ObjectivesObjectives

Discuss health system of NepalDiscuss health system of Nepal Describe the shifting trend in Describe the shifting trend in

disease patternsdisease patterns Discuss renal transplantation and Discuss renal transplantation and

issues of public health ethics and issues of public health ethics and ‘‘back-doorback-door’’ reality reality

Nepal is known asNepal is known as

Land of brave Land of brave ““Gurkha warrierGurkha warrier””

Land of Himalayas, Land of Himalayas, 8 out of 10 world highest peaks8 out of 10 world highest peaks

Birth Place of Lord Buddha,Birth Place of Lord Buddha,

World Heritage sitesWorld Heritage sites

Nepal At A Nepal At A GlanceGlance

Mount Everest Mount Everest & Buddha& Buddha

Bakhtapur

Kathmandu Valley: Kathmandu Valley: World Heritage World Heritage Sites Sites ( Contd..)( Contd..)

Changunarayan

Basantapur Durbar Square

Kathmandu Valley - Kathmandu Valley - World World Heritage SitesHeritage SitesSwayambhunat

hPatan Durbar Squre

Basic Basic CharacteristicsCharacteristics

NepalNepal Area of 147,181 sq. km Area of 147,181 sq. km Population: Population: 26.5 million (2011)26.5 million (2011) Total fertility rate: 2.6 (2010)Total fertility rate: 2.6 (2010) Infant mortality: 65.3 per 1,000 Infant mortality: 65.3 per 1,000 Life expectancy: 64.6 male/ Life expectancy: 64.6 male/

67.1 female (2010) 67.1 female (2010) Per Capita health expenditures: US-$64 Per Capita health expenditures: US-$64

(Int.)(Int.) GDP per Capita US$ 500 GDP per Capita US$ 500

Ministry of Health

Department of Health Services

Regional Health Directorate - 5

Central Hospitals - 5CENTRALLEVEL

Zonal Hospital - 11

District Public Health Office - 14

District Health Office61

Primary Health Care Centre/Health Centre - 188

Health Post - 698

Sub Health Post - 3,129

FCHV48,307

TBA15,553

PHC ORC Clinic14,769

EPI Outreach Clinic15,833

D I V I S I O N S C E N T R E S

District Hospital62

District health system is integrated – preventive and District health system is integrated – preventive and curative servicescurative services

Nepal Total Death by CauseNepal Total Death by Cause S.No. Particulars Deaths %

1 Coronary Heart Disease 21,152 14.22 Influenza & Pneumonia 18,406 12.43 Stroke 11,119 7.54 Diarrhoeal diseases 7,787 5.25 Tuberculosis 6,330 4.36 Lung Disease 5,973 4.07 Birth Trauma 5,967 4.08 Low Birth Weight 5,584 3.89 Hypertension 5,570 3.8

10 HIV/AIDS 4,796 3.211 Diabetes Mellitus 3,224 2.212 Lung Cancers 3,100 2.113 Maternal Conditions 2,791 1.914 Road Traffic Accidents 2,527 1.715 Violence 2,455 1.7

16 Othe Injuries 2,358 1.59

17 Kidney Disease 2,212 1.49http://www.worldlifeexpectancy.com/country-health-profile/nepal

Patients Increased in Patients Increased in HemodialysisHemodialysis

Kidney Kidney transplantationtransplantation

Treatment Treatment of choice and of choice and preferredpreferred

DialysisDialysis Temporary in Temporary in

End Stage Renal End Stage Renal Diseases Diseases

Kidney TransplantKidney Transplant

Treatment for Kidney Disease Remains Elusive

Treatment for Kidney Disease Remains Elusive

and Unaffordableand Unaffordable

Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir

Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir

HospitalHospital

History on Kidney Transplantation History on Kidney Transplantation in Nepalin Nepal

Three cases – nursing home (private Three cases – nursing home (private hospital) in 1996hospital) in 1996

One case – central govt hospital (Bir One case – central govt hospital (Bir Hospital) in November 2004Hospital) in November 2004

Prior to August 2008, abroad for transplantation mostly to India until TUTH, Nepal started..

Bir Hospital & TUTH

HECAF-Nepal / National Kidney HECAF-Nepal / National Kidney CentreCentre

Study on Kidney Transplant Study on Kidney Transplant Recipient Recipient

A cohort retrospectiveA cohort retrospective Follow up registryFollow up registry June 16, 2003 to July 15, June 16, 2003 to July 15,

2008. 2008. Population 452 Population 452

transplant recipientstransplant recipients

Lawful DonorsLawful Donors

Law of the land defined: the potential Law of the land defined: the potential kidney donorkidney donor’’s can be: s can be:

father, mother, sister, brother, father, mother, sister, brother, husband, wife, son, daughter, uncle, husband, wife, son, daughter, uncle, aunt, sworn friend (Mitajyu), mother-aunt, sworn friend (Mitajyu), mother-in-law and father-in-lawin-law and father-in-law

Type of Hospital and Type of Hospital and CountryCountry

93.75% - 45 different hospitals in India, 71.7% - private hospitals – IndiaOut of 45 - No. of cases 190, 58 and 25

Source of KidneysSource of Kidneys

Unrelated 315 (69.69%), related 134 (29.43%) and undisclosed 4 (0.88%)

EthnicityEthnicity

Age Group of Recipients Age Group of Recipients

AgeAge NumberNumber ≤≤15 years15 years 4 (0.9%)4 (0.9%) 16-3016-30 113 (25.0%) 113 (25.0%) >>

90%90% 31-4531-45 156 (34.5%)156 (34.5%) 46-6046-60 144 (31.9%)144 (31.9%) 61-75 61-75 35 (7.7%)35 (7.7%)

Male to female ratio of 3:1.

Benefit of Kidney Transplantation….. …Back to Work (contd…..)

Croatian vs Poland Croatian vs Poland

Final Euro Cup 2008Final Euro Cup 2008 played and won by 28 Yrs old Striker played and won by 28 Yrs old Striker Ivan Klasnic after 2Ivan Klasnic after 2ndnd Renal Tx Renal Tx

Benefit of Kidney Transplantation….. …Back to Work

Donor Lisa George Danhw Recipient: Dan Donor Lisa George Danhw Recipient: Dan GeorgesGeorgesRelationship to donor: Spouse Date of Relationship to donor: Spouse Date of donation: May 24, 2002donation: May 24, 2002

Your gift has given me a new outlook on life, our family, and our marriage. I thank God every day for you and our children, David and Alexandra. My life is not complete without you. And now that you're truly a part of me, physically, I know I cannot be complete without you. I love you, >Dan

http://www.livingdonorsonline.org/halloffame.htm

Who Got His Kidney?Who Got His Kidney?

Selling kidneys for a few rupees more

Kidney Stealing From Kidney Stealing From PoorPoor

http://www.canada.com/story.html?id=7a0f0f8a-daac-45f2-91c6-c4a3090d1e0d

http://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-http://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-46735.html46735.html

Ex-student Leader Among 8 Held Ex-student Leader Among 8 Held for Kidney Trade for Kidney Trade

BANEPA, May 14: Police have arrested eight persons including a former vice-president of Free Student Union of Patan Campus on the charge of their involvement in kidney trade.

A special team of police dispatched from Kathmandu arrested the eight individuals from different parts of the country within a period of one month and paraded them before the media at Dhulikhel on Tuesday.

The arrested have been identified as Puja Dahal aka Puna Thakuri and …………………….

Among the arrested, Sachin Maharjan was reportedly a former vice-president of the Free Students Union at Patan Campus.

Published on 2013-05-14 http://myrepublica.com/portal/index.php/twb/?action=news_details&news_id=54697

ConcernConcern

In some families there are four to five In some families there are four to five members who have sold their kidneys.members who have sold their kidneys.

Kidney seller do not know who got Kidney seller do not know who got his/her kidney?his/her kidney?

The Nepali Kidney Bank The Nepali Kidney Bank by by Sunil NeupaneSunil Neupane           http://www.asiacalling.org/en/news/nepal/2010-the-nepali-kid

ney-bank Saturday, 14 May Saturday, 14 May

2011 18:162011 18:16

The Village of Stolen KidneysThe Village of Stolen Kidneyshttp://www.youtube.com/watch?v=EE6cdPTkD5khttp://www.youtube.com/watch?v=EE6cdPTkD5k

MessageMessage

Tribhuvan University Teaching Tribhuvan University Teaching Hospital and Bir Hospital provide Hospital and Bir Hospital provide kidney transplantation kidney transplantation

Rigorously selected lawful cases only Rigorously selected lawful cases only

Results presented are based on the Results presented are based on the data on kidney transplantation done data on kidney transplantation done abroad, mostly in Indiaabroad, mostly in India

Where Are We?Where Are We?

What is individuals professionalWhat is individuals professional’’s s role? role?

Whether live donor is lawful Whether live donor is lawful volunteervolunteer

or or poverty driven, misinformed, poverty driven, misinformed,

forcefully mediatedforcefully mediated

Disrupting Ethical Issues Disrupting Ethical Issues Renal care team members (Nurse, Nephrologist, Renal care team members (Nurse, Nephrologist,

Radiologist/Sonologists, Pathologists etc.) participation Radiologist/Sonologists, Pathologists etc.) participation in the process of living donor screening and approval in the process of living donor screening and approval

Policy of homelandPolicy of homeland Initial Screening Process: Donor health and psychosocial historyInitial Screening Process: Donor health and psychosocial history Indication / contra-indicationIndication / contra-indication

http://www.youtube.com/watch?v=m96_v5b0Mws

ConclusionConclusion

Entire enterprise of transplantation is Entire enterprise of transplantation is vulnerablevulnerable

Protect ignorant and poor kidney Protect ignorant and poor kidney sellerseller

Protect health care workers (renal) Protect health care workers (renal) by implementing an appropriate / by implementing an appropriate / robust guidelines robust guidelines