language – Nepal despite being a small country, has a huge demographic variability. The mountains and hill terrain has made number of spoken language (culture) variation. “Nepali” is the official language, and English (UK) is taught from primary and secondary school. There are about 123 spoken languages (in 125 different community) and many who still do not speak or understand English at all.
  2. (limited) Mobile Technology – Most of the mobile handsets used in Nepal are under NRS.4000 (rough estimate USD=50  Euro=40). These are not Google Android OS phones, but Java based technology with proprietary OS from local market (mostly – China and India). There are about 5-6 different mobile company that have stronghold in budget feature phone in Nepal. The only technology similar (standard) in these feature phones is Java. However, almost all have Facebook (Java Application) installed in them. Facebook being number one Social Network in Nepal (at the moment).
  3. Lack of Government Initiatives – There is no standard Government based protocols regarding mHealth in Nepal. Although, Nepal Government has recently begun a trial phase of mHealth program in few districts; there is no details about this in government websites (This is something I  am considering to write for my first assignment also).
  4. Internet (Availability and Cost) – Internet access through mobile handheld is expensive; and this hasn’t reached throughout Nepal. As with mobile network, the mountainous terrain in most of the country is hampering the WiFi (WiDi, or WiMax, or LTE) rollout from Government and Private Initiatives. There is considerable progress, but more need to be done.
  5. mHealth education – is very new to Nepal. Health providers have very little knowledge about mHealth. Data Mining and Research are at its infancy in Nepali Health Community, very few if any are interested in mHealth (for this purpose) at present. Medical School (Doctors, Nurse, Health Assistant, Health Volunteers) do not have curricula to teach mHealth. Courses that offers technology (mobile or any) teaching is in Public Health related education. This education is concentrated in Data Entry, Evaluation and Analysis, but not in Health Education. I am a recent medical graduate and I had no proper formal education on Medical Technology. Most of the course work was limited to using MS Excel (2003) and SPSS (v11)
  6. Lack of (active) Open Source Community – There is a huge gap in programming education in Nepal, that most are financed/taught by proprietary holdings like Oracle and/or Microsoft. Most of the health initiatives related to technology are in the form of Outsourced Code writing by multinationals.
  7. Technical Infrastructures – present today in various Public and Private Health institute are scattered, rudimentary and closed source. Many hospitals and health care institution have both handwritten documents and e-records. Most of the time, its the physical documents that gets used, and the electronic records are forgotten. Most of the times doctors, nurses (or any other health worker) does not know how to use the electronic record. There is no inter portability between any two health care givers (both e-records or physical records).
  8. Lack of Adherence – Health providers do not seem to adhere to e-health technologies. Partly due to the lack of electricity or lack of proper motivation, or knowledge, electronic recording is seldom done in Nepal.
what can i explore for my next part?
well there are Ncell and NTC. and there network. There is Ministry of Health and its working, plus community members who love mobile. keep watch.

experience at medical (specialist) conference

English: Kathmandu sunrise
English: Kathmandu sunrise (Photo credit: Wikipedia)

I was fortunate enough to be a part of ten volunteers at a conference this past week. This was a specialist conference in medicine, and most of the attendees were prominent Nepali clinicians. I had a good opportunity to see these faces for the first time, and this post is dedicated to these heroes from Nepali Medicine Fraternity. I write names of few who were really impressive, quote few that were good, and mention some that were plain dumb. The conference was held in Kathmandu, for two days.

the good
As I see it, Dr SL (nickname) had the best presentation (also read the disclaimer below). He talked about emergency medicine and critical care management, and it was the most fruitful 20 minutes of learning experience during that 48 hours. Everyone else was mostly mediocre and some simply dumb. The post presentation / oral session discussions were quite good (all expect one related to Vitamin D). Few good questions and some great answers. Few faces came out again and again, with good talks and reasoning. Great learning experience.

Food was “okay” – nothing out of the world, but rather a standard Nepali set (of good looking rice, vegetables, meat and some cakes). Tea break had good tea/coffee, but very bad cookies selection. Lunch was crowded, but dinner was calm. As usual, dinner was served along with alcohol and 40+ doctors joined us (out of no where) during this feast.

the bad
There were ten of us (volunteers) and we did not get any public appreciation. We were junior doctors, working tireless throughout these two days and there was very little or no acknowledgement for us. There were few (three – to be precise – part of organizing committee) personal note of thanks from good people out of the 250 that attended. This, compared to another conference I attended three years prior, is a nightmare when it came to management (cultural and copycat) aspect.

Every speaker somehow had to be presented with a certificate of appreciation after the sessions, and even those who chaired the session got it. Then there were felicitations to some prominent senior doctors (read more than ten senior doctors). Then there were pharmacy company giving out weird appreciation/gift wrapped up. The so called prominent doctors society had very less ingenuity and patient to sit and listen properly. At one time, there were six audience/participants (three were volunteers), the MC was calling out names, and four doctors lined up to receive their post presentation certificates. The hall was empty.

There was virtually no interaction among the me and these senior doctors. This was mostly my fault (read busy). However, this is also due to our culture of not standing along with the senior faculty members and teachers. Asian education (Indian sub-continent) to be precise, has this great barrier among the teachers and student, which was very evident at this conference. Most of the junior doctors had no urge to question the authority and reason with our senior faculties.

we have this absolute anarchic culture; taught in medical school, not to question our teachers and seniors

The result of which makes most of us a little less bold, and we lack confidence. I know, that among the 45 of us, in my medical school, only handful were bold enough to utter wrong stuffs with absolute confidence. I wasn’t one of them, and a little part of me regrets for not being this. We were not to speak unless we were knew absolute concrete knowledge. If we spoke, were ridiculed and smirked upon.

the ugly
The last two years after my graduation has been very much revealing in aspects related to drug companies. I don’t hate them, but I am not comfortable with some marketing gimmick they put up with. They sure know how to suck it up to the doctors fraternity. There were around 20+ stalls of various pharmacy products just outside the hall where the conference was happening. One stroll through this, and I was filling my complementary bag with free pharmacy gifts, brochures, drug trial literatures/papers, posters/pamphlets and sample medicines.

I am uncomfortable with this. But hey !!! couldn’t resist the free stuffs that they were giving out. All my friends were getting it, some even went the second time, and came back with two sets of everything.

On the medicine side, I god ampules clindamycin (anti-biotics). Oral Tablets of PPI (proton-pump inhibitors) the brand name of which i don’t remember (they were not omeprazole or pantoprazole though). I got a month supply tablets of combination drug – Losartan + Amplodipine. This combination drug has something I will write in my next post. There were paracetamol leafs, and some wet-wipes also. Out of the ordinary, I got a key chain, a pen (good one), numerous cheap pens, coffee mug, a calendar, a beer glass, and lots of chocolates.

I took papers/pamphlets from all the available stores representing some 40 drugs. Read them, and found out that only seven of the medicine had mentioned their side-effects and adverse effect on these advertisement. Another thing I am uncomfortable with. It ought to have been written there. Only three pharmacy provided the drug trials (trials done in USA – sadly Nepal is too poor to conduct RCTs).

There was one strange oral tablet for curing hemorrhoids. It had not pharmacological name, and the brand name suggested it to be an ayurvedic medicine. This oral drug also had a small trial conducted in India among 300 patients with 90% cure rate. I am unaware of Ayurvedic medicines, and my knowledge to this is very limited, so I can’t really comment on it. However, this whole thing looked extremity dubious.

other stuffs…
Both of us went (my wife and I). She was the MC, and I was (as she put it) – “volunteer-by-relation”. We did had our friends circle there, and it was definitely an educational (some) and fun filled event. I had my camera, and at times, I’d go out and take pictures here and there (perks of being a volunteer). Some presentations were plain boring, so we (me and friends) would go out and talk, walk, or eat. With few extra passes, we’d also called our friends for dinner and free alcohol. I must thank Dr PP (nickname) for inviting us to this conference (as volunteers). We did not need pay the usual Nrs.2500 participant fee.

my judgement criteria (my perspective for presentations/oral-sessions)
I looked for the following criteria, in all the presentations for my judgement; and even though I was not present in all of the presentations and discussions, I now have the rough idea of who could present. It would be wise to mention that I very much like reading journal paper, and am keenly interested in public health issues, so my judgement – may be biased.

1. Simple English, Short Presentation.
2. Evidence based Medicine (preferentially local – Nepali evidence)
3. Up dated and latest research findings (with landmark research included)
4. Public or Primary Health related component.

Based on this, there were only three presentations that had all four components, five that had at least three of the component. Remaining were not so appreciable. The international faculty members who presented (read – four – from India) were all good. One of them even questioned the standards of Ethical Review Board (ERB) in Nepal. Rude thing to say, but somehow, he was correct and spot on on pointing out mistakes. So like can’t judge that.

in the end..
The weekend was not that bad, but it could have been a lot better. My past experience attending international conferences, tells me we need to do a lot. But, somehow, I am content, to know that, this is evolving and in times, we will get there. Still, there was no need to gift wrap every presenter with a certificate as soon after he/she spoke. Thats just stupid.

disclaimer – Dr PP and Dr SL was a faculty member to the medical school I graduated from, and I (we) have been in more than few of his lectures to highly appreciate them both.

corruption – medical residency in nepal


There are 18 medical college in Nepal, and five more are in paper works. Most have around 60 – 100 students enrollment for MBBS education every year. This is around 60 x 18 = 1080 (taking the minimum numbers) people applying to become a doctor.  MBBS is Bachelor for Medicine and Surgery, compared to English Education, and MD level when compared to American Education. Average tuition fee for this degree is NRS. 2.4 million (1 USD = 87 NRS – March 28, 2013)), with some ranging up to 3.4 million for Nepalese for a five (or six) years of bachelor education. When I got enrolled, my parents payed NRS.1.2 million (it was relatively cheap then). After this we (MBBS graduates) still has to finish the Post Graduate level (Residency) in various specialization subject. The PG seats are rare, of about 300 seats per year.

There are three university level examinations for Residency Seats within Nepal. Government affiliated TUTH (IOM) takes one which is valid for around one year, and applies to TUTH affiliated Medical College (some thing around 7-8 of them). Next is BPKIHS related Residency exams, for its own institution (semi-autonomous government affiliated). The last being exams from KU. My affiliated institution.

what happened?

Kathmandu University (KU) took an Residency Exam on March first week this year (here is the link). Around 400 – 600 of appeared for the various Residency subjects. Not Me. Results were out few days earlier, and quite wonderful that many of my friends got into it. Got into various Residency Seats offered by 7-10 KU affiliated Medical College. There was a written exam (MCQ) and then an interview. List of those who got into were published on KU website (result page) and then were asked to individual Medical College for Admission College. The list is arranged subject wise and then subdivided into individual school where he/she is being selected. There is also a waiting list (the all so important)  for every subject.

AS PER THE KUSMS WEBSITE (here) – its NRs. 2.2 million for Clinical Science based residency and NRs. 1.2 million for Pre-Clinical Science Residency.

Nrs 2.2 million for a three year course in Clinical Medicine Subjects. We pay to practice. We get payed NRs.17,000 per months which sums up to Nrs.0.612 million. So in total – its like we pay a total of Nrs.1.48 to the medical college just to practice our residency. Something that is free in developed world. One reason I haven’t given the exam here, I ain’t got that kind of money (and not asking my parents – again).


where is the corruption?

Once a student is selected by university for residency, he/she goes to the Medical College for admission. This is where the corruption begins, and I have known this for the last three years (you hear rumors, and stories). The 2.1 million NRs, is a fee set by the University (in this case KU) for a maximum allowed fee. This fee gets divided between the University and Medical College. A person now has to talk to Medical College to complete his admission – at which point there are three courses.

  1. THE GOOD and NON Corrupted WAY – After agreeing to pay NRS.2.1 million, he/she goes and gets his/her residency. Works hard for three years, and comes out with a new achievement. The  college is happy, the student is happy, and University has nothing to say.
  2. THE BAD (corrupted) – The College bargains for extra money, or else threatens to call a candidate in waiting list. The bargain price is determined by the subject. The unconfirmed rumor up until last year was like highest for Radiology and Dermatology. The college is happy, but the student ain’t. University has nothing to say.
  3. THE UGLY (corrupted) – The College bargains for extra money and/or keeps the student for three to five years of bonding. Bond by definition is the stipulation by which a new resident must serve under the Medical College for the added amount if time after he/she completes residency. The college is happy, University is happy (good staff addition) but the student is not.

abbreviation – BPKIHS = B.P. Koirala Institute of Health Sciences; IOM = Institute of Medicine; KU = Kathmandu University; KUSMS = Kathmandu University School of Medical Sciences; MBBS = Bachelor of Medicine and Bachelor of Surgery; MCQ = Multiple Choice Questions; TUTH = Trivhuvan University Teaching Hospital.

disclaimer – i have no idea who the person in above Facebook comment is. He might or not be as corrupted as stated in the image above. The image above may or may not reflect the truth. I can be sued or accused of false accusation, and hence I say this post has few fictional component in it too, the detail of which I shall divulge only upon personal inquiry.  Nonetheless, accusatory lawsuits are rare in Nepal. Most of the words here are my personal experience, except the image, which I copied and blurred some text (to hide names)  before posting.