KATHMANDU: Every year in Nepal, hundreds of medical students graduate to be doctors. Yet, the citizens of the country continue to succumb to treatable diseases, especially in rural Nepal. Explaining the reason behind this, Kabiraj Khanal, under-secretary at the Human

Resource Development Section, Ministry of Health and Population (MoHP), says, “There is no institutional posting, which means there are no posts for doctors at sub-health posts and health posts, in rural parts of Nepal.” While doctors have postings in Primary Health Care Centres (PHC) and district hospitals, Khanal informs there have been many cases where doctors have ditched their postings from those health facilities to work in the private health sector.

Opting for opportunitiesAs per the 2003 to 2007 Strategic Plan for Human Resources for Health (2003-2007 SPHRH), published by the MoHP in 2003, it is estimated that two per cent of doctors working in the public health sector abandon their posts to become involved with private institutions. Digging a little deeper into the postings also reveals a hierarchal system. Since doctors are first class officers, they fall under the category of ‘specialists’, and according to Khanal, specialists choose not to stay in villages.

Some relief to this dismal scenario is the government’s provision of mandating students who have studied under the state’s scholarship to serve in rural Nepal for two years — at PHCs and district hospitals. However, doctors are accused of malpractices even at this stage. Defending them, Dr Kedar Narsingh KC, immediate past president of Nepal Medical Association (NMA), opines that doctors are not to be blamed for the crunch in human resources and facilities in rural Nepal. “The government postings are insufficient — there are only 995 postings for government doctors — and not even 30 per cent of doctors are posted outside Kathmandu,” he argues. Stating that these postings were planned before 1990, he adds, “It is high time the provision was revisited to create enough posts for

doctors outside the capital.”

Explaining the reason for qualified doctors heading out of the country, Dr KC says, “Firstly, Nepali doctors lack security and secondly, the government has not paid any attention to their personal and professional growth in terms of promotion and education. This fuels their desire to emigrate for better opport-unities.” He further says that the government stipulated salary is extremely low in terms of today’s standards.

Posting predicamentHowever, MoHP is quick to point out that it operates under tight financial constraints, where staff salaries and benefits add up to 76 per cent of the health service budget. “It’s not only doctors, even health workers in gene-ral do not stay in rural Nepal for long,” says Khanal. “It’s their individual choice. If they get better opportunities in urban areas, then they’d naturally opt out of working in rural areas. Do we appoint in terms of individual preferences or the state’s needs?”

Dr Jasmine Tenpa Lama, a medical officer who comp-leted her MBBS from Tianjin Medical University in China, says that she has not worked in rural Nepal, but is not against the idea either. “I chose to work in Kathmandu as I felt a bigger, busier,

technologically advanced hospital could give me better exposure,” she says. “I’m interested to work in rural Nepal, but most experienced consultants are based here. I want to learn and train under them and then use those skills when I work independently,” Dr Lama adds.

While Khanal agrees that there is lack of opportunities and facilities for government doctors who work outside the valley, he insists that the

scenario has changed in the last couple of years. “Local authorities are mobilising local resources and hiring local employees for better

retention,” he says, adding that this initiative to decentralise has been successful in filling the posts of health workers and volunteers, if not doctors. When asked about the incentives that doctors get, he says, “Doctors who work in rural areas are paid more than those posted in the city and as a non-financial incentive, doctors who serve in rural parts for two years will automatically get higher marks in their MD

results. Fresh graduates who are yet to get their MD consider this a great opportunity and head to rural Nepal and serve there for two years.”

Dr KC informs that there are more than 12,000 doctors registered under Nepal Medical Council, out of which more than 52 per cent work outside the country. Among the remaining 48 per cent, 4,000 to 5,000 doctors work in the private sector and out of the 995 doctors in government postings, 200 posts are still vacant. According to 2003-2007 SPHRH, the MoHP has a stronghold in providing primary and secondary health care services. However, there is a general problem of understaffing in all those institutions, part-icularly in rural areas, with some 40 per cent of sanctioned and filled posts without the incumbent in place.

Resisting

roadblocks

According to Dr KC, doctors have to face unnecessary political pressure in district hospitals, whereas private

institutions are free of such hassles. “State run hospitals and health posts should be

devoid of politics if they are to attract more doctors,” he opines. Dr Lama further elaborates, “It is difficult to work when people are constantly accusing you of malpractice, threatening you and stoning the hospital. There is a lack of proper legal system for medical practitioners here. This has frustrated a lot of young doctors, which is why they prefer going abroad.”

There is also the case of ill equipped hospitals and health care centres. “If a doctor refers a case to another hospital — such as from Nepalgunj to Kathmandu — the patient doesn’t get the required services and care during the travelling period due to lack of personnel and equipments, which may lead to a patient’s death. But the unfortunate incident is blamed on the doctors alone,” Dr KC says.

Problems have been identified and solutions have been put forth, but what stops them from being implemented? Khanal says, “The government has already made a blanket policy to upgrade health centres, but the bigger issue is the financial aspect. Developing infrastructure in rural Nepal does not fall under our jurisdiction. We are also dependent on other ministries — Ministry of Finance and Ministry of General Administration — for support.” But even so, the government’s allocated budget for the health sector — 6.74 per cent of the total budget — is in itself extremely low according to World Health Organisation standards.

This past month, MoHP announced that the country will have eight doctors per 100,000 people by 2015 — twice the existing number at present. “There’s no doubt that we need to increase our postings. However, we cannot jump into it because there are various roadblocks such as relocation, change in policies, untimely advertising due to delay in decision making, et cetera,” says Khanal.

NMA and MoHP have already reached an agreement to increase 320 positions of doctors in the first class and second class and to increase 500 medical officers and 75 dentists (Dental Officer BDS) all over Nepal. However, the bigger question is whether the government will be able to get qualified doctors to serve their term in Nepal itself. With the right planning and incentives for doctors, the efforts to build better

infrastructure and facilities can, undoubtedly be a success. For now, Nepalis can only cross their fingers and hope this elaborate plan sees the light of the day.