Abandoned health facilities, mistakes in administering medicine and patients travelling abroad for healthcare are just some of the issues Nepal is facing due to a chronic shortage of health workers. A new report by the medical charity Merlin and Nepali NGO Society for Local Integrated Development (SOLID) shows that the most remote communities are the worst affected and calls for a radical rethink of health worker training and distribution.
Chronic poverty and a civil war which lasted for ten years have contributed to a ratio of only 2.9 public health workers per 10,000 people. The public and private sector combined has a ratio of 16 health workers per 10,000 population, but this still falls below the 23 per 10,000 set out by the World Health Organisation as the minimum for meeting health Millennium Development Goals (MDGs).
Nepal is one of the poorest countries in the world, currently ranking 157th out of 187 countries on the UN’s Human Development Index. Although the end of its civil war has seen health improve significantly, many indicators remain alarmingly high. Nearly half (47%) of children under five are stunted as a result of malnutrition, there are 170 maternal deaths for every 100,000 live births (compared to 12 in the UK) and less than 29% of all births are attended by a skilled medical professional.
Linda Doull, Merlin’s Director for Health and Policy said that: “Having an adequate number of skilled health workers is the first step in providing quality health care, but we also need to think about how these staff are distributed, the quality of their training, working conditions and how they are managed. In Nepal, investment in these areas is the most critical change which needs to be made in order to continue to make progress towards health MDGs.”
The need to earn a second income means that 45% of the 747 health workers interviewed by Merlin and SOLID also have jobs at private pharmacies or clinics. This often means that duties at government facilities are neglected. One health worker from Mugu district said: “The in-charge of the health centre is busy with his own private clinic so most of the time it is closed and people are not able to get the service, which is their right.”
Doctors were available in only 36.4% of health facilities with government-sponsored posts at the time of the survey. Public health facilities are frequently reported to be open for limited hours and in some cases permanently closed.
Even when staff are present, their ability to deliver medical care is limited by a lack of adequate drugs and equipment. Moreover, training is seldom updated to reflect policy changes and the outbreak of new diseases. For example, although the prevalence of non-communicable diseases is rising and now accounts for over 80% of outpatient and inpatient visits, only 17.4% of health workers have been trained to treat them. The number of government sanctioned health positions is based on the 1991 Health Policy, despite a population increase of 45% since then. Of these already limited official positions, more than 14% remain vacant.
Understaffing often leads to health workers undertaking duties beyond their level of training. Female community health volunteers – the backbone of the public health system in rural areas – felt the training they received was poor but are given new responsibilities on a regular basis: “We have to work in a complicated sector with pregnant women and children, but work with very little knowledge. Sometimes, we fear that we might give out the wrong medicine.”
High tuition fees in private medical schools (which account for 90% of academic institutions) deter graduates from working in rural areas. However, this is where the need is greatest – 81% of Nepal’s population live in rural areas, and the number of children dying before their fifth birthday is nearly twice as high as in urban areas (with 83 and 47 deaths per 1,000 live births respectively).
Furthermore, there are fewer private practice opportunities for health workers in rural areas, in addition to poor infrastructure and educational, employment and recreational opportunities for their families. Shortages are more serious in Nepal’s mountainous districts, where the higher wages for working in remote areas do not match the higher costs of living. In the most remote areas the only means of transportation for both people and goods is by air.
Although government-sponsored medical students are now required to work for two years in rural areas, Merlin and SOLID found that this is only a short-term solution as there is little to keep doctors in rural areas after these placements.
As a result, Mountain and Hill belt communities rely largely on unpaid female community health volunteers or traditional healers – and those who can seek medical care outside of the country. A resident of Darchula said “The hospital has provision of maternal and neonatal health services, a birthing centre, ambulance service and cooperative health workers. However, doctors are not always available and for complicated illnesses people go to the bordering Indian town for treatment."
Merlin’s Country Director for Nepal, Catherine Whybrow, said: “Despite huge gains in many health indicators, Nepal’s health care system will not be able to reach those who need it the most without the health workers who form its backbone. The research findings confirm that Merlin should enhance our support to the Nepalese Ministry of Health and Population to advocate for policy change and provide better training, monitoring and recognition for health workers.”
Notes to editors
Merlin (www.merlin.org.uk) is an international health charity, saving lives in the world’s toughest places. Merlin responds with healthcare when people are overwhelmed by natural disaster, conflict or disease. After the immediate crisis, Merlin stays on to assist recovery –building resilience so that those at risk of future health disasters are better prepared. Merlin is a force for health.
Merlin has worked in Nepal since 2007 in Pyuthan and Rolpa Districts, training female community health volunteers in remote villages and helping hospitals in Kathmandu to prepare for earthquakes and other natural disasters. We are currently working across Nepal to improve the number and quality of health workers, conducting detailed needs assessments and using this to call for policy change.
The report Barriers to Effective Policy Implementation and Management of Human Resources for Health in Nepal is the result of research conducted in 15 districts across Nepal by Merlin in partnership with Nepali NGO Society for Local Integrated Development (SOLID), including interviews 747 health workers from 375 health institutions. Funding was provided by the European Union and Ladham Trust.
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