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Medical Education, 1983, 17, 395-400

A comprehensive scheme of health manpower development for Nepal


H. DIXIT
AND

P. ABEYKOON

The Institute o Medicine, Tribhuvan University, Kaihmandu f

The economy is predominantly agricultural but the rough terrain has limited the countrys arable area to How does a land-locked, mountainous, newly 15% of the total land mass. Over the last 2 decades emergent country produce the manpower to serve the sustained efforts at industrialization have taken place essential health care needs of its population? The and these are showing tangible signs of fruition. absence of a tradition of medical education, a paucity The crude birth rate and death rate are 4.2% and of medical personnel and the major problems of 2.2% respectively resulting in an annual growth rate deployment and communication pose immense chalof 2.2%. The infant mortality rate is 105/1000 live lenges to health manpower producers. The policies, births and three children out of five survive until the plans and programmes of the Government of Nepal age of 5 years. There are approximately 700 medical to develop appropriate levels of manpower and the officers, most of whom have been trained in India, discernible problems and prospects faced by the practising in the country, but the distribution is Institute of Medicine are examined. The institutional limited to the Capital in Kathmandu and a few larger framework that has been established for an ongoing towns in the Terai. The sagged terrain has seriously monitoring and evaluation of the processes and some limited the accessibility of the health workers to the of the successes achieved have been described. people and the latter to the health facilities available. The mainstay of the health care system has been, and Key words: *HEALTH MANPOWER; PRIMARY HEALTH still remains, traditional medicine practitioners who CARE/man; HEALTHOCCUPATIONS/edUC; ALLIED include the ayurvedic practitioners and the sham HEALTH PERSONNEL/edUC; EDUCATION, MEDICAL, CONhealers. Thus health manpower development and TINUING;CAREERMOBILITY; HEALTH PLANNING; health care delivery constitute serious challenges and HEALTH POLICY: NEPAL responsibilities. This article examines the plans, programmes, problems and prospects of this task. The background
Summary

The Kingdom of Nepal is a rectangular land mass of 142,000 square kilometres lying between India on the South and China on the North. The high mountains and hills have imposed major logistical problems of communication and transport. The present population of approximately 15 million people is mainly of Indian and Tibetan origin. While Nepali is the national language there are nearly a dozen different dialects.
Correspondence: Dr H. Dixit, Dean, Institute of Medicine, Tribhuvan University, Kath&andu, Nepal. 0308-0110/83/1100-0395 0 1983 Medical Education

The evolution of health manpower development

The first institution to train basic level health workers in Nepal was founded in 1927 by the Department of Health Services. This instituted training programmes for traditional medicine (Ayurvedic) practitioners on an organized basis. In 1934, the Civil Medical School was opened to train compounders and medical dressers. The latter categories of personnel functioned under the direction of the few medical doctors in the hospitals in the country.

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H . Dixit and P. Abeykoon preventive services, strengthening of the existing curative facilities and the production of middle level workers. The fifth plan (1975-80) had the objective to expand the health services on the basis of social justice. In fact the National Education System Plan in 1971 included an objective of education laid down as to meet the manpower requirements of development through the spread of scientific and technical education. It was a consequence of these policy guidelines that all middle level health manpower training institutions which come under the Ministry of Health were brought under the newly formed Institute of Medicine of the Tribhuvan University. Another key governmental decision made in 1972 regionalization of development applied equally to the health sector as well. Thus the locations and development of the training institutions had to reflect this priority policy directive and at present the Institute of Medicine has at least one Auxiliary Nurse Midwife and Auxiliary Health Worker-since renamed Community Medicine Auxiliary (cMA)-campus in each of the four development regions. Categories of health workers trained by the Institute of Medicine The Institute of Medicine conducts programmes of study for eleven categories of health workers at present (Table 1). The numbers of different categories that have been produced in the country, before and after the establishment of the Institute of Medicine, and the projected outputs of each category of worker are indicated in Table 2. Thus it will be observed that in the next 4 years the Institute has made plans to double the total number that has been produced in the past 10 years of its existence. In conformity with the avowed policy of developing the primary health care services the maximum numbers that will be produced will be in the categories of auxiliary nurse midwife, community medicine auxiliary and health assistant. These three types of workers, it is hoped. would be the pivot around which the primary health care services of Nepal will be organized in the ensuing 2 decades. Continuing education and career advancement One of the cornerstones of the training programmes of the Institute of Medicine is the built-in opportunities for the basic-level health workers to advance to

The major thrust for the development of health manpower in Nepal was evidenced after the heralding of democracy in 1950 and the establishment of a wide range of health care institutions. Thus a nursing school was opened in 1954 with World Health Organization assistance, and a health assistant Training School in 1956. The health assistant, a middle-level worker, after a few years of service in the rural areas of the country, was to be recalled for a period of further study to be upgraded to a fully fledged medical officer. It was perceived by the health care managers that while the health assistant served in the rural areas in a role similar to a medical officer, there was a lacuna with respect to the delivery of the all-important preventive care aspects, particularly in maternal and child health services. Thus the auxiliary health worker (AHW) and the comparable level female health worker-the auxiliary nurse midwife-came into being in 1962. The major landmark in the health manpower production in Nepal was the establishment of the Institute of Medicine under the Tribhuvan University on 16 July 1972. The Institute of Medicine under the Minister of Education was granted the responsibility for the development of all categories of middle and certain basic level health manpower for Nepal. (This fact distinguishes the Institute of Medicine from most of the similar educational institutions in Asia, where exists a duality in the responsibility for health manpower training between the Ministries of Health and Education.) Policies and premises for health manpower production The policies for health manpower production in Nepal have been laid down by His Majestys Government in consonance with the overall plans for socio-economic development of the country. Health sector is thus viewed in terms of its place in the totality of development in the manner in which the two are mutually supportive and synergistic. Nepal, like all member states, subscribes to the World Health Organization policy of primary health care in the context of health for all by the year 2000 (HFA 2000). In Nepals third plan period (1965-70), the emphasis in the health sector was on curative and preventive services, training and miscellaneous services. The fourth plan (1970-75) gave highest priority to

Health manpower for Nepal


TABLE Categories of health workers produced by the Institute of Medicine 1.
Level Basic Middle Category Entry level Duration (years)
2 1

397

8 years school Auxiliary nurse midwife Community medicine auxiliary 10 years school
Health assistant Health laboratory technician Radiography technician Pharmacy assistant Nurse Ayurvedic assistant Intermediate Science (12 years)

1%
2
L

2 3

2%
(After 2-3 years of service as middle-level workers)
2

Higher

Bachelor nurse: Community nursing Midwifery Doctors (M.B. B.S.)

2
4

TABLE Categories of health workers produced before and after establishment 2. of the Institute of Medicine and 5-year projections
Projected output Category of health worker Basic level
CMA/AHW ANM

1972 480 24 I

1972-81

1981-85 680

515
21 1

1105

Certificate level Health assistants and nurses

504

852

(HA-390
N u r s i n g 4 15 )
48 46

1040

Bachelor level Nurses Doctors Retraining of ANM and AHW


-

1578

395 3351

1205

the middle level and then to be higher-level health workers. Thus a basic-level worker after having served as a community medicine auxiliary for 3 years could proceed to become a middle-level health assistant. Those who thus became health assistants, if exceptionally capable and interested, could go on to become community physicians (doctors). In fact, the intake for the community physician programme (doctor) at present is only from the six categories of middle-level workers listed in Table 1. It will therefore be evident that certificate level nurses do have an opportunity to become doctors. One of the reasons for affording this facility was the need to encourage more talented girls to enter the health assistants programme and it has paid palpable dividends. Thus in the years to come, the prospective

gynaecologistsand obstetricians, among other specialist categories, would most likely emerge from this pool of health assistant level nurses. Attempts are now being made to provide the health worker with opportunities for continuing education while they are in service. The rationale for the presently organized stepladder pattern of career advancement must be viewed from another angle. In a country with difficulties in terrain and communication and the attendant difficulties in persuading medical officers to work in the rural and peripheral areas, the present scheme provides some answers. As work in a rural health post for a few years is mandatory before entry into the community physician training programme, it helps to 6ll some of these rural health posts. Equally

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drain of medical personnel to non health fields which offer better rewards, incentives and opportunities of professional advancement. Thirdly, although the manpower requirements of the institute of Medicine have been determined accurately significant numbers of posts yet remain unfilled or unmanned. Some of the other factors which have a serious bearing on this problem include the lack of adequately trained staff, unequal and inadequate opportunities for training and development, constraints in co-ordination and supervision within the faculty, and inadequate incentives and rewards for teachers. The fourth set of problems results from a multiplicity of other factors affecting the educational programmes themselves. While some of these are internal and within a certain degree of control by the Institute the others are external and less amenable to redress by the institute. The key internal factors relate to the absence or inadequacy of teaching /learning facilities including space, learning aids and equipment and library facilities. The lack of awareness of what is available and lack of training in the use of even the available equipment has confounded this problem. At present the clinical and field sites available to the institute for its programmes are being overutilized and newer areas have to be developed. The evaluation system too demands attention to ensure that the trainees develop the competences which are expected of them in their practice. The external factors which have an adverse effect on the teaching/learning programmes include the wide variation of the entering abilities of the students, the difficulties in communication between the health workers and the community due to differences in culture and background, delays in recruiting personnel with specific skills for particular programmes and courses and the geographic separation of the campuses.
The prospects

important is the experience of real conditions and problems in these areas which become apparent to the health assistants so that they are able to visualize the health care needs and the services of Nepal in the proper perspective. We consider this to be a potent educating experience to build up their future. Our initial experience with the community physician programme lends credence to this belief and our expectation is to further strengthen this positive response of the health assistants. Even at the level of the auxiliary nurse midwife, she could undergo an upgrading course to become a senior auxiliary nurse midwife. Similarly courses are being conducted for the baidyas, basic traditional medicine practitioners to upgrade them to the middle-level senior baidyas.
The problems

The systematic approach adopted in the health manpower development process in Nepal has surfaced a number of problems which require attention. While some of these are likely to require certain structural changes and thus likely to take longer to overcome, the others are being attended to on an ongoing basis. The problems that have been identified could be classified into four main categories: (1) policy and planning; (2) manpower distribution and deployment for health services; (3) manpower requirements for teaching; (4)educational programmes. In policy and planning there still exists a number of gaps, partly as a result of manpower planning being in an embryonic stage in the country. The manpower requirements of the Ministry of Health are very varied, and uncertainty exists concerning the requirements both in terms of quantity and quality. Further the manpower policies formulated relate only to the medical and paramedical personnel and thus health care delivery is adversely affected due to inadequate attention being paid to structural development and non-medical manpower production. The second problem area relates to the above but concerns distribution and deployment of the trained manpower. Basically the co-ordination between the Ministry of Health and the Institute of Medicine has not yet developed to the desired extent. The internal brain drain, with the consequent concentration of staff in the urban areas of the country has left many less urban and rural areas unattended. There is also a

The awareness of the above problems and the healthy relationship the Institute of Medicine has been building with the Ministry of Health on the one hand and the health workers and teachers in the different campuses on the other have enabled it to initiate specific activities to alleviate some of these constraints. In the area of policy and planning, the Institute of Medicine and the Ministry of Health in collaboration

Health manpower for Nepal


with the World Health Organization and the United States Agency for International Development conducted the lirst ever workshop exercise on Planning for Health Manpower in 1980. This served as an eyeopener to both sides with regard to the need for close collaboration. The second follow-up exercise was in 1982. Many issues of manpower distribution and deployment also have been attended to since this exercise and an on-going dialogue has been established. The Institute on its own initiative has undertaken the process of staff development on a systematic basis. The main mechanism for this has been the Family Health Project which is being supported by the United Nations Fund for Population Activities and the World Health Organization. Under this project, all the teachers of the Institute are being provided with training in the process of education. A few of the teachers have been sent abroad to different centres of excellence to develop their expertise further in specific areas. The paucity of text-books, particularly in Nepali, for the trainees in the basic and middle levels, is being attended to by the textbook production division of this project. The field training activities of the students will be strengthened by the development of a field practice area around a village health post in Mahankal in the Greater Kathmandu Valley. While it is rather premature to make a precise assessment of these activities, the feedback obtained from the teachers in the campuses has been very encouraging. Thus there is a concerted attempt towards working at different levels, namely, individual development, instructional development, and organizational development. We are cognizant of the inescapable fact that health professions education can never, say should not, operate in splendid isolation from the health care system of the country. Thus our organizational development efforts impress upon our teachers the need to keep in mind their duality of responsibilities and not merely limit their horizons to the academic system in which they operate. We are also aware of the reality that staff and organizational development in ultimate analysis is influenced markedly by another factor over which we do not exercise direct control-the prevailing reward systems. Thus we are taking steps to recognize the functions of teaching as a key element in the reward structure that will be developed. In an effort to minimize the constraints imposed by teaching/learning materials in the campuses the

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Institute of Medicine is negotiating a project with the educational technology division of the World Health Organization. This project while going a long way to ease the present situation will, in addition, strengthen our relationships with the Ministry of Health as learning materials will be developed for the preservice and inservice programmes of all the categories of health workers. The field training programme for the different categories of health workers is being re-examined by a joint committee. The overall aim is to identify the gaps in the present field training activities, develop additional field areas, examine the possibilities for joint field education experiences and to develop the health care team concept. A number of United Nations and voluntary organizations have offered support for this activity. Thus we envisage a situation where a judicious balance will be struck between the hospital-based clinical training and field education.

Conclusions
Most countries, both developed and developing, are experimenting with alternate models of health manpower production and health care delivery. While these efforts in developed countries have been triggered mainly by financial constraints, the developing countries have been influenced also by the need to provide minimum standards of primary health care to all people. Equity of care has been the dominant theme. Viewed from the perspective of a developing country Nepals efforts at developing its health manpower to serve these needs demonstrate potential and hope. The political commitment from the highest levels downwards, the clear policy decisions being made regarding the nature and mechanisms of health care delivery and manpower development, the close ongoing dialogue between the producers and managers of manpower all have enabled the Institute of Medicine to adopt a rational approach to its responsibilities. It has therefore been possible to view the manpower education process from a wide perspective, paying attention to the career development of the health workers and institute a process of systematic staff and organizational development. A significant array of positive results has been achieved so far and the weaknesses which have come to light are being attended to on a continuing basis. The Institute of Medicine feels confident in hand-

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DIXIT, (1981) Health manpower training i Nepal. Journal of the H. n Nepal Medical Association, 19, (I), 174-96. Health Manpower Planning f o r Nepal (1980) Mimeographed, Kathmandu. HIS MAJESTYS GOVERNMENT NEPAL OF (1979) Country Profie of Nepal. Kathmandu. HIS MAJESTYS GOVERNMENT NEPAL OF (1980) Health Manpower Exercise. Mimeographed, Kathmandu. INSTITUTE OF MEDICINE (1982) Report of the Workshop on Profire of the Institute of Medicine. Mimeographed, Kathmandu.

ling the challenging task of meeting the manpower requirements of Nepal.

References
BERKELEY, (1978) Training health workers for primary care in a J.S. developing health service. Medical Education, 12, 209-13.

Received 9 December 1982; accepted for publication 16 March 1983

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