A prominent figure in both public health and medicine, Dr. Bhagawan Koirala has dedicated over three decades to building public institutions and performing as a highly respected cardiac surgeon. Dr. Koirala’s passion for institutional development and healthcare standardisation has established him as a ‘change maker’. He has reformed Nepal’s health system, notably by introducing a code of ethics for healthcare professionals through the Nepal Medical Council. His tireless work, integrity, passion and determination are widely praised across society.
During his long career, Dr. Koirala served as Executive Director of the Shahid Gangalal National Heart Centre, Manmohan Cardiovascular and Transplant Centre and TU Teaching Hospital, where his management skills led to significant turnarounds. As Chairman of Nepal Medical Council, he promoted ethical standards and medical conduct within the health sector. He also served as a Board Director for Civil Service Hospital, and Organ Transplant Centre assisting the senior management team in creating bylaws, legal frameworks, and efficient management and human resources processes.
Currently, as the Pro Bono Chair of KIOCH, he is dedicating his efforts to establishing this unique institution for child health. The HRM Nepal recently interviewed Dr. Koirala to discuss KIOCH and other aspects of Nepal’s healthcare system. Excerpts:
Q: You have played a key role in building institutions in Nepal and Kathmandu Institute of Child Health is your latest contribution. What motivated you to start this initiative?
A: My motivation stems from two extreme personal experiences and another from global experience. First, there’s the tremendous satisfaction and encouragement that comes from helping children, fixing their hearts, and empowering them to dream and succeed in life. Over the last 25 to 30 years, we’ve had countless experiences with children who, once cured, grow up to contribute to society both nationally and globally. We’ve seen them go on to lead institutions and companies. This powerful positive personal experience motivated us to continue and expand on that work.
Second, we also had negative experiences. Nepal is still in the process of developing and strengthening its healthcare system. For 25 years, ever since I completed my training in North America, I have been trying to establish and decentralise cardiac surgery and cardiology in Nepal. I have faced enormous hurdles, obstacles, and difficulties in this endeavour. While we became skilled in one specialty, cardiac surgery, we couldn’t provide holistic care for children with heart problems who also needed other support. This was a major setback and we realised that no single specialty can thrive without providing a child with holistic care. These two extreme experiences convinced us that we had to do something differently.
Globally, children are taken care of in a separate children’s hospital. If an adult expects specialised care when he/she falls ill, why shouldn’t a child have the same right? Although Nepal and other poor countries often declare child health a priority, in reality, this is limited to basic programmes like immunisation, WASH (Water, Sanitation and Hygiene) initiatives, and community-based treatments. It doesn’t extend beyond that. Our efforts should be directed to tackle the newer problems: neonatal issues, prematurity, congenital illnesses and neurodevelopmental disorders.
Q: What kinds of specialised care will KIOCH provide?
A: KIOCH intends to provide holistic care to children with diverse range of illnesses under one roof. The satellites will take care of most common childhood illnesses including critical care and selected specialties. The burden of infectious diseases has decreased, while the prevalence of non-infectious diseases among children, including in Nepal, has risen significantly. While infectious diseases remain a leading cause of death among children, they are now closely rivalled by issues like prematurity, malnutrition, obesity and other problems such as congenital deformities and neurodevelopmental issues. In short, non-communicable diseases are increasingly becoming the primary cause of death in the current era. That is what we want to deal with.
Q: Since there are very few children’s hospitals in the public sector, with only Kanti Children’s Hospital currently available, will KIOCH provide a full range of services for children?
A: KIOCH’s philosophy is to decentralise primary and secondary paediatric care, which means we want to move it outside of the Kathmandu valley and specialise the tertiary care. The goal is to ensure that the most common problems and conditions requiring hospitalisation, including admission to a Neonatal Intensive Care Unit (NICU) or Paediatric Intensive Care Unit (PICU), can be managed at the provincial level. This will prevent patients from having to travel all the way to Kathmandu for care.
Q: One branch of KIOCH has already been established in Damak as part of the vision to decentralise child healthcare, isn’t it?
A: Yes, that’s right. Our motto is to decentralise primary and secondary care outside of Kathmandu, ensuring that most health problems can be managed within their respective provinces. For tertiary care, we believe that specialisation and sub-specialisation are crucial.
Q: With a strong professional background as a cardiac surgeon, what led you to focus on child healthcare?
A: Even if you don’t ask, I’ll tell you why me. I’ve been in this country’s public sector for over 30 years and have helped establish and build multiple new public institutions and help reform existing ones. I genuinely love being with people, rich or poor, left or right, and helping them makes me happy. I together with our group, decided that we should do something that is sustainable, impactful, and of a high standard. When we do something, society also expects it to be at a ‘level’. In our view, no other public project or responsibility would be as impactful and powerful as this child health project.
One more thing that drives me is the opportunity to work with global partners, conduct research, write research grants and mobilise a team here. We never had that opportunity in government institutions because the concept of ‘approved number of staff and positions’ (darbandi) has always been a bottleneck. We are still struggling with this in the Ministry of Health. At KIOCH, we have the opportunity to address this. While funding is always a challenge, there is flexibility to hire people for specific projects, secure grants and collaborate with international universities. In fact, we are already conducting several significant research projects, even before the hospital has started.
We want this institute to cover a wide spectrum of activities, from community service to research, public health, clinical services and basic science. That is the dream. It’s not just about buildings. Obviously, a hospital needs buildings and money but that’s the whole functional purpose we’re aiming for. That’s what keeps us going and encourages us. It’s why we’re so enthusiastic about the future of this project.
Q: Is this children’s hospital a unique initiative in Nepal?
A: Though this idea isn’t unique to the West, it hasn’t been done here before. It may sound too ambitious because it’s a non-profit, and generating money for such a large project is a challenge. I don’t have a solution to tell you exactly how we’ll get the funds for the next project. But when we started, we didn’t have one either. Now, we have one completed and running, and a second one is about to be finished and will be operational next month.
The Kathmandu site is our biggest project, yet, we are close to reaching financial closure for it. Many people share our vision, many trust us, and many are sceptical. People are free to have their own opinions. However, we couldn’t have reached this far without broad community support. The trust from individuals, corporate houses and the government itself makes us feel even more responsible to see this through.\
Q: What is your vision for the capacity of KIOCH being developed in Kathmandu?
A: This will be a 200-bed hospital and it will likely expand beyond that in the future. We are ready to begin operations with 100 beds. The hospital will have a strong focus on sub-specialties but will also include general paediatrics. The idea is that when a child comes to us, the appropriate paediatric sub-specialist will handle the problem, ensuring the highest possible standard of care.
We know this concept has its limitations and challenges. But it’s also true that you can’t run or get anywhere unless you take the first step. We are receiving a lot of support. Initially, we didn’t have a paediatric team but now we are attracting what are likely the best minds in paediatrics. As a cardiac surgeon who has performed thousands of paediatric heart surgeries, I feel empowered to have such a team of paediatric sub-specialists.
Regarding concerns about sustainability, we can offer an example from our own non-profit paediatric hospital in Damak. Within two years, by setting fees at a nominal rate similar to government hospitals, that hospital became self-sustainable and reached its breakeven point. Sustainability is a challenge but I have been part of teams that ran various public institutions that proved to be not only sustainable but profitable. For example, the Shahid Gangalal National Heart Centre is making a healthy profit. The Manmohan Cardiothoracic Vascular and Transplant Centre could also be profitable if few things are corrected.
I believe that if you run institutions well and efficiently, attract a high volume of patients, and get well-off families to pay for private cabins to subsidise care for poorer patients in general beds, it’s doable. Nothing is easy but what motivates me most is the belief that this project can be impactful and sustainable over time, especially with an independent, professional management team free from political interference.
Q: Since child healthcare services like immunisation were previously largely subsidised by the government through donor funds, how do you see this affecting affordability now?
A: The child health programmes in Nepal that are supported by the global community, such as immunisation, WASH and community-based initiatives, will likely continue to receive that support. These programmes are running well. But that’s not enough. Children are going to get sick despite all the preventive measures. So the government needs to invest more on treatment of the children.
KIOCH was established precisely for this reason. We’ve not received large support from bilateral organisations like USAID, so it didn’t matter to us when the programme was shut down. We are mobilising national funds along with some limited international contributions. It’s very important to note that over 80% of the funds for these two children’s hospitals were collected within Nepal.
Q: You mentioned that some of the best paediatric specialists have joined KIOCH. Given Nepal’s ongoing challenge with brain drain, do you foresee difficulties in managing human resources?
A: That’s a challenge we’ll always face. It’s not just a problem in Nepal or other low- and middle-income countries (LMICs); even high-income countries grapple with brain drain. The highest bidder often wins the talent. We’ve seen professionals from Canada and the USA move to Saudi Arabia and other Middle Eastern countries for work. This is a reality we’ll have to deal with for the rest of our lives. But it is a much more acute and significant problem here, including in paediatric care.
That’s why we are focusing on training new people and new paediatricians even before the hospital opens. We need to train people and assemble a core mass of experts who can then train others. We can send people abroad, bring in outside experts, and have them work with our local team. It’s a whole dynamic process of training people. The challenges aren’t limited to doctors; they extend to nursing, paramedics, physiotherapists, speech therapists and more. You face challenges, you fix them, and you move on.
Q: After completing the projects in Kathmandu and Damak, are you planning to expand KIOCH to other locations as well?
A: Of course, that’s the whole idea. The entire purpose was to move paediatric care out of Kathmandu but it’s impossible to support these sites without a central hub. We are doing this not just to work in Kathmandu but also to support these satellite locations. The next likely site would be in Karnali or Sudurpashchim province, most likely Karnali. We’ve been speaking with the provincial governments for land. We can’t afford to buy land and ask for donations to do so. Once we secure it, we can start the long process of designing, fundraising for buildings and equipment, and hiring human resources.
Despite the fact that the government has the authority to mobilise all human resources produced by every university and academy in the country, it has been a challenge to post and retain doctors in remote areas. I believe that if we can successfully mobilise the pool of paediatricians from our Kathmandu project, even on a rotational basis, we could definitely help fill the gap in paediatric expertise at the provincial level.
If you’re asking us why we do this, it’s because we love doing it. My position at this institution is pro-bono chair. I won’t take a single penny from this institute but I will give it everything I possibly can. Our group has experience establishing and running public health institutions, so it’s easier for us to do this. Hopefully, the government will realise that KIOCH is a complementary project, and that it does not compete with Kanti Hospital or anyone else.
Q: After a long career building public institutions, particularly in this field, can you share some reflections on the ups and downs you’ve experienced, the moments of encouragement and frustration?
A: Many people have this misconception that Dr. Koirala is well-off and lives a comfortable lifestyle. I have had the chance to make a lot of money, legally, both here and abroad. But, I chose not to pursue wealth because it doesn’t provide the true feeling of being part of a larger society. Only those who have had that experience can understand this. I can’t do anything for those who haven’t. If I had chosen to continue practicing in the United States, I would have had a physically better life but probably not a fulfilling one. I’m not here to preach anyone; I’m simply doing what I can. Many people are yet to understand the value of being healthy, both physically and mentally as opposed to just being rich.
My family and I made a collective decision: we want to unclutter our lives: our minds, our wealth, and our bodies. That’s the most streamlined way to live. We are flexible and unencumbered. You don’t need a lot of money to enjoy life. And joy comes not only through physical materials. What we do with passion now is also a source of joy for us. It’s all about doing something impactful, something lasting, and leaving a legacy behind.
People are always complaining about everything. Yes, I get frustrated a lot, too. Governance in Nepal is a problem; getting things done here is difficult. There are great bureaucrats but there are also rotten ones. But it is humbling to see that a lot of people are supporting the cause and we are progressing.
Q: Given your success in transforming public institutions like the Gangalal and Manmohan Cardiovascular and Transplant centres, how did your family come to support your decision to continue this work?
A: When I started my profession, I was naive and a little crazy. I didn’t even have a grand vision at first; I just wanted to get a few good things done: practice medicine, with focus on social medicine. I was so consumed with establishing cardiac surgery at Gangalal that I could pay little attention to my family. They would wonder why I was spending so much time there instead of being with them, helping with the kids’ education, or going to my son’s school. My family took time to understand what I was doing. But when they began to see the results and the impact of the work our collective team was doing, they said, “He’s doing something right. Let him do it.”
My parents aren’t highly educated but they understand the value of education and contributing to society; they are 90 and 91 now. My wife is wise, educated very understanding. She has been supporting our cause. And, of course, my son also likes to tag along with his parents. Now, he understands the value of contributing to a larger societal cause. I am so lucky to have this family. I also think it was a process of us educating each other. I’m still learning from them and I believe they’ve also learned from me, particularly with some of the uncomfortable decisions I made at the beginning. Now, after 25 years, they say, “I think you were right.”
Q: How do you view Nepal’s recent successes in healthcare, such as in eye care and organ transplantation, and what policies are needed to standardise and scale up the health system to leverage these achievements?
A: Despite a few areas that are yet to meet global standards, Nepal has achieved significant success in healthcare. Eyecare is a great example; it has been decentralised to the district level, with highly standardised centres. not only in Kathmandu but across various regions. We also have decent organ transplant programmes. While we still need to progress in more complex transplants like liver, lung and heart, kidney transplants have been established at global standards and at an affordable cost. I am proud to have been a part of this process as a founding Board Member of the Organ Transplant Centre, where I helped shape their management concepts and ethical policies.
However, there is still a lot of work to be done to ensure standardised, guideline-based medical practices across the entire nation, not just in a few public or private institutions.
A second aspect of advancing medical care in the country is the ability to attract patients from abroad. Regardless of the term ‘medical tourism’, we should aim to draw more international patients to Nepal. This would not only bring in foreign currency but also help spread the word that Nepal offers decent healthcare services thereby increasing the trust of other tourists also. This is a real possibility. If we can establish a few outstanding institutions, whether public or private, that earn the trust of international patients and institutions, we can leverage this advantage. The government’s policies should be made conducive to this business, with easy fund transfers, medical visas, hassle-free permits for foreign experts, and a welcoming ecosystem that facilitates global partnerships.
Q: Given that a large portion of the population in Nepal still relies on public health institutions, what steps should the government take to ensure they provide efficient services nationwide?
A: I wish our public institutions, including hospitals, were much more efficient. Unfortunately, we have seen a decline in the management competencies and ethical standards of many of these institutions. Managing both public and private institutions is largely a matter of common sense, founded on ethical principles, integrity and commitment. If local leaders are honest and dedicated to solving problems, most issues will be resolved. I don’t mean that hospital managers or business people shouldn’t think about calculations; of course, those things matter and help shape transactions, businesses and expansion plans.
However, for public institutions to be efficient and truly helpful to people, we don’t need a lot of complex calculations. We just have to be honest and committed to helping patients when they come to us, rather than turning a deaf ear and a blind eye to their problems. Sometimes, inefficiencies are artificial. To combat this deliberate dysfunction, strong oversight is needed to curb such malpractices. I believe private healthcare should only flourish on the foundations of ethical and scientific practice grounds. I have always been in favour of ‘fee transparency rules’ for every procedure in hospitals. This would allow people to choose where to go, which would in turn auto-regulate the healthcare sector to some extent. If public institutions work well, the entire healthcare market will become self-regulating.
Q: How will disruptive technologies, such as Artificial Intelligence, shape the future of medicine?
A: Artificial intelligence has already become an integral part of medical practice globally, including in Nepal. All major medical equipment and technologies now use AI to provide solutions to physicians. For example, CT scanners come with AI-supported software, and we also use AI-supported medical record systems.
At KIOCH, we have already started using AI-powered software for our outpatient record system. When we have a conversation with a patient or their family, the software captures the key features of the discussion, makes sense of it, and proposes a diagnosis, coding, filing and a treatment plan. After endorsement by the physician, it becomes an essential part of the healthcare system.
However, it would be risky to rely too heavily on AI without using your own judgement and maintaining ethical medical practices. While AI can suggest important medical information to help medical professionals, it lacks emotional attachment.
Q: Based on what you’ve said, is the biggest challenge for the future of medicine the failure to uphold ethical norms, particularly with the rise of AI?
A: Yes, there must be an equal amount of effort from medical professionals to prevent AI from dominating human intellect, emotions and rationale.
Q: During the COVID-19 pandemic, Nepal managed to contain the spread with minimal loss of life. Was this due to the strength of our healthcare system, divine intervention or something else entirely? What is your assessment of Nepal’s capacity to handle public health emergencies?
A: This is a very interesting topic. When we talk about the public health system, a lot of issues can be resolved with strong management and that’s exactly what happened during the COVID-19 pandemic. The reason so many lives were saved was not because our technology and expertise were at par with European and American standards. We simply didn’t allow the situation to reach its worst-case scenario.
The timely interventions and the collective effort we all made, the role of local governments in tracking, detecting, isolating and quarantining people, along with public awareness about self-care at home, were what truly saved lives. I’m convinced that public awareness and the preventive measures taken by local governments made such a huge difference.
