Professional Documents
Culture Documents
P. ABEYKOON
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 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
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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
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
504
852
(HA-390
N u r s i n g 4 15 )
48 46
1040
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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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
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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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References
BERKELEY, (1978) Training health workers for primary care in a J.S. developing health service. Medical Education, 12, 209-13.