Nepal’s Healthcare Workforce: Status, Challenges, Trends, and Future Prospects

A robust and well-functioning healthcare system is the bedrock of a healthy society. At its core is a skilled, motivated, and equitably distributed healthcare workforce. For a nation like Nepal, striving towards Universal Health Coverage (UHC), understanding the intricacies of this workforce is paramount. PHC-Nepal (www.phcnepal.com) serves as a dedicated platform for exploring and promoting primary healthcare in Nepal. This blog post aims to contribute to this mission. It provides a comprehensive analysis of the current state of Nepal’s healthcare workforce. It delves into its composition and the significant challenges it faces. The blog post also examines the policies and strategies shaping its trajectory. Finally, it highlights the crucial role this workforce plays in the nation’s health.

The Current Landscape of Nepal’s Healthcare Workforce

Nepal’s healthcare needs are addressed by a diverse group of professionals, each playing a vital role in the continuum of care. This includes medical doctors, encompassing both specialists and general practitioners, who are essential for diagnosis, treatment, and overall medical management.¹ Nurses and midwives form another critical segment, providing essential care in hospitals, clinics, and within communities, particularly focusing on maternal and child health.¹ Dentists are crucial for addressing oral health issues, which are often overlooked but significantly impact overall well-being.¹ Community Health Workers (CHWs), especially the dedicated Female Community Health Volunteers (FCHVs), stand as the frontline of primary care, particularly in rural and remote regions, providing crucial health information and basic services at the grassroots level.² Paramedics and allied health professionals, such as laboratory technicians and pharmacists, provide essential diagnostic and support services that underpin the entire healthcare delivery system.¹

Examining the distribution of these vital human resources reveals a significant disparity. National statistics from 2011 to 2019 indicated a doctor density of 8.1 per 10,000 population, which slightly increased to 8.67 per 10,000 in 2021.¹ The density of midwifery and nursing professionals was notably lower at 3.3 per 10,000 during 2010-2019, while dentists stood at 1.1 per 10,000 in the same period.¹ However, these national averages mask the stark inequalities between urban and rural areas. Kathmandu Valley, for instance, boasts a doctor-to-population ratio that surpasses the World Health Organization’s recommendation, with approximately 0.9 physicians per 1,000 people (9 per 10,000) and even stands at 1:833 as of May 2024. This contrasts sharply with the situation in many rural parts of Nepal, where access to medical professionals is severely limited.² A 2024 study in the Journal of Global Health Reports indicated that medical officers are concentrated in the hill region (60%), followed by the terai region (45.8%), with only 27% in the mountain region, highlighting the challenge of equitable access [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities]. In 2021, Nepal had approximately 43.89 health personnel per 10,000 people, approaching the WHO’s recommended 45 per 10,000 for adequate healthcare coverage [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].

Over the past two decades, Nepal has witnessed notable shifts in its healthcare workforce. The density of medical doctors per 10,000 population saw a significant upward trend from 2004 to 2017, increasing from 2.07 to a peak of 8.92.¹ While this indicates progress in producing medical graduates, the trend fluctuated between 2017 and 2021, settling at 8.67, suggesting that other factors are influencing the overall availability of doctors within the country.¹ Indeed, Nepal’s medical institutions annually train over 2000 to 2500 doctors.¹ However, the modest increase in the national doctor density between the 2011-2019 average and the 2021 figure points towards a considerable outflow of these trained professionals, seeking opportunities beyond Nepal’s borders.¹ Furthermore, significant gaps exist within specific healthcare cadres. As of the fiscal year 2020/21, Nepal faced a substantial deficit of approximately 8,000 midwives, highlighting a critical area needing urgent attention.⁸ The proportion of nurses and paramedics significantly decreased from 36% in 2015 to 18.7% in 2021, weakening primary healthcare delivery [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].

Healthcare Professional Category	Density (per 10,000 population)	Years Covered	Source
Medical Doctors	8.1	2011-2019	1
Medical Doctors	8.67	2021	1
Nurses and Midwives	34.89	2021	[Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities]
Midwifery and Nursing Professionals	3.3	2010-2019	1
Dentists	1.1	2010-2019	1

Significant Challenges Facing the Healthcare Workforce

Despite the progress in producing healthcare professionals, Nepal continues to grapple with a persistent shortage, particularly in rural and remote regions.¹ Data from 2021 reveals alarmingly high vacancy rates in public health facilities, with 26.6% of healthcare provider positions remaining unfilled overall, and a staggering 62.1% vacancy rate for physicians and general practitioners.¹⁰ The situation is even more critical at the local level, where only 23% of the sanctioned posts for physicians and general practitioners were filled in 2023.⁸ Only one-third of clinical doctor positions and two-thirds of paramedic positions are filled in remote provinces like Karnali [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities]. This scarcity of medical professionals in rural areas directly impacts the quality and accessibility of healthcare for a significant portion of the population, leaving many without adequate medical attention when needed.

A major contributing factor to this shortage is the significant brain drain experienced by Nepal’s healthcare system. An increasing number of Nepali health workers are migrating abroad in search of better opportunities.¹ The number of medical graduates seeking a Good Standing Certificate (GSC) from the Nepal Medical Council to work overseas has seen a dramatic rise, nearly doubling from 869 in 2020 to 2,318 in 2023.¹ Notably, there has been a significant increase in applications to countries like the USA and the UK over the years.¹ This trend is not limited to doctors; over a third of Nepal’s registered nurses have also applied for licenses to practice in countries such as the United States and the UK.² Nepal graduates over 5,000 nurses annually, but fewer than 30% find employment in public hospitals, leading many to seek opportunities abroad. The primary drivers behind this migration are often the comparatively low salaries and limited financial incentives offered in Nepal.¹ For instance, the average first-year salary for a medical resident in the United States in 2020 was $63,400 ¹, a figure significantly higher than the average annual salary of approximately $4,357.32 for a doctor in Nepal. This economic disparity makes international migration an appealing option for many skilled Nepali healthcare workers.

Beyond recruitment challenges, retaining healthcare professionals within Nepal, especially in rural areas, is a significant hurdle. Low salaries and limited opportunities for career progression contribute to job dissatisfaction.¹ Furthermore, many doctors experience professional burnout due to overwhelming workloads, with nearly half reporting working more than eight hours daily.¹ The influence of political instability on the health system also creates an unhealthy and demotivating working environment for healthcare professionals.¹ These factors collectively contribute to a sense of disillusionment and push professionals to seek more supportive and rewarding environments elsewhere.

The alarming issue of violence against healthcare workers further exacerbates the challenges in retaining a motivated workforce.¹ Numerous incidents of workplace violence, often perpetrated by frustrated or enraged relatives of patients, have been reported across Nepal.¹³ The lack of consistently enforced laws to protect healthcare workers has often resulted in impunity for the perpetrators.¹³ This constant exposure to threats and assaults can lead to severe burnout, stress, and mental health issues among healthcare professionals, prompting some to migrate for a safer and healthier work environment.¹ While the government has made amendments to the Health Workers and Health Organisations Act 2010 to address this critical issue, effective implementation and enforcement are crucial.¹

According to World Health Organization’s recommendation there should be 45 health personnel (doctors, nurses, and midwives) available for every 10,000 people, whereas, Nepal has 34 available health experts for every 10,000 individuals in the country.

Source

Finally, concerns exist regarding the quality and relevance of health professional training in Nepal.⁸ A 2019 study revealed that Skilled Birth Attendants (SBAs) often exhibit deficiencies in both knowledge and clinical skills, failing to meet the required standards.⁸ This raises concerns about the preparedness of graduates to handle complex medical situations and can contribute to job dissatisfaction and the desire for further training and experience abroad. Skill misallocation, partly due to federalization, has also led to nurses trained in specialized roles working in general health posts, causing frustration and inefficiency [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].

Government Policies and Strategic Directions

The Government of Nepal has recognized the critical importance of a strong healthcare workforce and has implemented various policies and strategic plans to address the existing challenges. The National Health Policy 2019 aims to develop and expand a health system grounded in social justice and good governance, with a core objective of ensuring access to quality health services for all citizens.¹⁴ This policy emphasizes the need to strengthen the institutional capacity of local health governments and facilities, directly addressing the limitations in human resources that hinder effective healthcare delivery at the local level.¹⁴ Furthermore, the policy acknowledges the health needs of migrant populations and aims to strategize the demographic dividend for sustainable socioeconomic development, which indirectly relates to the planning and utilization of the healthcare workforce.¹⁴ The policy also aims to shift the focus of the health sector from profit-orientation to service-orientation [National Health Policy – 2019 | Nepal (English Version)]. Key policies within the National Health Policy 2019 include the development and expansion of quality health workers with strategies for training, equitable distribution, and rural incentives, as well as the improvement of the Health Professional Council for enhanced regulation [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].

Building upon this foundation, the Nepal Health Sector Strategic Plan (NHSS) 2023-2030 outlines a comprehensive roadmap for strengthening the health system, with a significant focus on human resources for health.¹⁹ Strategic Objective 1 of the NHSS is to enhance the efficiency and responsiveness of the health system, with Outcome 1.1 specifically targeting the production and mobilization of a skilled and appropriately mixed healthcare workforce.²¹ The plan aims to strengthen the development, utilization, governance, and information systems related to human resources for health, aligning them with national health priorities.⁴ Recognizing the existing shortcomings, including the inadequate and inequitable distribution of healthcare professionals, the NHSS seeks to build a more resilient and responsive health system.²⁰ The Nepal Health Sector Strategy for 2015-2020 also aimed to improve aid effectiveness in the health sector and guide the government and development partners.

The Nepal Health Workforce Management Information System (NHWMIS) represents a significant initiative to improve the governance and planning of the healthcare workforce.²⁵ This centralized digital platform aims to create an updated repository of all health workers in Nepal, including doctors, nurses, and allied health professionals. By digitally tracking health cadres, the NHWMIS facilitates evidence-based planning and overall governance of the health workforce across the country, providing crucial data for informed decision-making.

Furthermore, several acts and regulations govern the healthcare workforce in Nepal. The Security of Health Workers and Health Organizations Act aims to ensure the safety and security of healthcare professionals and facilities in the face of increasing incidents of violence.¹ This legislation includes provisions for security measures and penalties for those who commit violent acts against health workers. The Nepal Health Professional Council Act plays a vital role in regulating health professionals, excluding doctors and nurses registered with the Medical Council, by setting standards for qualifications, registration, and professional conduct, thereby contributing to the quality of healthcare services. The Nepal Health Service Act of 1997 outlines the constitution, operation, and service conditions of the health service to make it more competent and service-oriented [Government of Nepal].

The Vital Contribution of Community Health Workers (CHWs)

Community Health Workers (CHWs), particularly the extensive network of Female Community Health Volunteers (FCHVs), are an indispensable component of Nepal’s primary healthcare system, especially in bridging the healthcare access gap between urban and rural areas.² The FCHV program has proven to be a highly effective model, with these dedicated volunteers providing essential health information, promoting healthy behaviors, and facilitating access to basic healthcare services, particularly in maternal and child health.² Each FCHV can serve as a vital lifeline for up to 200 individuals annually, offering guidance on pregnancy, antenatal care, nutrition, and postpartum care.² Beyond maternal and child health, CHWs also play a crucial role in assisting individuals with chronic illnesses in managing their daily health needs.² Partnerships between local governments and non-governmental organizations like Nyaya Health Nepal (NHN) have further leveraged the potential of CHWs in delivering healthcare services at the community level.² The Journal of Global Health Reports suggests a need for a 25% increase in FCHVs to meet expanding program demands, emphasizing their importance in rural wards [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].

Despite their significant contributions, CHWs often face challenges related to compensation, recognition, and adequate support.² Concerns have been raised about the long-term sustainability of the FCHV program, which largely relies on volunteerism, without providing full payment and social security coverage.² There has also been a perceived lack of acknowledgement from provincial authorities regarding the crucial role played by CHWs.² However, recent positive developments include the enrollment of some CHWs in the national social security scheme, along with increases in their transport allowance and the extension of health insurance coverage to CHWs and their families, indicating a growing recognition of their importance.²⁹

Progress and Positive Developments in Nepal’s Health Workforce

Despite the multifaceted challenges, Nepal has demonstrated significant progress and positive developments in strengthening its healthcare workforce. During the surge of the COVID-19 pandemic, the Ministry of Health and Population, with support from partners, successfully trained over 11,000 healthcare workers on critical care management, showcasing the nation’s capacity for rapid upskilling during health emergencies.³³ Furthermore, Nepal has achieved remarkable progress in reducing maternal and infant mortality rates in recent decades, a testament to the collective efforts in improving healthcare access and quality.³⁵

Innovative initiatives are also contributing to a stronger healthcare system. Nyaya Health Nepal’s development and scaling of the Nepal Electronic Health Record (NepalEHR) system is a prime example of leveraging technology to improve coordination of patient care and enhance efficiency in healthcare delivery. The recognition of the Union of Private Hospitals and Healthcare Workers in Nepal (UNIPHIN) with the UNI Global Union’s Breaking Through Award highlights the growing advocacy for healthcare workers’ rights and better working conditions. Moreover, the government has taken steps to address the urban-rural divide by urging health workers to return to their designated workplaces, particularly in rural areas, and by introducing telemedicine services to connect urban-based specialists with patients and healthcare providers in remote regions.³⁸

Successful programs aimed at strengthening the healthcare workforce also provide valuable lessons. The public-private partnership between the Government of Nepal and Possible has developed an innovative CHW program that has expanded access to high-quality care in remote areas, demonstrating the effectiveness of collaborative approaches.³ Similarly, the Nick Simons Institute has been instrumental in innovating solutions for rural healthcare by providing crucial support to hospitals and training human resources in underserved regions.³⁷ The continued success of community-based health programs and the ongoing training of local health workers for maternal and child care further underscore the importance of investing in frontline healthcare providers.³⁵

Recommendations and the Way Forward

To further strengthen the healthcare workforce in Nepal and ensure equitable access to quality healthcare for all citizens, several key recommendations emerge:

• Enhancing Recruitment and Retention: Implementing attractive incentive packages, including competitive salaries, housing allowances, and opportunities for continuous professional development, is crucial for attracting and retaining healthcare professionals in rural and remote areas.¹ Exploring strategies such as bonding medical graduates to serve in underserved regions for a specified duration could also help address the geographical maldistribution. Academic incentives for remote postings have shown success in the hill region [Understanding Nepal’s Healthcare Workforce: Challenges and Opportunities].
• Addressing Brain Drain: Investing in creating a more supportive and rewarding professional environment within Nepal, with clear pathways for career advancement and opportunities for specialization, can help encourage healthcare professionals to remain in the country and contribute to the national health system.¹
• Combating Violence Against Healthcare Workers: Strict enforcement of existing laws protecting healthcare professionals and facilities, coupled with severe penalties for perpetrators, is essential to create a safer working environment.¹ Simultaneously, efforts to improve health literacy and communication between healthcare providers and the public can help manage expectations and reduce the likelihood of frustration leading to violence.¹³
• Reducing Burnout: Addressing the issue of overwhelming workloads requires a concerted effort to increase staffing levels, particularly in understaffed facilities. Implementing policies that promote work-life balance and providing access to mental health support services for healthcare professionals are also critical.¹
• Improving Training Quality: Strengthening the curricula and practical training components of health professional education programs is vital. Investing in faculty development and ensuring adequate resources for training institutions will help produce a more competent and confident healthcare workforce.⁸
• Strengthening the Role of CHWs: Providing adequate compensation, social security benefits, and ongoing training and supervision for Community Health Workers, recognizing their invaluable contribution to primary healthcare, is essential for the sustainability and effectiveness of community-based programs.²
• Effective Utilization of NHWMIS: Ensuring the consistent and accurate updating of the Nepal Health Workforce Management Information System database and actively utilizing the data generated for informed decision-making in health workforce planning and management will enhance the system’s effectiveness.
• Promoting Public-Private Partnerships: Fostering collaborations between the public and private sectors can leverage resources and expertise to strengthen the healthcare workforce, particularly in specialized areas and in reaching underserved populations.³

Ultimately, sustained and increased investment in the health sector, encompassing infrastructure, equipment, and, most importantly, human resources, is fundamental to building a resilient and responsive healthcare system that can effectively meet the needs of the Nepali population.

As Conclusion

A strong and well-supported healthcare workforce is not merely a component of a functional health system; it is its very foundation. In Nepal, while significant progress has been made in expanding the healthcare workforce and improving health outcomes, persistent challenges such as geographical maldistribution, brain drain, retention issues, and violence against healthcare workers demand continued and focused attention. The government’s commitment, as reflected in national health policies and strategic plans, alongside the dedication of healthcare professionals and the vital contributions of community health workers, offer a solid base for future advancements. Addressing the existing challenges through strategic policies, targeted investments, and collaborative efforts among all stakeholders – the government, healthcare professionals, educational institutions, non-governmental organizations, and the community – is crucial for building a robust and sustainable healthcare workforce that can ensure the health and well-being of all Nepali citizens.

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