Cooperative clinics revolutionizing primary care in Nepal.

The women’s cooperative clinic in Kathmandu, Nepal, takes up two small rooms in a building on a hill where the city’s brightly-painted, low-rise apartment buildings end and a rolling, green field of small family plots begins. There is a thin lumpy mattress on an examining bed; a small shelf of antibiotics and a tray with contents that seem to have been transported from the 1930s (a tongue compressor, a mercury thermometer and a leather pouch filled with gauze). It may be rudimentary, but the cooperative is part of a revolution in primary care in Nepal. “If I went to the government clinic, I would have to wait five, maybe six hours,” says Purna Maharjan, who has come to the clinic because of dizziness and a headache. A farmer, mother and tailor, Maharjan wears a red floral dress and sports a tika, a smear of red paint on her forehead that is symbolic of the mind’s eye and typically associated with meditation and spiritual enlightenment. She has paid the per visit fee of 25 rupee (about 35 cents) because she views the care as more comprehensive than that offered at government facilities. “Here, I can ask the doctor how I should take the medicine. At a government clinic, you don’t have time to do that.” Indeed, government health care has become renowned for pushing patients out the door, as well as damaged medicines, informal fees and health workers who try to convince patients to visit their private clinics. The chaotic world of Nepalese health care has spawned an array of care delivery mechanisms, including primary health care cooperatives, which first began surfacing in wealthier communities and neighbourhoods. They are slowly spreading to poor communities as it becomes apparent that primary care is a major deficiency of the government system, which is perceived as subpar because of corruption and inadequate funding, says Dr. Tulsi Narayan Shresth, the rotating doctor for six health care cooperatives. International donors “provide money for polio and other vaccinations, but not for basic health care.” To fill the gap, the nongovernmental organization, Public Health Concern Trust, which is partly financed by the Canadian International Development Agency, has facilitated the development of six cooperatives that serve more than 2500 people. The trust provides the rotating doctor as well as technical support to five of the cooperatives. The cooperatives offer patients membership at an annual family fee of $2 to $4 per year, for which they receive clinic services, as well as a 50% discount on fees at the Kathmandu Model Hospital operated by the trust. (Full hospital subsidies are available for the extremely poor.) Alternatively, patients can cough up the per-visit fee.